Annotations What are Signs Symptoms of Gastroesophageal Reflux (GER) in the Neonate

What are Signs / Symptoms of Gastroesophageal Reflux (GER) in the Neonate?

Gastroesophageal reflux (GER), which is the passage of gastric contents into the esophagus, is a common problem for newborn infants, as well as premature infants in the NICU setting. Since the signs, symptoms, treatments, and co-morbidities vary widely from the premature to the healthy term infant, we have focused this EBP review and algorithm on the premature infant in the NICU setting.

GER is very common in healthy infants, as gastric fluids reflux into the esophagus multiple times each day. It appears that GER is more common in healthy preterm infants, as compared to term infants. The pathogenesis of GER is multifactorial, with the most important etiology being the transient relaxation of the lower esophageal sphincter.

Controversy remains as to the severity of the disease and what, if any, treatment should be attempted for GER. Convincing studies are difficult to perform, which has further contributed to the variation in clinical practice. (Vandenplas et al, 2009)

In the NICU setting, apnea and bradycardia events are often thought to be caused by GER. Many studies in premature infants have been performed, which have failed to demonstrate a temporal relationship between GER and apnea. Hence, this EBM review and algorithm will not address this topic.

Epidemiology:

Premature infants and chronically ill infants appear prone to GE reflux and the complications that can arise due to GE reflux.

  • Gastroesophageal reflux in the neonate occurs in 22-85% of preterm infants (Tipnis & Tipnis, 2008).
  • Twenty five percent of very low birthweight infants are treated with acid suppression therapy at discharge (Tipnis & Tipnis, 2008).
  • In term infants, vomiting is a common symptom of gastroesophageal reflux and recurrent vomiting occurs in 50% of infants from 0-3 months, 67% in four month old infants and 5% in 10-12 month old infants (Bhatia & Parish, 2009).

Differential Diagnosis:

Gastrointestinal

  • Obstruction
  • Pyloric stenosis
  • Malrotation with intermittent volvulus
  • Intestinal duplication
  • Hirschsprung disease
  • Antral/duodenal web
  • Foreign body
  • Incarcerated hernia
  • Appendicitis

Other Gastrointestinal
Disorders

  • Achalasia
  • Gastroparesis
  • Gastroenteritis
  • Peptic ulcer
  • Eosinophilic esophagitis/gastroen-teritis
  • Food allergy
  • Inflammatory bowel disease
  • Pancreatitis

 Neurologic

  • Hydrocephalus
  • Subdural hematoma
  • Intracranial hemorrhage
  • Intracranial mass
  • Infant migraine
  • Chiari malformation

Infectious

  • Sepsis
  • Meningitis
  • Urinary tract infection
  • Pneumonia
  • Otitis media
  • Hepatitis

Metabolic/Endocrine

  • Galactosemia
  • Hereditary fructose intolerance
  • Urea cycle defects
  • Amino and organic acidemias
  • Congenital adrenal hyperplasia

Renal

  • Obstructive uropathy Renal insufficiency

Toxic

  • Lead
  • Iron
  • Vitamins A and D
  • Medications-ipecac, digoxin, theophylline, etc 

Cardiac

  • Congestive heart failure
  • Vascular ring

Others

  • Pediatric falsification disorder (Munchausen syndrome by proxy)
  • Child neglect or abuse
  • Self-induced vomiting
  • Cyclic vomiting syndrome
  • Autonomic dysfunction


These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

 

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