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Pediatric Primary Care Exam 4 > GI Problems of Infancy > Flashcards

Flashcards in GI Problems of Infancy Deck (44):

Regurgitation (3)

1. Defined as “spitting up” is effortless passage into the pharynx or mouth

2. Typically will come up with a burp
*Check -Does it come up with normal gas or when baby is passing a stool?; Because this would be fairly benign

3. Not projectile


Vomiting (3)

1. Forceful expulsion of the gastric contents

2. Projectile

3. If happening every time the baby eats, may not be vomiting; more regurgitation and baby didn’t burp well


GERD Definition

the passage of gastric contents into the esophagus that results in uncomfortable symptoms or complications


Checking color of vomit (4)

1. Bilious vomiting can be surgical emergency

2. Pyloric may not be bilious but can be projectile

First question → what color is it?
3. If it is green or bilious then it is not GER and needs further work-up to rule out surgical emergency
*Any reason that would make the bile come out through the mouth because it is obstructed the other way
*Something blocking the pathway below the ampula

4. Milk colored → typically OK and don’t need to rush to ER


Definition of GER (4)

1. Normal physiologic passage of stomach contents into the esophagus – AKA “regurgitation”

2. Causes few or no symptoms & doesn’t lead to esophagitis

3. Most often in the postprandial period (after feeding)

4. Normal in infants due to low-tone sphincter


Epidemiology of GER (4)

1. Common in healthy infants and children

2. 50% < 3months of age will experience at least one episode/day

3. ~5% at 12 months of age will experience GER/regurgitation

4. Usually decreases with age – will “outgrow it”


Physiology of GER (4)

1. Decreased lower esophageal sphincter (LES) pressure
*Relaxation of the LES is transient in healthy infants

2. Increased abdominal pressure
*Gastric distention in infants from large feeds lead to more frequent episodes of sphincter relaxation

3. Several times a day

4. Alterations in gastric motility; delayed gastric emptying can also increase episodes of sphincter relaxation


Clinical Presentation of GER (4)

1. Infants with benign GER are called “happy spitters”
2. Occurs most often in the postprandial period
3. Occurs several times per day
4. Commonly causes caregiver distress


How is GER different than GERD? (4)

1. No other associated symptoms

2. Esophageal clearance and mucosal defense prevent esophagitis

3. Compromise of these protective mechanisms can lead to gastroesophageal reflux disease (GERD)

4. In healthy infants this should not be an issue – in neurologically impaired infants → decreased tone = increased GER (may lead to GERD)


How is GERD different than GER? (3)

1. The passage of gastric contents into the esophagus that RESULTS IN TROUBLESOME SYMPTOMS or complications.

2. The reflux of stomach acid causing discomfort; burning and irritating

3. Initially will just be spitting up, over time if they continue to do it they burn a lot of calories and won’t be gaining weight appropriately
*More frequent visits will be important


Pathophysiology with GERD

LES relaxes and is unable to put pressure on the esophagus, leading to the back flow of stomach contents into the esophagus
*As the LES is damaged, it loses the ability to protect your esophagus from the contents of your stomach


GI Presentations with GERD (3)

1. Regurgitation with or without vomiting
2. Feeding difficulties
3. Hematemesis


Extra-intestinal presentation with GERD (10)

1. FTT
2. Wheezing
3. Stridor
*Irritation causes inflammation which can be enough to cause an obstruction or narrowing
4. Persistent cough
5. Apnea/ALTE
*Treat reflux right away if this is happening as you begin to rule out other things that could be causing it
6. Irritability
7. Sandifer Syndrome
8. Ruminative behavior
9. Hoarseness
10. Dental erosion


Infant Presentation of GERD (6)

1. Feeding refusal
2. Recurrent vomiting
3. Irritability
4. Poor weight gain
5. Sleep disturbance
6. Respiratory symptoms


Older children/adolescent presentation of GERD (6)

1. Abd pain/heartburn
2. recurrent vomiting
3. dysphagia
4. upper airway respiratory symptoms - chronic cough/hoarse voice
5. recurrent pneumonia
6. may have asthma


GERD: High risk populations (8)

1. Neurological impairment
*Hypotonia → increased LES relaxation → GERD

2. Obesity

3. History of esophageal atresia (repaired)

4. Hiatal hernia

5. Achalasia

6. Chronic respiratory disorders / BPD

7. Cystic fibrosis

8. Preterm Infants


GERD Differential Dx (4)

1. Gastroenteritis
*Ask about other exposures – someone sick at home, day care, etc.

2. Formula Intolerance
*Allergies can present as vomiting

3. Pyloric Stenosis
*Projectile vomiting
*Ultra sound shows olive-pit in RUQ

4. Improper feeding technique
*Watch them feed in the office


Warning Signs: Non-GERD (12)

These need further investigation!

1. Bilious emesis
2. Forceful vomiting
3. Hematemesis
4. FTT
5. Diarrhea
6. Constipation
7. Abdominal distention or tenderness
8. Projectile vomiting
9. Fever, lethargy
*Rule out sepsis first then go back to GERD
10. HSM
11. Bulging fontanelle
12. Seizures


CNS Abnormality Causes of Infant Irritability (2)

1. Subdural
2. Nonaccidental trauma


GI Causes of Infant Irritability (3)

1. Constipation
3. GER


Infection Causes of Infant Irritability (4)

1. Meningitis
2. Otitis
3. UTI
4. Viral Illness


Pain Causes of Infant Irritability (4)

1. Hair tourniquet syndrome
*Hair so tight around that it is constricting circulation
2. Foreign body
3. Hunger or neglect
4. Torsion of ovary or testes


Symptoms that Overlap with GERD (5)

1. Eosinophilic esophagitis (EoE)
2. Allergic esophagitis (CMPA)
3. Infectious esophagitis (Candida, CMV, HSV)
4. Anatomic anomalies
*Strictures, webs, vascular rings
5. Ingestions
*Foreign body, Caustic chemicals


GERD: Diagnostic Approach (14)

History and Physical Exam, Ask the questions:
1. Nature of the vomiting?
2. Bile or blood?
3. Irritable with emesis?
4. Change in eating habits?
5. Arching during feeds?
6. Feeding history – volume /frequency?
7. Type of formula or BM?
8. Preparation of formula?
9. Positioning of infant during feeds?
10. Prematurity?
11. Neurological problems?
12. Developmental concerns
13. Family history of GERD?
14. PE- weight, growth, Height, abdominal assessment and neurological


GERD Diagnosis based on Presentation (4)

1. There is no classic presentation in infants with GERD- unlike older children with
-Epigastric pain

2. These can be used to diagnose GERD in older children.

3. For Infants and children the history and PE are sufficient to diagnose GER

4. GERD- diagnosis needs further diagnostic evaluation


GERD Lab tests (4)

1. No lab tests needed to diagnose
2. Sepsis work up for infants including urine
3. Electrolytes
4. CBC (anemia)


GERD pH probe (6)

(intra-esophageal pH Monitoring)

1. Measurement of the intra-esophageal pH for 24-48 hours is considered the “Gold Standard” for diagnosis of GERD

2. Place a catheter trans-nasally into the distal esophagus to measure the intraluminal pH as the patient records symptoms

3. Meals are recorded,

4. Safe in all age groups

5. Wireless device for children – capsule size big for smaller children

6. COMBINATION- MULTIPLE INTRALUMINAL IMPEDANCE and pH Monitoring – detects acid and nonacid reflux episodes…superior to pH probe, not determined if this is effective to determine disease severity, prognosis, and response to therapy?


GERD UGI Series (2)

1. Not useful in diagnosing GERD

2. Used to confirm or rule out anatomic abnormalities (malrotation, esophageal or intestinal webs, hiatal hernia) – all that might cause symptoms similar to GERD


GERD Endoscopy (3)

1. Allows direct visualization of esophagus and can get biopsies

2. Can see the esophagitis and infection can be ruled out

3. Good to Identify mucosal erythema, pallor, or increased or decreased vascular pattern- Suggestive of Reflux


GERD Management

1st: Lifestyle modifications

2nd: Medications

3rd: Anti-reflux precautions

4th: Surgical options


GERD Lifestyle Modifications (4)

1. Positioning in infants-prone at a 30 degree angle is the only proven position
*Decreases the amount of acid esophageal exposure
*NOT recommended – SIDS risk – must be carefully observed
*Pick up the baby and move around (think about how you feel after eating a big meal and then lying down immediately afterwards)

2. Breastfeeding Interventions: exclusion diet trial (mom’s diet)
*May eliminate spicy, dairy or other foods; but the data for this isn’t strong
*Be careful with this and mother’s because mother’s need to have a well-balanced meal
*Can try it with mother’s who are willing to for 2-4 weeks

3. Formula Interventions: less volume more frequently
*“Formula roulette” –cow’s milk vs. soy?
*Allergy will usually present with diarrhea and rash, not just mild vomiting

4. Reflux Formulas - NEW- pre thickened with rice starch – good if poor weight gain
*Can add Rice cereal yourself – 1 tablespoon of RC to 2 oz formula – out of fashion – to thick and have to cut nipple –Dangerous!


Gentlease, Alimentum and Nutramigen (2)

1. Partially hydrolyzed (“broken down”) formula (PHF)

2. Hypoallergenic – good for true cow milk protein allergy


Elecare, Alfamino, and Neocate and Neocate Syneo (3)

1. Extensively hydrolyzed formulae (EHF)

2. 100% synthesized free amino acids – good for allergies and GERD

3. Expensive


GERD Medications: First line treatment (3)

1. FIRST LINE: Histamine-2 Receptor Antagonists (H2RAs): decreases acid production by binding to histamine-2 receptors on the gastric parietal cell → inhibits gastric acid secretion

2. Ranitidine (Zantac) 1 month-16 year DOSE- 5-10 mg/kg/day in 2-3 divided doses (15mg/mL)

3. Can be used to heal the esophagus and treat GERD


GERD Medications: PPIs (4)

1. Most effective for acid suppression, a 4 week trial is suggested for children >8 years

2. If PPI and lifestyle changes do not improve the symptoms in children refer to Pediatric Gastroenterologist

3. NOT the best option for INFANTS- not approved for infants under 1 year of age

4. Must be given 30 Minutes before meals to achieve peak serum concentration
*Must be given correctly- parent education is key!


Medications that shouldn't be given for GERD

NO antacids in infants – contain aluminum which is associated with bone and nervous system toxicity- osteopenia, rickets, neurotoxicity in infants


GERD Feeding Changes (5)

1. Adjust Mother’s diet if BF

2. 2-4 week trial exclusion diet

3. Formula changes (EHF/AA recommended)

4. Want to optimize all the nutrients the baby is taking in

5. Feed less volume more frequently
-Positioning therapy
-Prone is best but dangerous
- Must be observed – better if over 1 year of age – decrease risk of SIDS


GERD Surgical Options (4)

1. Surgical interventions reserved for those with intractable symptoms or at risk for life threatening complications of GERD

2. Not used as much anymore

3. Refer to Pediatric Gastroenterologist first

4. Nissan fundoplication


Nissan fundoplication (2)

1. The upper curve of the stomach is wrapped around the around the esophagus and sewn in place to strengthen the LES to keep contents down

2. Reserved for those with respiratory complications and aspiration


GER/GERD Parent Education (7)

1. Avoid overfeeding. Smaller and frequent feedings will empty the stomach faster.

2. Minimize intake of air during feeding. If the bottle is too low, the baby can swallow air, causing gas and crying.

3. Avoid tobacco smoke – relaxes the esophageal sphincter

4. Keep upright for 30 minutes after feeds

5. Consider changing diet if breastfeeding

6. Consider alternate formula if bottle feeding

7. Reassure if gaining weight



1. Frequent office visits

2. Monitor growth and development

3. Weight loss is a crucial warning sign to alter management of infants

4. Re-evaluate diet and feeding techniques

5. Adjust medications based on weight

6. PNP must have the ability to distinguish between GER/GERD and other etiologies this is the key to best practice!

7. Parental reassurance


Sandifer Syndrome (6)

1. Present like seizures: Arching of the back, spasmodic torsional dystonia, and rigid posturing

2. Often times this is misdiagnosed as severe reflux and they are treated for reflux even though it isn’t the underlying cause

3. Mainly involves the neck, back and upper extremities

4. Associated with GERD

5. Often see a neurologist before gastroenterologist because of seizure look a like

6. Infants to 2 years of age is most common


Exam and Referral for Sandifer Syndrome (4)

1. Referral usually gets immediately made to neuro due to the presentation (eye rolling, head nodding, dystonic movements) but it should actually be made to gasteroenterology

2. Do a complete and thorough neuro exam and if that is normal then suspect SS and refer to gastro

3. Physical examination will be normal

4. Associated with hiatal hernia


Typical case presentation of Sandifer Syndrome

Patient may have history of vomiting for a month then parent says the infant began to present with abnormal movements during or just after feeding; these movements always stop during sleep