Gastroesophageal Reflux - NICU Newborns and Infants

Treatment

• Avoid Overfeeding

• Positioning

• Proper feeding position / Consider lactation consult
  
• Upright 30-45min after feedings

• Thicken Feedings

• Cereal - Link Here
• Thickeners
• Breastmilk can be thickened with xanthum gum or carob bean based thickeners but not with cereal which is digested by the amylases in breast milk.
  
• NEC concerns:
  
• Carob bean thickeners are approved for use in infants >42 weeks EGA
  
• Xanthum gum thickeners are approved for infants >1 year old
  

• 2-4wk trial of protein hydrolysate or Amino Acid based formula or elimination of Cows milk proteins from maternal diet (Breastfeeding)

• 4-8wk trial of acid suppression

• Consider Additional Diagnostic Testing/Procedures:

• Post-pyloric feeds (NJ placement)
  
• UGI study (not supported by literature or clinical practice)
• Patients with symptoms that are particularly intense or not responsive to traditional therapies.
  
• In order to evaluate for anatomic abnormalities.
  
• To r/o other conditions that might mimic or predispose to GERD such as hiatal hernia, malrotation, pyloric stenosis, duodenal web, duodenal stenosis, antral web, esophageal narrowing, Schatzki’s ring, achalasia, esophageal stricture, and esophageal extrinsic compression.
  
• One of the most important roles for barium imaging is in the evaluation of children who have had anti-reflux surgery who are symptomatic with persistent typical or atypical reflux symptoms, dysphagia or pain;
  
• barium imaging can be helpful to differentiate an obstructing fundoplication with esophageal stasis from a slipped or loose fundoplication
• Ultrasound (can not diagnose reflux)
• Use to evaluate for other conditions that might mimic GERD including, pyloric stenosis.
• Abdominal ultrasound may also pick up other diagnoses, which may trigger symptoms of discomfort and vomiting including diagnoses such as hydronephrosis, uretero-pelvic obstruction, gallstones, and ovarian torsion.
  
• Similar to barium study, ultrasound can detect hiatal hernia, length and position of the LES relative to the diaphragm and magnitude of the gastro-esophageal angle of His.
  
• It has also been proposed as a diagnostic test for gastric dysmotility, which may have implications from a reflux perspective
• EGD can be used to r/o complications of reflu

• Trial of promotility agent

• EES
• Reglan :(
  

• Surgery

• Severe refractory reflux with significant comorbid conditions
• Fundoplication

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Differential Diagnosis

Gastrointestinal obstruction

• Pyloric stenosis
• Malrotation with volvulus
• Intussusception
• Hirschsprung disease
• Antral/duodenal web
• Foreign body
• Incarcerated hernia
• Superior mesenteric artery (SMA) syndrome

Neurologic Infectious

• Hydrocephalus
• Subdural hematoma
• Intracranial hemorrhage
• Intracranial mass

Metabolic/endocrine

• Galactosemia
• Hereditary fructose intolerance
• Urea cycle defects
• Amino and organic acidemias
• Fatty acid oxidation disorders
• Metabolic acidosis
• Congenital adrenal hyperplasia/adrenal crisis

Toxic

• Lead poisoning
• Other toxins

Cardiac

• Heart failure
• Vascular ring
• Autonomic dysfunction

Other gastrointestinal disorders

• Achalasia
• Gastroparesis
• Gastroenteritis
• Peptic ulcer
• Eosinophilic esophagitis
• Food allergy/intolerance
• Inflammatory bowel disease
• Pancreatitis
• Appendicitis

Neurologic Infectious

• Sepsis/meningitis
• Urinary tract infection
• Upper/lower airway infection
• Otitis media
• Hepatitis

Others

• Pediatric condition falsification (PCF)/factitious disorder by proxy (FDP)
• Child neglect or abuse
• Self-induced vomiting
• Cyclic vomiting syndrome
• Rumination syndrome

Renal

• Obstructive uropathy
• Renal insufficiency