Diagnosis and Treatment of Gastro-Oesophageal Reflux

82 Archives ofDisease in Childhood 1995; 73: 82-86

PERSONAL PRACTICE Arch Dis Child: first published as 10.1136/adc.73.1.82 on 1 July 1995. Downloaded from

Diagnosis and treatment of gastro-oesophageal reflux

A E M Davies, B K Sandhu

Gastro-oesophageal reflux (GOR) is defined as quency of the vomiting if presents and a the involuntary passage of gastric contents into detailed dietary assessment is essential. the oesophagus, and is a common cause of Systematic inquiry should also establish the morbidity in childhood. GOR is an occasional presence of associated failure to thrive, and physiological event in normal adults and child- respiratory or neurological symptoms. On ren,1 2 but becomes pathological when its examination, an assessment should be made of intensity or frequency increases or when com- nutritional status, respiratory signs, and neuro- plications arise (for example, oesophagitis, fail- developmental milestones, searching also for ure to thrive). GOR may be primary (due to signs of the causes of secondary GOR. anatomical or physiological abnormalities) or secondary to other diseases such as urinary tract infection, metabolic disorders, food Investigations allergy, etc (see table 1). The increasing avail- In those patients with uncomplicated primary ability of lower oesophageal pH monitoring, GOR, few initial investigations are needed, paediatric endoscopic skills, and newer more although we routinely check a urine culture to effective pharmacological agents has led to a exclude urinary tract infection. We check a full greater awareness of the range of symptoms blood count, and faecal occult blood tests if attributable to gastro-oesophageal reflux disease occult gastrointestinal blood loss is suspected (GORD), and the need for a structured clinically. An estimation of acid-base balance approach to diagnosis and management. may also be helpful. Other tests to exclude complications for GOR (for example, chest radiography to exclude aspiration pneumonia) http://adc.bmj.com/ Presenting symptoms or causes of secondary GOR may be indicated Although vomiting is the most common symp- (for example, antigliadin antibodies). tom of primary GORD, it is now recognised that children and infants may present with a wide variety of other symptoms (see table 2). (1) LOWER OESOPHAGEAL pH MONITORING These may be related to oesophagitis, for Extended oesophageal pH monitoring over example, haematemesis, anaemia, chest pain, 18-24 hours is now well established as the on September 26, 2021 by guest. Protected copyright. or general irritability or from respiratory com- 'gold standard' for documenting acid GOR, plications such as recurrent aspiration pneumonia, apnoea, or stridor. GOR may also be a Table 2 Symptoms of GORD factor in the aetiology of apparent life threatening events. Certain seizure-like events or dys- (A) Oesophageal symptoms (1) Specific symptoms tonic posturing (Sandifer-Sutcliffe syndrome) * Regurgitation may result from GORD.3 * Vomiting * Nausea * Failure to thrive (2) Symptoms due to oesophagitis * Haematemesis and melaena Clinical assessment * Dysphagia The history must establish the nature and fre- * Epigastric or retrosternal pain * Heartbum * Symptoms related to anaemia Table 1 Causes ofsecondary reflux * General irritability * Feeding problems * Infective * Oesophageal obstruction due to stricture Gastroenteritis, urinary tract infection (B) Respiratory symptoms * Aspiration pneumonia, especially recurrent * Intestinal obstruction * Apnoea, especially in the preterm infant Volvulus, intestinal atresia, pyloric stenosis * Apparent life threatening events and sudden infant * Intracranialpathology death syndrome Institute of Child Hydrocephalus, neoplasia, subdural haematoma * Cyanotic episodes Health, Royal Hospital * Food intolerance; coeliac disease * Cough Cows' milk, soy or egg intolerance * Stridor for Sick Children, * Bronchospasm or wheezing, especially intractable St Michael's Hill, * Metabolic asthma Bristol BS2 8BJ Diabetic ketoacidosis, uraemia, inborn errors of metabolism * Worsening of existing respiratory disease, for example A E M Davies * Psychological cystic fibrosis B K Sandhu Anxiety or as feature of cyclical vomiting (C) Neurobehavioural symptoms * Drugs/toxins * Sandifer-Sutcliffe syndrome Correspondence to: Cytotoxic agents, theophylline, iron or digoxin * Seizure-like events in infants Dr Sandhu. Diagnosis and treatment ofgastro-oesophageal reflux8 83

providing more physiological and accurate have found that it may be totally misleading information about reflux as a dynamic pheno- and even dangerous to evaluate the study on menon than barium studies.47 the summary data alone, as events such as accidental probe disconnection or slipping of the Arch Dis Child: first published as 10.1136/adc.73.1.82 on 1 July 1995. Downloaded from probe position may pass undetected unless the (A) Study techniques whole trace is examined carefully. We use a study period of 24 hours (minimum 18 hours), and record significant events during the study period such as symptoms, feeds, and (2) BARIUM RADIOGRAPHY changes in position. H2 antagonists (cimeti- We request barium studies if an anatomical dine, ranitidine) should be discontinued 3-4 abnormality is suspected, such as hiatus hernia, days before the procedure, prokinetic agents oesophageal stricture, malrotation, or gastric (cisapride, domperidone, metoclopramide) 48 outlet obstruction. Although used historically hours before, and antacids 24 hours before. for diagnosis, barium studies should not be Care should be taken with the positioning of used to diagnose or quantify GOR, as gastro- the electrode. The Strobel formula (length oesophageal dynamics are only examined over from nostril to lower oesophageal sphincter in a very short period of time; results may be cm=5+0252 [height]) gives an approximate totally unreliable and misleading as severe guide for positioning, especially in infants GOR may be missed, and physiological reflux under the age of 1 year, but we confirm this detected. 10 with chest radiography or fluoroscopy before starting the recording. Secure fixing 'of the probe wires to the face with adhesive tape is (3) SCINTIGRAPHY important to prevent accidental movement of Iffacilities are easily available, this may be par- the electrode position. A working group on ticularly useful in the diagnosis of non-acid GORD of the European Society of Paediatric reflux and for studying gastric emptying time. Gastroenterology and Nutrition (ESPGAN) However, we do not use it as a routine investi- has published a protocol for lower oesophageal gation unless surgical intervention in planned. pH monitoring,8 which provides a useful guide for those carrying out the procedure. (4) ENDOSCOPY Upper gastrointestinal endoscopy enables a (B) Interpretation ofdata definite diagnosis of oesophagitis to be made, Although several different scoring systems both macroscopically and histologically. have been developed for the interpretation of Oesophageal strictures, hiatus hernia, Barrett's pH studies, we use the normal values based on oesophagus, and other conditions which cause studies by Vandenplas and Sacre-Smits (table epigastric pain or haematemesis may all be 3).9 A 'reflux episode' occurs when the lower diagnosed endoscopically. Histological con- http://adc.bmj.com/ oesophageal pH falls below pH 4. The reflux firmation of oesophagitis is important in a index is the percentage time of the study patient suspected ofreflux associated oesopha- during which the lower oesophageal pH is less gitis, both to show oesophagitis where than 4, and provides a useful summary of a endoscopy is equivocal or negative, and to con- period of monitoring. However, data on the firm that the oesophagitis is due to reflux in the duration of the longest reflux episode and the patient wh-ere endoscopy is positive.11

number of prolonged reflux episodes (five on September 26, 2021 by guest. Protected copyright. minutes or longer) may also be of value, as such episodes may be matched with clinical Management ofuncomplicated GOR events such as cyanotic episodes or seizure-like Infants with uncomplicated GOR, usually events. When using pH 4 to indicate reflux, it those under 12 months of age with regurgita- must be remembered that non-acid reflux may tion, may be diagnosed on the basis of history occur and will not be detected. In general, and examination alone, and often respond to a those children with a reflux index of 5-10% regimen of fairly simple measures. We use (mild) or 10-20% (moderate) will often be antacids, positioning, and simple dietary controlled by medical treatment, but those advice, and add cisapride if these measures with over 30% reflux (severe) often require have already been tried. surgical intervention such as a Nissen fundoplication. Although a computerised summary of these values is produced at the end of a (1) POSITIiONING study period, it is of vital importance that the The baby should be positioned for sleep with the results are interpreted with the printout of head raised to 30 degrees from the horizontal,12 actual pH data from the entire study period by best arranged by a folded blanket placed under a person with understanding both of the the head end of the mattress. Although lower methodology and of the clinical problem. We oesophageal pH monitoring studies have previ- ously shown GOR to be reduced by positioning the infant in the raised prone position, we do not Table 3 Scoring system for oesophageal pH monitoring recommend this position as the prone sleeping * Per cent of time pH <4 for total period (the reflux index) position has been found in many studies to be an * Number of reflux episodes lasting 5 minutes or longer independent risk factor for sudden infant death * Duration of the longest reflux episode * Total number of reflux episodes syndrome, and the Departnent ofHealth guide- lines currently recommend lying babies in the 84 Davies, Sandhu

supine position.'3 Our preferred position is for pH monitoring studies are indicated to docu- the babies with GOR to be nursed on the side ment and quantify GOR. with the head raised to 30 degrees and with the If pH monitoring results suggest no

lower arm placed well in front of the body to significant GOR, the diagnosis should be Arch Dis Child: first published as 10.1136/adc.73.1.82 on 1 July 1995. Downloaded from avoid rolling to the prone position. Blankets or reconsidered. A full clinical reassessment is wedges should not be used to support the posi- necessary, and further investigations to tion because of the risk of rolling into the prone exclude an underlying cause of the vomiting or position. other symptoms should be considered (see table 1). If GOR is confirmed by pH monitoring, we (2) ANTACIDS base any modifications to treatment on the Antacids such as infant Gaviscon (Reckitt and severity of GOR confirmed, and on the pres- Colman; sodium salt of alginic acid) may be ence of complications. added to milk (1-2 g/100 ml) and are effec- tive14 15 but they contain a high sodium load that may be inappropriate in preterm babies. MILD-MODERATE GOR Antacids may be used in the older child as a In patients in whom pH monitoring confirms tablet or liquid, to be taken before meals, mild (5-10%) or moderate (10-20%) GOR, before bed, or as symptoms arise. we continue treatment with general measures and cisapride for a further period of up to three months. (3) MILK THICKENERS Thickening agents may be added to feeds to increase feed viscosity and decrease the symp- SEVERE GOR toms of regurgitation and vomiting. They may If pH monitoring indicates severe GOR (over be based on carob seed flour such as Carobel 20%), we add an H2 antagonist (cimetidine at (Cow and Gate) or Nestargel (Nestle), or on a dose of 30 mg/kg/day or ranitidine at 4-8 modified maize starch (Thixo-D; Cirrus). mg/kg/day) to prevent oesophagitis,21-23 while Although such thickeners may reduce the continuing the regimen of cisapride and general number of reflux episodes,16 17 they may pro- measures as outlined above. We would also long the duration of remaining episodes, and proceed to early endoscopy before starting H2 therefore may be inappropriate in patients with blockers if there were clinical indicators of known or suspected oesophagitis. oesophagitis.

(4) DIETARY REGIMENS OESOPHAGITIS Our usual dietary advice in infants is to give We investigate patients presenting with symp-

smaller feeds of increased frequency, although toms suggestive of oesophagitis (chest pain, http://adc.bmj.com/ periods of postprandial reflux may thereby melaena, haematemesis, positive faecal occult increase, and to give solids at a different time blood in the stool, etc) with pH monitoring from liquids. Severe failure to thrive may arise and endoscopy. Barium studies to exclude if significant calories are lost through vomiting, hiatus hernia and malrotation, and scinti- and ensuring adequate energy intake is of vital graphy to exclude alkaline reflux or abnormal importance. In older children we advise the gastric emptying, may be appropriate in some

avoidance of spicy foods, coffee, tea, cola and cases. We treat the GOR with a prokinetic on September 26, 2021 by guest. Protected copyright. other fizzy drinks, and late evening meals. agent and the general measures outlined above. If oesophagitis is minimal (grade 1-3, mucosal redness), healing may occur with a (5) PROKINETIC AGENTS prokinetic agent and general antireflux If the general measures outlined above have measures alone, continued for 4-12 weeks, but failed to improve symptoms after 4-6 weeks, it is our practice to add H2 antagonists to pre- and secondary causes of GOR have been vent worsening ulceration. More severe excluded, it is reasonable to start cisapride, one oesophagitis (above grade 3 with mucosal of the prokinetic drugs, without performing ulceration), however, is a definite indication oesophageal pH monitoring.18 Cisapride is a for H2 antagonists to be used2'-23 in combi- non-dopamine receptor blocking agent, which nation with a prokinetic agent and general acts by enhancing acetylcholine release in the measures. Omeprazole, a proton pump gut, thereby increasing gastrointestinal motility inhibitor, is also effective in treating GOR and improving antroduodenal coordina- related oesophagitis,2426 although experience tion. 19-21 Reported side effects are usually of its use in children is limited. We have used minor and transient: colic, diarrhoea, headache, omeprazole in 20 children with severe and occasional drowsiness. The usual dose is oesophagitis in whom H2 antagonists had 0-8 mg/kg/day (0A4-1-2 mg/kg/day), given in failed.26 An optimal dose regimen is yet to be 3-4 divided doses before meals and before bed. established, and our centre is contributing to a multicentre trial to evaluate an effective dose regimen for children. We currently use a dose Indications for oesophageal pH of 5 mg daily for children under 5 years of age, monitoring 10 mg for 5-10 year olds, and 15 mg above 10 If the above regimen fails to show any benefit years of age. after a further 4-6 weeks, lower oesophageal We aim to perform a follow up endoscopy at Diagnosis and treatment ofgastro-oesophageal reflux 85

2-3 months after starting treatment. If the treat oesophagitis with an H2 antagonist, mucosa has healed, H2 blockers or omeprazole using omeprazole as second line treatment if may be discontinued, but prokinetic agents, healing has not occurred. Fundoplication is

antacids, and general antireflux measures frequently needed in this group,30 36 however, Arch Dis Child: first published as 10.1136/adc.73.1.82 on 1 July 1995. Downloaded from should be continued for a prolonged period, and is preceded by full assessment in joint certainly over six months. If there is no evi- medical/surgical setting. dence of healing, we continue to treat med- ically for a further three months, ensuring once again that anatomical or other problems have Children with 'silent' GOR and been excluded. respiratory manifestations Since the advent of oesophageal pH monitoring, it has become apparent that GOR may be Surgery clinically 'silent', that is, may present only with Surgical treatment of GOR (usually a Nissen complications in the absence of regurgitation fundoplication) may be inevitable if full med- or vomiting.37 Many respiratory complications ical treatment has failed, or if there is an have been linked to GOR on the basis of pre- oesophageal stricture or Barrett's oesophagus sumed aspiration or via oesophageal-respira- at initial diagnosis. We assess such patients in a tory tree reflexes. Up to three quarters of joint gastroenterological medicalsurgical clinic children with apparent life threatening events at an early stage to consider each child's prob- may have pathological GOR,38 39 and it is our lems individually. Surgery should be preceded practice to investigate these children with pH by a full functional and anatomical assessment monitoring combined with overnight sleep including review of barium studies, repeat studies in conjunction with the respiratory oesophageal pH monitoring, motility and team. The duration of reflux episodes during gastric emptying studies to enable appropriate sleep may be an important determinant of surgical procedures to be selected after consul- reflux associated respiratory disease and sud- tation with the parents.27 28 These may, for den infant death syndrome,40 and pH monitor- example, include a pyloroplasty or insertion of ing is directed at determining the duration of a feeding gastrostomy. Complications of surgi- the reflux episodes and their correlation with cal treatment include dumping, retching, clinical events such as apnoea, bradycardia, intestinal obstruction, 'gas bloat', and recur- and drops in oxygen saturation rather than rence of GOR.29 30 relying on the reflux index alone. If GOR is confirmed, energetic medical treatment is instituted in such infants and our own practice GOR in neurologically abnormal children is to treat with cisapride in full dosage and H2 Children with neurological disability often antagonists, with early consideration of surgery suffer from feeding difficulties, vomiting, fail- if medical treatment is ineffective.

ure to thrive, recurrent chest infections and Silent reflux may be a contributing factor in http://adc.bmj.com/ irritability, and such symptoms are often intractable asthma and chronic lung disease accepted as part of the disability. The associa- such as cystic fibrosis, although its precise role tion between GOR and cerebral palsy was first in pathophysiology is unclear.37 If clinically reported by Abrahams and Burkitt in 1970,31 suspected, we carry out 24 hour oesophageal who found reflux in 75% of cases, and pH monitoring before starting any treatment. extended lower oesophageal pH monitoring

has confirmed this association.32 GORD on September 26, 2021 by guest. Protected copyright. remains undiagnosed in many of these Conclusion patients, but even when recognised, this group We recommend that children with typical is difficult to mar%age effectively. Spontaneous symptoms of GOR without complications can resolution of GOR is less common in such be treated with simple measures and prokinetic children, as the neurological deficit itself agents such as cisapride without extensive causes delayed oesophageal clearance, delayed investigations. However, oesophageal pH gastric emptying, etc. Our experience with a small number of children with Cornelia de Table 4 Summary oftreatment ofprimary GOR Lange syndrome, for example, has been that the reflux as as (1) Uncomplicated GOR index is high 50%, and most Antacids have needed early surgery for failure ofmedical Positioning treatment. Head raised to 30 degrees Nurse in lateral position In the neurologically abnormal child, we Dietary advice use at an stage to +/- Prokinetic agents - cisapride 0-2 mg/kg four times a always pH monitoring early day before meals establish the severity of GOR. We use a pro- If treatment fails - perform oesophageal pH monitoring kinetic agent with central nervous system (2) Mild-moderate GOR (reflux index <20%) as Continue as for (1), including prokinetics for up to 3 activity such domperidone (1 mg/kg/day) months or 5 34 metoclopramide (0 mg/kg/day)33 (3) Severe GOR (reflux index >20%) because cisapride has been found to be poorly Add H2 antagonist effective in this group of patients compared Ranitidine 24 mg/kg/twice a day (or) with its effects in Cimetidine 5-10 mg/kg four times a day neurologically normal (4) Oesophagitis children,35 although this finding needs further Use H2 antagonist +/- omeprazole* evaluation. We If medical treatment fails - surgical treatment, for example endoscope those children Nissen fundoplication found to have severe GOR on pH monitoring or those with symptoms of oesophagitis. We *Dosage schedule yet to be established. 86 Davies, Sandhu

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