Diagnosis and Management of Infant GERD – PediaCast CME 113
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Show Notes
Description
Dr Sudarshan Jadcherla visits the studio as we consider gastroesophageal reflux in babies. We explore the difference between GER and GERD, including their symptoms, diagnosis, and management. We hope you can join us!
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Topic
Gastroesophageal Reflux Disease (GERD) in Babies
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Dr Sudarshan Jadcherla
Neonatologist and Principal Investigator
The Center for Perinatal Research
Nationwide Children’s Hospital
Learning Objectives
At the end of this activity, participants should be able to:
- Differentiate between physiologic GER and pathologic GERD in infants.
- Interpret instrumental testing methods, including pH-impedance, for GERD diagnosis.
- Evaluate treatment options for infant GERD, including nutritional, pharmacologic, and surgical approaches.
- Apply evidence-based strategies to manage GERD in both healthy and high-risk infants.
Links
Neonatology at Nationwide Children’s Hospital
Center for Perinatal Research at Nationwide Children’s
Slide Deck: Diagnosis and Management of Infant GERD
Pediatric GERD Clinical Practice Guidelines (NASPGHAN)
GER and GERD in Infants: What Are Your Treatment Strategies?
Esophageal pH-Impedance Monitoring in Children
The Role of Esophageal pH-Impedance Monitoring in Infants with BRUE
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No one in a position to control content has any relationships with ACCME-defined ineligible companies.
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Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Neonatology and the Center for Perinatal Research at Nationwide Children's Hospital.
[Music]
[Dr Mike Patrick]
Hello everyone and welcome once again to PediaCast CME. It is a pediatric podcast for healthcare providers.
This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. It's episode 113. We're calling this one diagnosis and management of infant GERD.
I want to welcome all of you to the program. So, we're talking about gastroesophageal reflux today. It is a common condition in infants.
However, distinguishing physiologic gastroesophageal reflux from pathologic gastroesophageal reflux disease can be challenging. However, it is an important distinction because the treatment for each of these conditions is quite different and the treatments that are available have consequences. Pretty much all of them have consequences of one sort or another.
And as we're walking parents through a shared decision-making and thinking about the risks and benefits of everything that we do and that we recommend, it is important to distinguish between sort of normal reflux that babies can have. And when does that then become a disease process where we really want to do something about it? And then what exactly do we do?
So today we are going to talk about the diagnostic challenges, different testing methods and evidence-based treatment strategies related to infant gastroesophageal reflux. We'll also discuss the role of acid suppression, feeding modifications, and when surgical options are considered. Of course, in our usual PediaCast CME fashion, we have a terrific guest joining us in the studio to help us sort through the science and determine best practices for clinical diagnosis and management of this common problem.
Our guest today is Dr. Sudarshan Jadcherla. He's a neonatologist and principal investigator with the Center for Perinatal Research at Nationwide Children's Hospital. Don't forget after listening to this episode, you can claim free category one CME and CE credit really easy to do.
Just head over to the show notes for this episode at pediacastcme.org. You'll find a link to the post-test in the show notes, follow that link to cloud CME, click on the materials tab taken past the post-test and the category one credit is yours. You will need an account at cloud CME, but those are free and they're really easy to sign up.
Just click on that link and it'll take you through the whole process. We offer credit to many pediatric professionals, including doctors, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the credits you need to fulfill your state's continuing medical education requirements.
Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pediacastcme.org. Also want to remind you, the information presented in every episode of our podcast is for general educational purposes only.
We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME terms of use agreement, which you can find at pediacastcme.org. So, let's take a quick break.
We'll get Dr. Sudarshan Jadcherla settled into the studio, and then we will be back to talk about gastroesophageal reflux disease in infants. It's coming up right after this.
[Music]
[Dr Mike Patrick]
Dr. Sudarshan Jadcherla is a neonatologist at Nationwide Children's Hospital and a professor of pediatrics at the Ohio State University College of Medicine. He also serves as director and principal investigator with the Innovative Infant Feeding Disorders Program, and he is the Nationwide Foundation Endowed Chair in Neonatal Research in the Center for Perinatal Research at the Abigail Wexner Research Institute at Nationwide Children's. Dr. Jadcherla has a passion for supporting infants and families impacted by gastroesophageal reflux disease. That is what he is here to talk about, the diagnosis and management of infant GERD.
Before we dive into our topic, let's pause and offer a warm PediaCast CME welcome to our guest, Dr. Sudarshan Jadcherla. Thank you so much for visiting the studio today.
[Dr Sudarshan Jadcherla]
Thank you very much for having me.
[Dr Mike Patrick]
Yeah, I'm really excited to talk about this because it's something that as pediatricians we see often and we often are also sort of scratching our heads at exactly how do we treat this, if at all. And so, this I think is going to be a great conversation. I also want to mention that we have a slide deck that you have put together.
It's in the show notes. So, folks, if you head over to pediacastcme.org and it's episode 113, we'll have a link. Now, because this is an audio podcast, we're really going to do our best to describe everything.
So, the slides are not mandatory, but I do think that they, that there'll be helpful, especially as we talk about the diagnosis of GERD and pH impedance and exactly how it works and what the results sort of look like. So, we will have those slides available for you again over in the show notes. So, as we start off with a slide one, we're going to talk about what exactly is gastroesophageal reflux versus gastroesophageal reflux disease.
So, GERD versus GERD. And then, you know, how do those show up both in the NICU, but also at home for young babies. So, let's start there with some definitions.
[Dr Sudarshan Jadcherla]
Thank you. Gastroesophageal reflux is a normal scenario. It happens very commonly.
It's very physiological and occurs quite often in babies who are eating well, gaining weight and have very negligible symptoms. On the other hand, gastroesophageal reflux disease, disease as the name implies is an abnormality or a pathological condition. And these infants have troublesome symptoms manifesting as poor feeding abilities, poor weight gain, esophagitis, emesis, growth disturbances, arching and irritability, sometimes airway and digestive symptoms, respiratory rhythm disturbances, bronchospasm in some situations, and very, very rarely problems related to chronic lung disease, such as aspiration and or recurrent pneumonia.
These have been reported very rarely. This constellation of symptoms in the context of troublesomeness along with reflux is considered GERD.
[Dr Mike Patrick]
So gastroesophageal reflux, when they just spit up after eating and they're not necessarily fussy, they're growing great. They're, I guess what you would call happy spitters. From a parent standpoint, it seems like the end of the world, and we want our baby to stop spitting up.
And so, you know, they go through and try different formulas and, and, you know, make changes and positioning and all of these things. But really it is normal and not something that we need to treat if there are no symptoms associated with it and the kid's growing. Okay.
Correct.
[Dr Sudarshan Jadcherla]
That's absolutely correct.
[Dr Mike Patrick]
And then we would call it GERD with the D on the end. So now we're adding this as a disease of gastroesophageal reflux. And now we've got kids who are not growing well because they're spitting up so much or they are, you know, screaming and upset and really seem to be uncomfortable.
Then my question becomes as, as babies get a little bit older at home and we start to see some colic, how do we distinguish between just GERD and colic versus gastroesophageal reflux disease?
[Dr Sudarshan Jadcherla]
Yes, it is a, it's a very difficult question to ascertain objectively. Again, going back to gastroesophageal reflux definition, these babies have persistence of symptoms throughout the day and in relation to feeding more so. And also, they have disturbances with growth and multi-organ disturbances sometimes.
And they have some antecedent factors as well. For example, the NICU infant who is, or premature infant, who has been discharged with these similar symptoms behaves differently, you see. And at the same time, colic, generally these babies are eating well and sometimes suddenly in the evening, most commonly, you know, they tend to have a spasmodic pain type of thing and then have severe irritability.
The best way to answer this question is by testing, instrumentation and testing, you know, to distinguish it is truly GERD or something else.
[Dr Mike Patrick]
Yeah. Yeah, absolutely. And so, we can start with the clinical history to sort of get an idea.
If you have a kiddo who's crying, who's a little older, you know, and they're not a brand newborn and they're, you know, a couple of months old and they're crying at nighttime, seem to be happy during the day and tolerating their feed's okay. And they're growing well, that's more colic. But if they're fussy all the time during the day, or you notice they're just fussy right after feeding, then we have a little bit more concern for GERD.
But again, especially if it's, if you're, it's that gray area, you know, like maybe sometimes they are more fussy at night, but they're also fussy during the day. Some it can be hard to tease out just with clinical history. And that's when testing can help us differentiate.
And we'll get more into testing in a minute. I do want to mention, and this is going to be on slide number two, there has been an evolution of definitions. And so, a lot of us who may have trained back in the early 2000s, for example, or earlier for some of us, the definitions have changed.
And so, we really do want to be up to date with the current definitions. So, can you talk a little bit about how the definition of gastroesophageal reflux disease has evolved over the last 20 years or so?
[Dr Sudarshan Jadcherla]
Absolutely. Simply put, gastroesophageal reflux is movement of any contents from the stomach into the esophagus. And therefore, the stomach contents are very variable.
Depends upon the time of the day, depends on the feeding cycle, you know, and what the baby ate and so on. For example, the stomach contents can be acidic before we eat, but after we eat, the food neutralizes the acid and therefore becomes less acidic. Then after a while, the partially digested food is there, then the composition also is different.
It may be from liquid; it may change to mixed. In other words, a little bit of solid, a little bit of liquid, a little bit of air and all that is present. Therefore, anything that moves from the stomach into the esophagus backwards can be considered reflux.
And that when the gastroesophageal junction gives way during that time and that meaning gastroesophageal junction is more relaxed and then therefore the material comes up into the esophagus. And that's when the symptoms start, which can be problematic. Now this is the physiology of the reflux, and the symptoms can be due to stimulation of the receptors and the nerves in the esophagus.
And therefore, the motor components can be locally, regionally or remotely. For example, if the clearance happens without any problem, then the material that comes up goes down and therefore is of no consequence. This happens quite often and therefore the babies are asymptomatic.
On the other hand, if the material comes up or if it's more acidic or if it stays in the esophagus for too long a time, it causes irritation in the esophageal mucosa. And therefore, the babies tend to be arching more or coughing or having some throat clearing spells, you know, frequent repetitive swallowing. Some of these things can happen and some of this can be problematic.
Okay. So, this is the real context of the physiology perspective. But over the years in late nineties and early two thousands, you know, providers thought that the reflux can be a problem similar to what is seen in the adults.
But an infant is not a small adult, and a NICU infant is very unique because reflux depends upon gestational maturation and postnatal maturation and whatever the other conditions the baby has during the NICU stag. Now, with all that said, the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition came up with a guideline developed by an expert panel. And the first guidelines came in 2001.
Essentially, they defined the reflux as movement of gastric contents in esophagus and GERD as complications from this. And this definition got revised in 2009 and passage of same gastric contents into the esophagus with or without vomiting or regurgitation. And again, the presence of troublesome symptoms or complications of GERD.
Then this definition got revised even further in 2018 and the definition remains the same, but here they added vomiting as an additional component. And in the disease per se, the troublesomeness and symptoms that affect daily functioning and or complications. Then they added a new terminology called refractory GERD, which means this condition is not manageable after eight weeks of therapy.
So, in other words, a chronic condition. Now none of these guidelines are applicable for high-risk infants such as NICU infants. You know, this is intended for children per se, but when you are talking about the troublesome symptoms and so on, for a mother of a NICU infant, every symptom appears to be troublesome.
[Dr Mike Patrick]
Yeah. Yeah, absolutely. And when you mentioned that it affects daily functioning, it's a little hard to determine what is the daily functioning of an infant.
And as you said, it, you know, it's more likely to interfere with the daily functioning of the parent than of the infant, but that doesn't mean that we need to treat it just because the parent doesn't like it.
[Dr Sudarshan Jadcherla]
So, in such a situation, oftentimes education is very important, and anticipatory guidance is very important and daily functioning for a NICU infant is eating, sleeping and normal breathing.
[Dr Mike Patrick]
Yeah. Yeah. I do want to pay attention to something that you said, and that is that not all reflux is acidic and that even though there's a lot of stomach acid present, which of course is acidic, after they eat, the formula or the breast milk is going to dilute the acid and make it, bring it more toward neutral.
And so, when we see these babies who are spitting up, most of the time it's right after they've eaten and often have a full belly. In fact, overfeeding may be one of the components of what causes this, but it doesn't necessarily have to be acidic. And so, there was a time when like all of these babies, if they were spitting up and they even looked at you funny, like, oh, they might be a little, have a little discomfort associated with this.
Then we're going to put them on acid suppression medicine, but we're really getting away from that and recognizing that just because they're spitting up after they eat does not mean that what they are spitting up is acidic or that is the cause of their symptoms. Is that, is that correct?
[Dr Sudarshan Jadcherla]
Absolutely.
[Dr Mike Patrick]
Okay. So then how do we go about diagnosing GERD? How can we tell whether this really is an acid problem that we may want to, to treat versus something that we're just going to watch and wait, especially if the kid's growing well, not choking on, on the vomit, that sort of thing.
[Dr Sudarshan Jadcherla]
Yes. If the, if the, if the baby is gaining weight and eating well, sleeping well and has no troublesome symptoms, as I explained earlier, and simply anticipated guidance and, you know, watching closely for growth and functioning would be adequate and monitoring for any changes in this kind of scenario. In other words, we are giving the natural healing a chance in the sense that sometimes in nutrition and the nutrients themselves can modify health and well-being.
On the other hand, the symptoms are troublesome and persistent and bothering and so much so that the daily function in the growth and sleep and activities are getting lesser. Then such a situation requires testing. Otherwise, we are managing based on assumptions.
[Dr Mike Patrick]
Yeah. Yeah.
[Dr Sudarshan Jadcherla]
So, there are consequences of treating on assumptions because, because these symptoms are very nonspecific. In other words, our research has shown that using instrumentation and testing using 24-hour pH impedance methods, wherein we are able to examine the degree of esophageal acid exposure and how high it has gone up. And if we correlate with the symptoms during that time, during this 24-hour period in relation to the feeding cycle, then we can actually understand is the reflux truly causing the symptom?
Is it truly associated? And if so, how bad it is and what is, what caused reflux and what cleared the reflux or the symptom? Some of these kinds of things would be very helpful.
So, this, this methodology helps us to clarify the chemical composition of the reflux, meaning is it acidic, weakly acidic or non-acidic, you know, and it also helps us. Is it liquid or gas? Because sometimes only gas reflux can be there.
If only gas reflux is there, really efficient burping may be sufficient. Taking time to burp the baby may be sufficient because that relieves the symptoms. If it's mixed, then both, both entities will be helpful.
If it's, if it's very much weakly acidic or alkaline, really those babies don't need any therapies and watching time and modifying the feeding techniques and the nutrition, it may be helpful.
[Dr Mike Patrick]
Yeah. Yeah. So, lots of, lots of reassurance in that case.
And I will quote one of my mentors from my residency days who used to say to parents, this is not a baby problem, it's a laundry problem and it will go away. And we understand, you know, you do want to have empathy and understand that, yeah, this is frustrating. It's not fun cleaning this up, but your baby is growing well.
Their physical examination is normal. You know, they're not choking on it and having color change and such. And so, reassurance is really the way to go when you've done the testing and the pH is, is not an issue in what your child is, is spitting up.
So then how do we order this testing? Is this something that primary care provider can order from their office?
[Dr Sudarshan Jadcherla]
So again, we perform these procedures in the hospital setting because this is a 24-hour study and therefore we have a patient care assistant at the bedside or the parent, you know, to document the symptoms in real time. And therefore, we are able to do this in the NICU setting, for example, or in our feeding disorders program setting, you know, for a 24-hour period. Now, and the physicians order, the pediatricians order the test, and then therefore we are able to evaluate using the sticks.
Now in the outpatient setting, a referral to the GI would be advisable if GER is truly a problem because sometimes there are many other conditions that can masquerade as GER and we want to make sure that it is, we are dealing with the right problem.
[Dr Mike Patrick]
Yeah, yeah, absolutely. So, if we want this sort of testing done, our best bet, especially this is after a kid has been home, obviously if they're in the NICU, it's a different situation because they're there and you can, you can do that. But if we have a pediatrician that wants this test done, referral to GI is the sort of the gateway to get something like this done.
Let's, let's talk about the test itself. So, the pH impedance monitoring, tell us what does that look like and how is it accomplished and what are the results look like?
[Dr Sudarshan Jadcherla]
Sure. This is on the slide number three, I think. So basically, it is a probe that has got an acid sensor and also the liquid sensor as well.
So, this probe is almost like a six French caliber. We place this into the esophagus and then after calibration and connecting to the system, this is capable of recording any esophageal acid exposure of any material from for that matter, whether acidic material, weakly acidic or non-acidic, because the pH sensor can sense the degree of variation of the pH. That's first thing.
That alone may not be adequate sometimes to treat because you know, everybody refluxes and reflux can be very common as I said earlier, but how high it has gone up, you know, into the esophageal column is equally important. Therefore, the impedance sensors sense that because if the reflux is going all the way down to the pharynx and causing problems like this, troublesome symptoms, whether area symptoms or digestive symptoms or sleep disturbances, and that can be problematic for babies to function normally or children to function normally. And therefore, this study would help us clarify that over a 24-hour period during which time we exclude the feeding periods because a lot of things happened at the feeding time.
And if the parent or the nurse or the parent or someone attendant, can document the symptoms as they're happening in real time, we have the ability to correlate that reflux with the symptom and associations. Then that will help us to understand, you know, is it a true, true correlation? Is reflux causing the symptom or symptom happening from something else?
[Dr Mike Patrick]
Yeah.
[Dr Sudarshan Jadcherla]
Yeah. And that is, that is very, very critical for the diagnosis as well as for ascertaining the mechanisms. And then we can develop targeted therapies for that matter.
[Dr Mike Patrick]
So, the, the probe with the pH sensor on the probe, are there multiple ones on the catheter? So, so that's how you're able to determine the pH at particular levels.
[Dr Sudarshan Jadcherla]
So, there's only one pH sensor, but multiple impedance sensors.
[Dr Mike Patrick]
Okay. And so, what, what's the difference between the pH sensor and the impedance sensor?
[Dr Sudarshan Jadcherla]
Certainly. The pH sensors sense the degree of acid exposure. It records the acidity of that liquid, whereas the impedance sensor senses the fluidity of the material and how high it has gone up.
Meaning, is it liquid? Because liquid has got a different pattern in the signature pattern. If it's gas, it has got a different pattern because it depends upon the resistance offered.
You know, if it's mixed, a combination of these things are there.
[Dr Mike Patrick]
So, the impedance sensor is up high, and the pH sensor is down low. And so now the liquid that's coming up from the stomach into the lower esophagus, we're testing the pH of it. And then the impedance sensor is letting us know, does that liquid make it all the way up to the top or is it just gas or is it more solid, I guess, food?
Okay. All right. So, this is important because many of us are familiar with the pH probe, which I think was sort of the older way of diagnosing GERD where we would just have the pH probe.
But just because at the lower esophagus, there is some acid there does not necessarily mean that there's a problem. Correct?
[Dr Sudarshan Jadcherla]
That's correct. In slide number four and five, I've shown examples of the liquid reflux, the acidic reflux, the gas reflux, and the combinations of it.
[Dr Mike Patrick]
Okay. So, I would recommend folks check out the slide deck and it just gives you a better idea of what this looks like in terms of placement and then the reporting as well, which looks complicated. So, as I look at the report, it's almost like a neurologist reading an EEG.
So, but this makes sense to you, correct? As you're looking at it and reading the results.
[Dr Sudarshan Jadcherla]
Absolutely.
[Dr Mike Patrick]
So, this is not something that I don't think a primary care doctor is going to get the tracings and then try to analyze this. Just like when you send someone for an x-ray, the radiologist reads the film, gives you the report. In this case, the gastroenterologist is going to give us a report back if they're the ones that we have sent them to and have done this.
And then in the NICU, you may be the one taking a look at the results and deciding what to do with these kiddos.
[Dr Sudarshan Jadcherla]
Yes.
[Dr Mike Patrick]
Okay. So again, I would recommend that folks take a look at this. It is again, and you know, maybe it's just because I have not done primary care practice for a few years that maybe it's just me or maybe there's others out in the audience that didn't necessarily realize that there was a difference between just a simple pH probe and then the pH impedance test, which is going to give us a lot more information and help us decide if the reflex is really causing symptoms or not. And as you said, this is a 24-hour test and generally requires admission to the hospital to get it done. Let's talk a little bit about the cause of gastroesophageal reflux and gastroesophageal reflux disease.
Why is this something that frequently occurs in babies and young infants?
[Dr Sudarshan Jadcherla]
Absolutely. So, babies have small structures. In other words, the esophagus is small relative to the size of the stomach, and the gastroesophageal junction is also weaker to start with because these muscles are still developing and not completely developed yet.
And similarly, the neural innervation is there, but neural innervation is not completely functional as well. And babies have to eat a lot of volume per kilo when you look for their growth because their metabolism is greatest and the requirements are greatest because the neonate, particularly the high-risk infant is in a very rapidly accelerating growth state, right? So therefore, the requirements are more.
So, in slide number eight, I have shown the potential mechanisms why these problems can happen. And this is shown using manometry methodology, wherein this beautiful color plots that you see mechanisms of reflux in this slide number eight. What I'm trying to show over here is that manometry is a very advanced technique has a high-resolution impedance manometry wherein we are able to analyze the topography plots of the pharynx, upper esophageal sphincter, esophageal body, lower esophageal sphincter and stomach.
And these are all the important participants and contributors for the reflux and or clearance mechanisms and or symptom generating mechanisms because when the exposure happens to the esophagus, all of these are participating. The mucous membrane is participating. The nerves are participating.
The muscles are participating and therefore is very, very important means to understand the mechanism. Now the most common mechanism is shown in a figure eight, a slide eight figure eight. What it means is that transiently the lower esophageal sphincter relaxes completely and therefore there's a pressure gradient which is usually greater in the stomach than in the esophagus and therefore the material goes up.
And this is the most common mechanism, and it is a reflex causing reflux, you know, is a neurological reflex. In other words, the stomach distends, the fundus distends and therefore triggers this reflux. And interestingly, the clearance mechanisms are also operational because it stimulates the muscles of the esophagus and therefore it goes down and therefore if it happens normally the babies do not have symptoms, but if it goes up and then cause other symptoms and arching, irritability, throat clearing mechanisms, coughing, you know, choking, these kinds of spells can happen.
Now in the same slide I've shown some other less common mechanisms such as hypotonic lower esophageal sphincter. You know where the muscle is there, but just as the rest of the body muscles, the muscles are weak. And oftentimes, oftentimes the best way to manage this is efficient nutrition, advancing the nutrients or modifying the feeding methods.
This itself may be very helpful because ultimately these muscles need to become stronger. The baby needs to put on some muscles in the esophagus, in the lower esophageal sphincter and therefore the tone improves and the abdominal strain, you know, can increase the gastric pressure and therefore reflux can happen. And sometimes excessive swallowing can also make the sphincter relax too much and therefore reflux can also happen.
These are some of the common potential mechanisms, but most of these mechanisms get better with maturation. Another important thing that is very, very unique to the infants is that so gastroesophageal junction, part of it is thoracic, part of it is abdominal, that is below the diaphragm. So that part of the lower esophageal sphincter below the diaphragm is not developed in newborns.
This develops as the baby puts on weight with efficient nutrition over a period of time. And therefore, with adequate nutrition, monitoring growth, the sphincter becomes stronger and therefore over a period of time, once the sphincter becomes stronger, reflux disappears. And that is a common mechanism why with growth and age and appropriate esophageal length, length is equally very important, and reflux can get better over a period of time.
[Dr Mike Patrick]
Yeah. As that sphincter matures and that's a normal thing. Some kids it matures very quickly, and, in some kids, it takes several months to completely mature.
And so, this manometry impedance testing helps us determine sort of the exact cause in a particular kid. I would imagine that you don't always need to know that, especially if it's sort of run of the mill reflux or they do have some significant symptoms, but you do some interventions which we're going to talk about, and things seem to get better. You might not really need to do this test on everyone, but it is interesting.
And if we did want to know more about the specific mechanism in a particular kiddo, because maybe it's an outlier and the reflux is not behaving like we normally would expect it to. This is something that could be done to give you a little bit more and different information.
[Dr Sudarshan Jadcherla]
Absolutely. Most of the studies that we do, about 40% turn out to be normal. And therefore, even if you have the symptoms who these are the children or infants, high risk infants who are suspect for GERD, even upon studying they do not have GERD.
[Dr Mike Patrick]
Yes.
[Dr Sudarshan Jadcherla]
About 40%. And therefore, among the remaining 60% of these high-risk infants, you know, some of them are intermediate or not severe reflux. And therefore, simply nutrition and modification of the feeding methods or strategies, paying attention to advanced nutrition, you know, micronutrition, macronutrition alone may be sufficient sometimes.
And therefore, not everybody requires these specialized studies. These specialized studies are intended only if we want to rule out GERD complications and potential need for surgeries. If any, you know, those are some of the situations that we may need to perform.
[Dr Mike Patrick]
So, we've talked about pH impedance. We've talked about manometry. Is there a role for fluoroscopy?
So, like the upper GI, where we have a kiddo swallow something that has contrast material in it, and then we are able to sort of watch in real time if stuff comes back up and how far up it comes. Is that something that's still used?
[Dr Sudarshan Jadcherla]
So only when we suspect some structural problems, GI structural problems, then upper GI fluoroscopy studies may be helpful. Now one has to understand that there's a risk of radiation exposure with upper GI radiological studies, fluoroscopy studies, and so on, even though the amount of time they use is minimal, but still exposure is exposure. And only when we are strongly suspecting structural problems, such as malrotation of the small bowel or congenital upper GI anomalies like hiatal hernia or diaphragmatic defects, sliding hernias and so on, or pyloric stenosis, although it can be identified by using ultrasound also, but sometimes upper GI may be necessary.
And in high-risk infants who are followed by pediatricians, again, possibilities for scarring in the bowel or strictures can be a concern as well. So, some of these kinds of things, if there are structural problems there, then upper GI can help not only with that, but also assessing the transit and how quickly it has gone or how slowly it has gone as well. But if we see a reflux on upper GI, that can be normal in the sense that the material is going under pressure very quickly and therefore reflux can happen.
That should not be considered as GERD.
[Dr Mike Patrick]
Because we don't know if that by looking at contrast on in real time with the fluoroscopy, we don't know if it's acidic or not acidic. We just know it's there. And so, it's not quite as helpful for GERD.
However, if you have a kiddo who's vomiting and losing weight, especially in young infants, if there's bile green in the vomitus, there's blood in the vomitus, then these are reasons that we may want to really examine the structures. And so, the appropriate test for that is going to be the upper GI. And then how does the upper GI different from a video fluoroscopy swallow study?
[Dr Sudarshan Jadcherla]
Yes. Upper GI fluoroscopy is they give the barium by mouth in those children or babies who can swallow and take the pictures. Whereas in those children who cannot swallow, then the contrast is given by the NG tube, you know, for upper GI because it's the upper gastrointestinal fluoroscopy series of x-rays.
Whereas in the video swallow study, whether these babies can swallow properly or not, they're assessing for swallowing problems, if any, and then contrast is given by mouth depending upon their limitations. And they're examining the movement of the contrast as it goes from the mouth after being extracted from the bottle into the upper part of the esophagus. And therefore, they're mainly assessing the oral and pharyngeal phases mainly, or upper esophageal phases.
[Dr Mike Patrick]
So, so in the upper GI we're putting the barium into the stomach and seeing what happens. And with the swallow study we're having them suck and drink the barium and watching it go down and rather than evaluating it coming back up, although you might see that.
[Dr Sudarshan Jadcherla]
Yes. The evaluation of the esophagus is equally very important. And therefore, in those children who can swallow, giving contrast by mouth during the upper GI would be very helpful because we get the benefit of evaluating the esophagus.
[Dr Mike Patrick]
So, I think the take home here for primary care providers, which is our main audience of this podcast, is that when you are suspecting GERD and so we're saying now, Hey, it's not just physiologic reflex. We think there's a disease process going on, that there's significant symptoms. Our best bet is really to refer to gastroenterology because they're going to be able to decide which of these tests and which combination of things is going to be best in terms of the evaluation.
Having said that, it's really important that all of us understand, especially in young infants, if they have poor weight gain, if they are having color change when they're choking on it, if there is bile in their vomit, these are not things to just refer to GI and, Oh yeah, we'll get them in in a month. I mean, these can be medical emergencies. And so, you're going to want quicker evaluation.
And whether that's, if GI can't get them in for a while, then you may need to send them to an emergency department to at least get a workup going, especially with color change and bilious vomiting, blood in the vomit, that sort of thing. So, I just wanted to make that real clear for folks out there. And by the way, slides eight and nine talk or, and 10 really go through the upper GI and the video fluoroscopy swallow study.
So, folks can, can take a look in a little bit more detail with those things. Let's talk about symptoms. When we're, when we're thinking about GERD with the D, what sort of symptoms are we looking for that would clue us in that maybe this is caused from their reflux?
[Dr Sudarshan Jadcherla]
Absolutely. It's a great question. In the course of the retrograde movement of the material from the stomach, the, the physical or chemical components of the refluxate stimulates different regions or layers of esophageal musculature and evokes several reflexes in the pharynx or the esophageal column, or it can also stimulate the airway as a reflex.
The material is not going to the airway, but esophageal stimulation can cause airway reflexes. Very interesting. Our research has shown this.
So, these are called airway and digestive reflexes, which, which is basically there's a crosstalk between the organs. You stimulate the esophagus, distend it, whether chemically or distension, airway responds, you see. And therefore, the symptoms can be of digestive origin, like frequent swallowing, you know, arching to swallow.
Or, or airway symptoms like sneezing and coughing. Sometime when, when all of these happen, there can be transient, transient changes in vital signs, you know, slow, you know, slow and slow breathing or rapid breathing or, you know, those kinds of symptoms can happen. And sometimes if there is a change in the pressure in the stomach, then forceful emesis also can happen after a child coughs a lot.
Then what happened? The stomach pressure increases and therefore emesis also can happen. So, these are, these are considered troublesome symptoms.
Now, the best way to analyze are the symptoms really from GERD or something else. This is where a specialty consultation needs to happen. You know, in the case of a high-risk infant, our program gets consulted in the case of a bigger child, we do not want to miss the differential diagnosis.
It could be something else, you know, therefore, therefore like food allergies, esophagitis or scarring, strictures, congenital anomalies that may not have been recognized. Now those are, those are some of the other issues that can be seen in later part of the childhood or early childhood. And so those can do, therefore, a specialty referral, maybe a testing may be necessary.
[Dr Mike Patrick]
Yeah. And so, we don't want to just look for the spitting up and the fussiness and of course weight, weight gain. We also want to be thinking about the airway and coughing, sneezing, wheezing, all sorts of things that can happen in the airway that could be from reflux.
But as you said, it could also be from a pulmonary problem. And so bigger workup, you know, may be needed and getting the specialists involved, especially GI pulmonary is going to be important. So then how do we decide if we're going to treat GERD and what are the main treatments that we should use if we determine that that is what's happening and that it's not just physiologic reflux?
[Dr Sudarshan Jadcherla]
Absolutely. So always dietary and nutrition management, feeding method modifications should be the first line of approach. Now, in the case of infants, like, for example, NICU infants, for example, you know, we are focusing more on personalizing the nutrition alone and improving the growth and length of the esophagus and appropriateness of the sphincters alone may be sufficient.
And in the case of a little older child or an older infant or a child, you know, again, paying attention to feeding methods, frequent feeding as opposed to large volumes at a small period of time, you know, some of those kinds of things can also factor in. Then oftentimes lifestyle changes such as feeding and positions, breastfeeding, encouraging breastfeeding, positions and so on, very rarely formula changes may be necessary. Again, if such a thing is considered, then food allergies may need to be thought about as well, you see.
And oftentimes cutting down the feeding volume and ensuring frequent burping and comforting the infant may be sufficient. Very rarely thickeners may be needed. In other words, added rice cereal, but everything comes with consequences.
That is very important to know. Then the positioning, holding the baby for some time after eating, burping is very important. The car seat positions should be avoided because the angulation at the gastroesophageal junction can be modified, and therefore babies will also drop their head down, you know, and therefore breathing can be a factor.
Therefore, one has to be very careful about those kinds of positions. Ultimately, when the material comes up, the baby should be able to swallow and breathe normally. That should be the focus.
Now, if we know that it is acidic and indeed associated with symptoms and in the presence of troublesome symptoms, pharmacological management may be necessary. And how long, how best to treat, how long to treat exactly is not known. And in other words, a short course of therapy you know, two weeks to four weeks should help.
If that doesn't help, then that is not the right way to manage for long. Therefore, prolonged usage of these medications is not indicated because prolonged use of acid suppressive medications comes with side effects, consequences, long-term repercussions. Similarly, with added rice formulas or thickened formulas as well, you know, there can be problems with macronutrient and micronutrient absorption.
Changes in the bowel flora, you know, microbiome, so many factors are there. And inadequate nutrition can result in failure to thrive. When I say failure to thrive, the length may not be optimal, that we want the length to grow well so that the symptoms develop very well.
You see, therefore, there are some unknown factors in here, particularly when we are examining the high-risk infants for that matter, because simple attention to advancing the nutrition, nutrients, personalizing the nutrition, that's what I mean, personalizing nutrition, examining what exactly the child is taking and careful attention to volume, the calories and protein content with micronutrient, macronutrient content of the nutrition, and modifying that alone may be sufficient, as I said, it improves the growth, improves healing. Now, when required, acid suppression may be necessary, but again, which of these best approaches is not yet known. We are currently doing a randomized controlled trial of high-risk and high-risk infants who are at risk for any of these therapies, you know, comparing personalized nutrition strategies during natural maturation versus acid suppressive therapy versus added rice formulas, which of these becomes the best therapy, we don't know.
But one of these may help.
[Dr Mike Patrick]
And this is where it's really going to be personalized and shared decision making with the family. We do want to let them know what the negative consequences of anything that we do could be. So, for example, with the thickening, yeah, they spit up a lot less, but they also gain a lot of weight.
And we know that babies that gain a lot of weight turn into toddlers who are heavy. And we know that that can cause problems through a lifetime that may be started with thickening cereal, thickening with cereal, the formula. And so, we have to be careful about what we're doing.
And then the whole microbiome is we're discovering more and more about the importance of that. And you know, our bodies have stomach acid for a reason. And so, when we disrupt that stomach acid, and we didn't really need to, then we're creating other issues down the road.
So, we have to really, as you said, think about the consequences of everything that we're doing, the smaller volume and more frequent feedings. I find that that is such an easy thing to implement, but parents get really concerned. You know, I'll have a baby come in the ER and, you know, they're taking four ounces at a time, and you take that four-ounce bottle and hold it up to the kid's belly.
And you're like this, this, it's not going to fit because this is a small baby. And so, you know, doing two to three ounces every two to three hours instead of four ounces every four hours may be helpful for those kids in terms of just spreading out the volume over more time. So, lots to think about.
These are things that pediatricians think about pretty much every day, because as we think about the epidemiology of gastroesophageal reflux, this is a pretty common condition, right? This is something that we're going to see a lot of. Can you talk a little bit about that?
That's on slide 14, by the way, where we talk a little bit about the epidemiology of gastroesophageal reflux disease.
[Dr Sudarshan Jadcherla]
Sure. This slide pertinent to the prevalence of GERD is about 10 percent of babies, infants can have GERD. I'm talking about this is based on the physicians' worrisomeness of the troublesome symptoms thought to be due to GERD.
And in a study that we did for over 33 freestanding children's hospitals in the United States, you know, involving almost 18,000 babies, what we noted was that there is a 13-fold variation in the GERD diagnosis. Now, if this happens in the hospital setting, I'm sure such variation is there in the outpatient pediatric practice setting. And such a study has not been done, to my knowledge, in the office-based practice setting.
And therefore, common thought process is that it's GERD, and therefore, you know, a provider of a treat. But there may be other reasons behind it. It could be simply normal with expectant management and anticipated guidance and paying attention to lifestyle.
Things may get better, but only when problems persist, that's when they may need to be evaluated in a systematic manner. So, the data I have is from the NICU, per se. Even a thought process of GERD can increase the length of hospital stay by a month, costing an additional $70,000.
This is 10 years back data now. So, I'm sure with inflation, you can add much more. At the same time, I also want to bring out another important point, is that certain surgical approaches are also being considered across the globe, particularly gastrostomy and fundoplications, basically narrowing down the gastroesophageal junction during gastrostomy for children who have the problem with reflux or poor oral feeding and or other consequences.
So not everyone does the testing like how I mentioned earlier. There are some programs, you know, that may not have the capability. Therefore, one has to make a good diagnosis before changing the structural integrity of the gastroesophageal junction.
[Dr Mike Patrick]
Yeah, so important because these are not, well, especially as we talk about fundoplication, this is not an easy operation. Like, this is major surgery, and you are altering the anatomy for a lifetime at that point. And so, it is really important to think about the risks and the benefits and shared decision making and all of those things.
Gastrostomy, you know, to put in a GI tube in and doing feedings a little lower is not quite as invasive as something like a fundoplication. But again, anytime that we are having surgical procedures, there's risks involved. And sometimes that's necessary.
You know, if a kiddo is having severe complications and aspirating and getting pneumonias and not growing, and I mean, there is a place for it, but hopefully we try to avoid that whenever possible, right?
[Dr Sudarshan Jadcherla]
Absolutely.
[Dr Mike Patrick]
Yeah. All right. Well, this has been a really fantastic conversation.
And I think, again, the key takeaway is that if you aren't sure, a referral to GI is going to be a great idea so that they can have a better evaluation, figure out exactly what's going on. And that may put a lot of parents' minds at ease a little bit. The other thing too, I think, is just taking the time to explain to parents what's happening.
And in our busy office practices today where we're trying to see so many people, and you know, we feel an obligation to our communities to see as many people as we can so that they, you know, don't end up in an emergency room and they come to our office. But at the same time, we need to, you know, to sit down and it may take longer to explain the physiology of reflux, why it happens. And that is improving the health literacy of parents.
And then they're more likely to say, oh yeah, this is just a laundry problem as opposed to my doctor doesn't care that my child is spitting up. And to get from my doctor doesn't care to, oh, I understand what's happening, doesn't magically happen. Like we have to sit down and have relationships with people.
And even if it means, you know, drawing on the exam table paper, you know, what the, what the sphincter looks like and, you know, how it's loose. And this, when the stomach squeezes, the stuff is going to go in whichever direction the sphincter opens, whether that's at the bottom or the top of the stomach, the stomach just squeezes. And that's all that it can do.
And it's really those sphincters that determine whether the food goes up or down. And always when it comes up, it seems like it's more than it really is. Like if you take a little shot glass of water and dump it on your kitchen counter, it looks like a lot of fluid, not just a little shot glass.
And so how well kids are growing is a pretty good indication of how much is staying down versus how much is coming up. Just little tidbits from my own experience in primary care. So, thank you so much for stopping by and explaining all these things to us.
Tell us a little bit more about neonatology at Nationwide Children's Hospital. We have really one of the largest neonatal programs in the country and lots and lots of research in our perinatal research center. So, tell us a little bit more about neonatology at Nationwide Children's.
[Dr Sudarshan Jadcherla]
Absolutely. As I said, this is the largest neonatal network in the United States. And we cater for a very high-risk population of NICU infants, not only from within Ohio, but from several other states as well, other countries too in some situations.
We have specialty programs with small baby program, caring for tiny infant. And we have a comprehensive center for bronchopulmonary dysplasia or BPD program for chronic lung disease. And then our own program is innovative program for infant feeding disorders, as well as a neonatal infant feeding disorders program.
We have a research program and a clinical program wherein we do research and apply the new knowledge to the babies in real time in hopes of improving the outcomes. In other words, this translational research is happening now, as opposed to later on, because we are seeing a problem in the baby and applying that knowledge. Yeah.
So, this is one of the unique programs in the world, actually, that is applying this kind of action medical research model, wherein research is showing direct benefits to the babies. And one of the strategy plans of the Nationwide Children's Hospital and Neonatology Service is that translating research to clinical practice at a record pace. And that's happening in our division.
[Dr Mike Patrick]
That's really exciting. And it is so important that the research arm and the clinical arms talk to one another so that as we have new discoveries, we're implementing them appropriately. So, I think that's so important and such a unique aspect of our program.
For folks who want to learn more about neonatology and the Center for Perinatal Research at Nationwide Children's, we will have links in the show notes over at pediacastcme.org. It's episode 113. We'll also have that slide deck that we have been referring to.
So, you can download that and take a look. We also have some journal articles for you from NASFGAN. We have the Pediatric GERD Clinical Practice Guidelines.
That's going to be important to take a peek at. GERD versus GERD in infants. What are your treatment strategies?
That's from Pediatric Nutrition, Continuing Education for Clinicians. And then esophageal pH impedance monitoring in children from the Digestive and Liver Disease Journal. And finally, the role of esophageal pH impedance monitoring in infants with BRUI, or those Brief Resolved Unexplained Events, when we have kids with color change and we're not exactly sure why.
And especially if that's happening repeatedly, then the pH impedance monitoring may be helpful to get the diagnosis of GERD. In that case, I would think acid suppression may be worth, you know, then you are thinking about that a little bit more when kids are having airway problems, especially when they're young infants. So, we'll have, again, that's from Pediatric Gastroenterology, Hepatology, and Nutrition Journal.
So be sure to check that out as well. So, lots of resources for you over in the show notes. Again, episode 113 over at pediacastcme.org.
So once again, Dr. Sudarshan Jadcherla, Neonatologist and Principal Investigator with the Center for Perinatal Research at Nationwide Children's Hospital. Thank you so much for stopping by today.
[Dr Sudarshan Jadcherla]
Thank you for having me. Thank you very much.
[Music]
[Dr Mike Patrick]
We are back with just enough time to say thanks once again, to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Sudarshan Jadcherla, Neonatologist and Principal Investigator with the Center for Perinatal Research at Nationwide Children's Hospital. Don't forget, you can find our podcast wherever podcasts are found, or the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pediacastcme.org. You'll find our entire archive of past programs there, all 113 episodes.
Show notes for each of those episodes are CME information, our terms of use agreement, and the handy contact page if you would like to suggest a future topic for the program. By the way, the CME credit is good for three years after the release of this podcast. We do keep the episodes up longer than that, but just as a reminder, you do have to claim the CME credit within the first three years of a particular episode being out and about.
It's really easy to claim your free Category 1 CME credit, just head over to the show notes for this episode at pediacastcme.org. You'll find a link to the post-test in the show notes, follow that link to Cloud CME, click on the materials tab, take and pass the post-test, and the Category 1 credit is yours. Super easy, right?
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[Music]
