Baby with vomiting, when to worry

Overview What is reflux Primary and secondary reflux What is normal reflux Red flags Treatment of reflux EE

What is gastroesophageal reflux ? PASSIVE movement of stomach contents into the oesophagus A SYMPTOM

Why do we reflux ? Gastric pressure exceeds LES pressure

What is reflux a symptom of ? Short intra-abdominal oesophagus Lax LES TLESR pre-term infants allergy / inflammation Disabled  Gastric compliance Airways obstruction

Primary v Secondary Reflux Short intra-abdominal esophagus Lax LES TLESR pre-term infants Disabled

Primary v Secondary Reflux Reduced stomach compliance Food allergy Inflammation Mechanical obstruction Malrotation TLESR Sliding Hiatus hernia Airway obstruction

Gastroesophageal Reflux Associated feeding problems Pain with or after feeding Association of pain/discomfort with food Loss of interest in food

Most infantile GER is not pathological >20% infants “regurgitate excessively” ~7% infants brought to medical retention 80% resolve with little/no Rx and no investigation

GER Normal Pathological

Warning signals Irritability Poor feeding Bile stained vomiting Retching Hematemesis Onset > 6 months of age Failure to thrive Recurrent aspiration pneumonitis ALTEs Lethargy Neurological abnormality Abdominal distension Dysmorphic syndrome / chromosomal anomaly

Conditions Mimicking GER eosinophillic oesophagitis Anatomical problems hypertrophic pyloric stenosis / annular pancreas / duodenal web achalasia Upper gut dysmotility Rumination

When to suspect food allergy as a cause of vomiting? Other atopy FH Change in feeds Immune dysregulation

Diagnosis of gastroesophageal reflux IF appropriate: Ascertain the severity Define the cause Delineate complications

Investigation order None Symptoms guided

Gastrooesophageal reflux What investigations: Upper gut contrast For anatomy 24 hours pH vs Impedance Inflammation Gastric compliance Milk scan Electogastrography Motor activity Manometry

Ambulatory pH catheter placement. 33

Ambulatory pH monitoring tracings. 34

Combined multichannel intraluminal impedance and pH catheter. 35

Impedance changes produced by liquid, mixed, or gas boluses. 36

GI Motility online (May 2006) | doi:10.1038/gimo31 Gastroesophageal reflux detected by combined multichannel intraluminal impedance and pH (MII-pH) monitoring. GI Motility online (May 2006) | doi:10.1038/gimo31 37

Suggested diagnostic gastroesophageal reflux disease (GERD) algorithm. 43

Management of GER Treat the cause ! (If it’s indicated)

Management of uncomplicated GER (1) Simple measures: Position Feed frequency / volume Milk thickening / pre-thickened milks if unresponsive Acid suppressants

Management of GER (2) If unresponsive to simple measures / PPI Investigate Define foregut anatomy (Ba study) Determine severity – 24 h pH/impedance study EGD & mucosal biopsy - oesophagus and duodenum ?Prokinetics and acid suppressants +/- Dietary manipulation

Management of GER (3) Transpyloric feeding – NJ / GJ Surgery Refractory to medical treatments Complicated GOR Failure to thrive Pulmonary aspiration Refractory esophagitis ALTEs Other approaches Novel pharmacotherapy - Baclofen

Nissens fundoplication gastric volume   compliance extrinsic denervation   compliance Retching

Eosinophilic Esophagitis Any age Vomiting Upper abdominal pain Dysphagia Respiratory symptoms Seasonal variations

Treatment of EE Diet exclusion Montelukast Swallowed inhaled steroids AA formula Montelukast Swallowed inhaled steroids Budesonide paste Systemic steroids Immune modulators ?? Anti IL-5