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Arvind Srinath, MD, discusses gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). It’s the first of a three part series about gastrointestinal issues that impact children with Down syndrome.
Dr. Vellody: Hello everyone and welcome back for another Down Syndrome Center podcast. As always, I am your host, Dr. Kishore Vellody. In the next three podcasts, we will be discussing gastrointestinal issues that impact children with Down syndrome. With us today, and hopefully for the next few podcasts, is Dr. Arvind Srinath. Hey Arvind! Thanks for being here with us today. Before we get started, could you fill us in a little about your medical background?
Dr. Srinath: Thank you Dr. Vellody for this opportunity. I’m glad to be here. I grew up in Connecticut and ended up going to college in Baltimore at John’s Hopkins. I ended up doing medical school training over at the University of Pittsburgh, then went back to Baltimore to Hopkins to do my residency in pediatrics before coming back to Pittsburgh again for my fellowship in pediatric gastroenterology.
Dr. Vellody: Well we are all really glad that you did eventually bounce back to Pittsburgh to join us here at the faculty of Children’s Hospital. But before we get too far into this, we should probably start with the basics. Can you tell us what gastroesophageal reflux is and how it is defined?
Dr. Srinath: Absolutely. To answer that question I’d first like to distinguish between two entities, the first of which is called gastroesophageal reflux, or GER, and gastroesophageal reflux disease, or GERD. The first of those, GER, is passing of the stomach contents into the esophagus or food pipe with or without regurgitation or vomiting. It is a normal, or physiologic, process and can occur several times per day in healthy infants, children and adults. In contrast, gastroesophageal reflux disease, or GERD, is present when the reflux of stomach contents causes troublesome symptoms or complications. Now these symptoms are dependent on the child’s age and developmental level and can include, for example in infants, vomiting in the setting of a distressed child after feeds – so not necessarily your “happy spitter” who has gastroesophageal Reflux or GER – and potentially fussiness or irritability after feeds. In older children, your more typical symptoms prevail, namely heartburn, regurgitation, vomiting, and potentially trouble swallowing.
Dr. Vellody: Well let me just summarize for our listeners what I think you’re saying. You are saying that are two very different diagnoses out there when it comes to reflux. The most common one is gastroesophageal reflux, or GER, where there is some spitting up or vomiting but it’s not really causing any serious problems to the child. And then there is gastroesophageal reflux disease, or GERD, which has some potential complications. Do I have that right?
Dr. Srinath: Absolutely, you are exactly correct.
Dr. Vellody: Ok great! So now that we know what gastroesophageal reflux and what gastroesophageal reflux disease are, can you tell us a little bit more about how common they are in kids in each age range?
Dr. Srinath: Excellent question. About 85% of infants will vomit in the first week of life. 60-70% of infants will have gastroesophageal reflux by 3-4 months of age. The majority of these kids will have resolution of their symptoms by the age of 1 year. In contrast, in terms of the true rates or prevalence of GERD, it’s a difficult thing to study because it is a difficult condition to diagnose. But, GERD is usually present in about 10% of pediatric patients, and it is more common in the adolescent population. The rates of this condition go up in adulthood to 10-20%.
Dr. Vellody: Ok so if that is how common it is in the general population, can you give us some idea to why reflux seems to more common in the population of children with Down syndrome?
Dr. Srinath: That is a great question, and it is actually a little unclear as to why GER and GERD is more common in babies with Down Syndrome. The most prevailing postulate is that the nerves that supply the gut and contribute to the control of the movement of the intestines are somewhat dysfunctional. This could lead to poor propelling of food through the food pipe and the stomach and poor control of the valve, or the blocker, that prevents food from coming to the stomach back into the food pipe. All of which can mediate the symptoms of GERD.
Dr. Vellody: Thanks, Arvind. But just so our listeners can understand this completely, can I just try to summarize? So, the food is swallowed and it goes down the food pipe, or esophagus, and into the stomach. And then there is a valve at the top of the stomach that is supposed to close so that the food and the stomach acid that is now mixed in with the food will stay in the stomach. But if that valve is open instead of closed, this is what causes the stomach contents to reflux back up. Hence the term gastroesophageal reflux. Do you agree with that summary?
Dr. Srinath: I completely agree.
Dr. Vellody: Perfect. So now that we know all of this background about GER, do we really need to do anything about it? I mean it seems like it is a pretty common condition for which we can’t really treat everyone, with a medication at least. Let’s start with infants who are what we would call “happy spitters,” meaning they are babies who spit up so they have gastroesophageal reflux but they do not really have any other problems associated with it – so they do not have disease. What do you do with them?
Dr. Srinath: First of all, with regards to GER, since GER is a process that can occur in healthy infants, there is no need to treat.
Dr. Vellody: That’s interesting that you say that because I know that many parents and practitioners will try to manage GER with different kinds of techniques. Could you touch on some of these and whether there is any data to support using them?
Dr. Srinath: That’s a great question. Potentially controversial topics include thickening of the formula, upright positioning after feeds, and feed volume. First of all, in regard to thickening, studies have shown that thickening only decreases the height of the reflux contents; it does not change the frequency of the reflux events or the acidity of the stomach contents that the esophagus is exposed to. So in effect, you are really not changing the reflux itself. With regards to upright positioning after feeds, although this technically makes sense from a gravity standpoint, it’s debatable whether upright positioning after feeds alleviates GERD in infants. With regards to the head of the bed being elevated in infants who have GERD, there are studies that suggest that this position may actually worsen reflux. Hence there might not be any utility.
Dr. Vellody: Is there any position at all that’s helpful in GERD in infants?
Dr. Srinath: The only true position that may help GERD in infants is the prone, or face down, position. Though, I can not reinforce enough that this is not recommended since the risks of Sudden Infant Death Syndrome, or SIDS, far outweighs the risks of GERD with this position.
Dr. Vellody: A lot of what you’re saying maybe new to some of our listeners. Can you tell us where you are getting this information from?
Dr. Srinath: Absolutely and thanks for asking that question. These suggestions and this data are summarized periodically in our guidelines statements and that association is the NASPGHAN. They meet on a regular basis, go over what studies have come out, and come to consensus over how things should be practiced based on the most recent literature out there.
Dr. Vellody: Wonderful. Well I think it is kind of telling that here we are, almost at the end of this podcast, and we haven’t even yet talked about medications for GER. I think that just goes to show that there are really many other things we can do other than medications to manage this condition. But I know there is definitely a role of medications in treating GERD – could you touch on some of those now?
Dr. Srinath: That is a good point and you are exactly right, there definitely is a role for medications in patients who have GERD and that is when lifestyle changes fail. The major types of medications used to help GERD can be defined into medications that suppress acid production, neutralize acid, or surface barriers of the lining of the gut. With regards to acid suppressant medications, examples include pantoprazole or lansoprazole, but one must be wary of the side effects of chronic use, which can be risks of pneumonias and gastrointestinal infections. With regards to medications that neutralize acid, or antacids, these take effect immediately. They are useful to be used on an as needed basis; they are for the patients with the occasional symptom. It is important to keep in mind that chronic use of medications like these may lead tolerance overtime in patients. Lastly, with regards to mucosal surface barriers, these are mainly used for pain relief, and I would not recommend them for chronic use or in infants due to some of their systemic side effects. The other class of medications that I would like to touch upon that we do not use on a regular basis include medications that help to make the gut move faster, since that might play a role in the development of GERD. And I did discuss earlier that patients with Down syndrome may have motility dysfunction leading to their reflux but I would say that without further testing and referral to a specialist, such as a pediatric gastroenterologist, I wouldn’t recommend a trial of medication to help the food pipe and stomach move faster.
Dr. Vellody: Wow thanks a lot for that great review of the medications that are out there. Let me just ask you this question now, because we get a lot of babies who come in and are started on one of these medications for their reflux. Is there any role for acid suppression in a baby who has no disease but just some spitting up?
Dr. Srinath: There is no role for acid suppression and actually none of these medications will prevent the child from spitting up.
Dr. Vellody: And often times acid suppression medication is started because it’s felt that there is minimal or no side effects, but, based on what you just said, that does not seem to be true, right?
Dr. Srinath: Exactly, there are potential side effects - mainly the risk of GI infections and pneumonias.
Dr. Vellody: Hey thanks Arvind for clarifying all of that for us because I think it is really important for people to hear. There is a role for stomach acid. Our acid is there not just for digesting our food but also to fight off all the bacteria and viruses that we eat everyday and do not even realize it. So it makes sense conceptually that by taking that acid away we are increasing our risk for infections with bacteria and viruses we may have been able to kill off had we had our stomach acid.
Dr. Srinath: I couldn’t agree more.
Dr. Vellody: Let me just ask you one final question then before I let you go. What signs should a doctor or a parent look for in a child who is vomiting or having reflux symptoms that would be more worrisome, and therefore mean they should be seen by a pediatric gastroenterology specialist?
Dr. Srinath: So I think it is important to consider warning signs. One must consider conditions whose symptoms can mimic GER but warrants referral for further testing. And these include conditions that are due to obstruction, food going down the wrong pipe, or signs of potential problems in the brain, intestinal irritation, and metabolic disorders. Signs of obstruction, examples include food getting stuck when swallowing, painful swallowing or vomiting that is green. Signs of food going down the wrong pipe could include coughing or gagging when eating, hoarseness, or recurrent pneumonias. Signs of potential problems in the brain could include a head out of the range of normal size, a bulging fontanelle, poor development, lethargy, or even seizures. Other possible reasons to refer to a specialist include poor weight gain or weight loss, masses felt on abdominal exam or blood in the stool.
Dr. Vellody: Ok well thanks for going through that for us because now our listeners know what to look for and when to be concerned enough to seek out specialty advice from a gastroenterologist. Hey Arvind, that was a lot of fun! Thanks for being here with me today and I hope that next time you will come back and join us so we can talk about more gastrointestinal issues, especially as it relates to kids with Down syndrome.
Dr. Srinath: You are very welcome and thank you again for this opportunity. I would be more than happy to join you again for another podcast.
Dr. Vellody: Well that sounds great! I’m looking forward to it. To our listeners, thanks for joining us again and as always send us your questions to DownSyndromeCenter@chp.edu. Until next time, goodbye!
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