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Gastroesophageal Reflux Disease (GERD) in Children

  • Woman: We are excited to have you join us today as part of our Boys Town Physician Education Series for February. We encourage you all to stay connected with us and take advantage of these free monthly CME opportunities for all physicians, virtual style. Before we get started, I'd like to announce that this series is jointly provided by Boys Town National Research Hospital and Creighton University. I would now like to introduce today's presenter, Dr. John Vanderhoof. Dr. Vanderhoof is a gastroenterology physician at Boys Town National Research Hospital, as well as an attending physician at Boston Children's Hospital. Dr. Vanderhoff also serves as senior lecturer in pediatrics at the Harvard Medical School, and professor emeritus of pediatrics at the University of Nebraska College of Medicine.

    Dr. Vanderhoof received his doctor of medicine degree in 1972 from the University of Nebraska College of Medicine, and completed his fellowship in pediatric gastroenterology and nutrition at the University of California Los Angeles in 1976. Dr. Vanderhoof has published roughly 250 referred papers in various areas, pediatric, gastroenterology, and nutrition, and has written comparable numbers of chapters and reviews on areas such as short bowel syndrome and probiotics. He served as president of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition from 1986 to 1988. He has lectured widely both nationally and internationally on a variety of issues related to all areas of pediatric gastrointestinal disease and nutrition. Dr. Vanderhoof received the Shwachman Award in 2001 from the North American Society of Pediatric Gastroenterology and Nutrition, and the Mentorship award from the North American Society of Pediatric Gastrointestinal Nurses.

    His interest in intestinal failure in short bowel syndrome led to the observation that small bowel bacterial overgrowth was a major contributor to the pathology associated with short bowel, and this led to an interest in the microbiome years before it became popular. He did initial studies with probiotics in a variety of different disorders, and worked with ConAgra Foods in Omaha, Nebraska, to develop the probiotic Culturelle. This led to an interest in applied science in commercial applications, and he subsequently became vice president, global medical affairs, and chief medical officer for Mead Johnson Nutrition from 2002 to 2011. Please welcome Dr. John Vanderhoof.

    Dr. Vanderhoof: Hi, folks. I thought if you were going to have a talk by an old gastroenterologist, you ought to have a talk on an old topic. And so I thought today I'd talk about gastroesophageal reflux, which is something I usually don't do, but it's something I thought we ought to review, because there have been some changes in how we view reflux in kids, and what it does and how we diagnose it and how we treat it and when we treat it, that a lot of you are probably familiar with, but some of you may not be, some new things about pathophysiology and so forth. So, let me go through this and kind of give you what I would probably call an update on reflux disease in infants and children.

    Matter of disclosures, I give talks for a whole lot of people, and always happy to do so. The information you're going to get today is totally mine. It hasn't really been developed by anyone else. So, we'll start with the esophagus. And the esophagus is, as you all know, a muscular tube that transports food from the mouth to the stomach. And the upper third of it's skeletal muscle and it's under voluntary control. And you can decide what you want to do with that when you want to do it. And the lower two-thirds are smooth muscle and involuntary, and once food gets there, you have no control over what it does. It sort of takes its own course, and it's run by the lower levels of your brain.

    The lower esophageal sphincter is a little kind of a valve at the bottom of the stomach that remains tonically contracted, and its function is to keep the food in the stomach once it gets there, and to open when food needs to go through. And if you look at an esophagus in a cadaver, you don't really see any kind of a valve there. It's not like a heart that has a valve in it. What it does is, you can see or perceive some element of muscle that's under maybe some little bit of hyperplasia. But what you can't see anatomically is that this muscle is sort of tonically contracted. And it's the major mechanism that we have to keep acid and food in the stomach. And there are a couple of other ones. The, you know, the location through the diagram, and the fact that some of the esophagus is located inside the abdominal cavity, helps a little bit as well, but the sphincter is the main thing that keeps the food down in there where it's supposed to be.

    And if the sphincter is functioning normally, the pressure in the stomach is going to be lower than the pressure in the sphincter. And what happens is food will stay where it's supposed to. But if on the other hand the pressure in the stomach is higher than the pressure in the sphincter, you'll reflux. And that happens when the sphincter relaxes, or when there's a lot of abdominal compression, or when you vomit, or when you overeat, which is something I think we've all experienced at one point in our lives. And so that's kind of the main mechanism that we have to protect ourselves against reflux.

    So, the other thing that we can do is, to protect ourselves from reflux, is we can increase the gastric accommodation. And of course, if gastric accommodation decreases, and our stomach contracts, that's gonna make it more likely to reflux. So, gastric accommodation, the sphincter, the capacity in the esophagus, the fact that we're constantly swallowing saliva and pushing acid through, by peristalsis, and the upper esophageal sphincter, are all protective mechanisms that we have to protect our esophagus and our lungs from reflux. Now, if we have effortless passage of gastric contents into the esophagus, that's called reflux, by definition, and we abbreviate that GER, gastroesophageal reflux.

    May or may not be symptomatic, depending upon the status of the esophagus and how much acid you get in there and how much reflux you have. And it may be totally a normal phenomenon, and it may not produce any symptoms at all. However, gastroesophageal reflux accounts for about 20% of referrals to pediatric gastroenterologists and... I don't think this is true anymore, but fundoplication used to be one of the most common procedures, surgical procedures, done in children. The fact that... And I could say this is true about 20% of the kids that come into my clinic have on their chart the reason for referral is GER or a gastroesophageal reflux.

    So, what causes reflux? Most of the time, the vast majority of reflux episodes are caused by transient relaxation of that sphincter. So, the sphincter is not always tight. The pressure kind of goes up and down and up and down and up and down. And in some people, it goes up and down more than in others. And if you happen to be one of these people that kind of hits a low point, and you increase your intra-abdominal pressure at the time the sphincter is a little bit low, you're going to have reflux. And so, the majority of reflux episodes are caused by a transient relaxation.

    Prolonged episodes of reflux may have something to do with posture or gravity or defective peristalsis, etc. But here, this is just kind of shows you how the vast majority of reflux episodes actually result from transient lower esophageal sphincter pressure, and only a very, very small ones are related to chronically decreased LES pressure. And, you know, I have to go back... And this sort of demonstrates how old I am. But back in the mid-'70s, when I started in gastroenterology, you know, the big thing was that reflex was caused by decreased lower esophageal sphincter pressure. And people had to think to defective sphincters, and we're now learning that there's a little bit more to it than that.

    So, what about babies? Well, babies reflux. Everybody knows that a baby refluxes. Babies spit up all the time. That's how they protect themselves from overfeeding and gastric distension. They're supposed to do that. It begins before three months of age. They don't do it when they're asleep. It doesn't interfere with their growth. It doesn't cause any symptoms. And by the time they're six months of age, it pretty much goes away. And back in 2002, there was a nice little paper that showed in pediatrics that the natural history of spitting up from infancy up to 9... Should say 9 months of age, not 9 years of an age there.

    And now this has been duplicated by a whole number of different papers all showing the same thing, that by the time kids are 7, 8, 9 months old, they pretty much quit doing this. And that's sort of the natural history of healthy regurgitation in babies. Babies are supposed to spit up. And it's supposed to go away when they get older. And I always like to tell the parents when they have a baby that spits up, I say, "Well, this goes away when they walk, because that little muscle that controls the acid contents in the stomach, that little valve there, that thing wakes up and works about the same time the legs learn how to walk. And so you don't expect the baby not to spit up until they start to walk. And most parents can appreciate that.

    So, is gastroesophageal reflux a problem? Well, occasionally it is. And then we change the letters. So, GER, gastroesophageal reflux, is GER, and GERD, gastroesophageal reflux disease, is what happens when it indeed becomes a problem to have gastroesophageal reflux. And so, when we as pediatric gastroenterologists look at babies like this, and we see this history of regurgitation and recurrent vomiting, and we do a history and physical exam, and what we're looking at is, are there warning signs? Does this baby have any evidence that this might actually be gastroesophageal reflux disease, and not gastroesophageal reflux? And things we typically look for are growth failure, esophageal symptoms, like hematemesis and anemia. And I put in here question marks after pain and irritability and feeding refusal, because one of the new things that's sort of come along is that people don't really believe that gastroesophageal reflux causes these things anymore. Pain and irritability in people my age, yeah, you know, we all get irritable when we reflux. That's part of getting old. Not so with little babies. They don't get any crying or irritability when they reflux.

    Apnea or acute life-threatening events, you know, maybe in some cases, but usually it's not related to reflux. Wheezing and asthma can occasionally be related to reflux, but it usually isn't. Recurrent pneumonia with aspiration and upper airway symptoms, occasionally. But the vast majority of episodes aren't. So, these are potential complications of gastroesophageal reflux that might push us over into the GERD category, but usually not. Hematemesis and anemia from reflux esophagitis, probably the most common in old folks like me, but pretty uncommon, certainly doesn't happen in babies. In older children, you know, we occasionally see this, but not very often.

    And so, just, you know, kind of a few little things to back up what I've been saying here. Here's a paper from a little over 10 years ago that was doing impedance and pH probes in kids with apnea and bradycardia and reflux, and it showed that really, the vast majority of episodes of bradycardia, reflux, desaturation, and so forth were not associated with reflux. And it's kind of probably unrelated in the vast majority of kids. And I think this is... I try not to dabble too much in neonatology because I don't know very much about it, but these are what the data show, that probably trying to blame these events on reflux is a mistake.

    Gastroesophageal reflux symptoms in infants, as I mentioned, usually relates to intermittent relaxation of the sphincter. The infant spits up or vomits. And I put the question marks here because people think that they, or used to think that these kids had heartburn and were irritable, but they're really not. And our big problem with when we see babies like this is trying to figure out if babies have a cow milk protein allergy. And one of my good friends, who's probably done more reflux studies than anybody else, whenever she did a reflux study, she always put the kids that wanted to enroll in the study, or the babies that... Well, they didn't want to enroll in the study, but their parents did. She always put them on an extensively hydrolyzed formula for two weeks before she'd ever enroll them, because a lot of them were undiagnosed milk-intolerant kids, and they got better, then she wouldn't put them in the study.

    So, then, if reflux doesn't cause irritability, what does? And so, the vast majority of irritability in babies is caused either by infantile colic, which is primarily a disorder, probably of... Well, I'm not sure it's even a disorder, but it's related to excess crying that's probably originates in the central nervous system and not in the GI tract. And then the other one is cow milk protein allergy, which is a non-IgE allergic phenomenon. Non-IgE meaning it doesn't go through the IgE system, and you can't test for it with IgE tests, but nonetheless, it's still immunologically mediated, and therefore it's a "allergy."

    So, infantile colic. What's that? How does it present? So, typically, colicky babies present between one and three months of age, peak incidence around six weeks of age, with episodic crying. And by episodic crying, it means they cry in the evenings in the vast majority of time. And the rest of the day, they're fine. They don't have any other symptoms. They don't spit up more than another baby. They don't have diarrhea or constipation. They just cry. If you pick them up and you rock them, or you make shushing sounds with them, or you take them for a ride in the car or put them in an infant seat and stick it on top of the washing machine or something like that, the baby will quit crying, because the repetitive stimuli cause the baby to relax. And because this is really a central nervous system problem and not a GI problem, that works. And by three to six months of age, they resolve. And if kids are still doing this beyond about four months of age, we start to worry, do we really have the right diagnosis here?

    People have kind of thought that these babies have abdominal pain because they draw their legs up when they cry, and a lot of times, they pass gas. Well, babies do these things all the time, so you just don't notice it when the baby isn't crying. So, it's not really a GI pain, but it's been thought of this way, and unfortunately, that sends them to folks like me. Cow milk protein intolerance is different. They cry and scream too, but they tend to cry and scream all day long. They have diarrhea. Some of them even have constipation, but they typically have abnormal stools. Occasionally, they'll have little blood flux in their stool, and then it makes it easy to diagnose, but usually, you're not that lucky, and usually, they don't. And they often vomit. And the reason they vomit is because they have inflammation in their duodenum. And you see all these little lymphoid nodules, with some denudation of the epithelium over the lymphoid nodules. This basically is an inflamed lymphonodular inflammatory process going on on this poor little baby's duodenum.

    And any time you put food or anything into the duodenum that looks like this, two things are gonna happen. One is you're gonna get pain, which is gonna make the baby cry. And the other thing that's gonna happen is the stomach is going to start to empty slowly, because this duodenum is trying to protect itself from the food, so the pylorus climbs down, the stomach gets distended, the gastric pressure is greater than the pressure in the lower esophageal sphincter, and what happens? It comes up. It looks like reflux. But it's really not the same thing as the typical GER that we talked about. It's just that you often can't tell it. And it's these screaming babies that do this that I think gave people the misimpression that gastroesophageal reflux causes pain.

    So, that's kind of what's really going on in these babies. And so, when I see a fussy baby, I kinda run through this little algorithm in my head, between an allergic baby and a colicky baby. Colicky baby has normal stools. Allergic baby has abnormal stools. Colicky babies usually gain weight fine. Allergy babies may gain weight fine, but because they don't like to eat, because of the pain and discomfort, a lot of times they'll lose weight. Colicky babies actually feed fine. Allergic babies feed poorly because when they put food in their stomach, it causes pain. Colicky babies cry in the evening. Allergy babies will usually cry right after they eat. Colicky babies spit up, but not a lot. Allergy babies spit up a whole lot. You can take a colicky baby for a ride in the car and he'll quit crying. An allergic baby probably won't, because he's got all this pain going on. So, that kind of helps you a little bit telling whether you got a colicky baby or an allergy baby.

    So, when do you suspect gastroesophageal reflux? In a baby that spits up a lot, with normal stools, normal studies, if you do them, like occult blood and calprotectin, are gonna probably be normal. Calprotectins are usually elevated, and especially in breastfed babies, so I wouldn't advise you doing those in these babies unless you have a set of normals for babies, and I don't think we have those. And then, how do we diagnose it? I put down here at the bottom towel sign. And that's sort of one of my favorites. If the mom walks in with a towel over her shoulder, that pretty much nails it, and that tells you the baby has reflux. But there are a lot of different tests that you can do. And some tell you some things and others tell you other things. An upper GI series basically is a lousy test for reflux, but it tells you about the other end of the stomach. It tells you if the baby has pyloric stenosis, or a duodenal web, or an annular pancreas or something like that, but it doesn't tell you about reflux. Scintiscans, I don't think we do much anymore. pH and impedance studies, we occasionally do. The vast majority of them we diagnose by history and physical examination. And we're usually right when we try to do that.

    So, what does a pH study do? Well, it measures esophageal acid exposure. This was a test, and I actually think it was kind of developed by Tom DeMeester over at Creighton when he was chief of surgery over there many, many years ago. That's where that DeMeester score comes from and all that. And what he was looking at at that time was in adults, seeing how much acid exposure the adult had, which would tell him whether the patient likely had esophagitis. It doesn't tell you if they're refluxing non-acid substances, and it doesn't help you if you have a positive towel sign, because you know that baby already refluxes, so there's no point in doing the [inaudible 00:23:58].

    So, what it does do is it tells you if somebody who has soft signs of reflux, who doesn't have classic symptoms, has reflux. It doesn't tell you that it's causing the baby's problem, but it tells you whether or not it's there. The fact that you have so much non-acid reflux that's missed with a pH study, what we've now done is we've got the equipment that also includes esophageal impedance, which basically measures water or fluid in the esophagus, so you can pick up not only acid, but you can pick up fluid in the esophagus, and you can tell if a child actually has acid and non-acid reflux. And this is probably the gold standard to look for reflux. Not certainly something that we need to do in every baby, certainly not something we need to do in every baby that spits up, but occasionally, when we're really worried about the diagnosis, and we can't make a diagnosis based on history and physical, we can do this, and we can nail it that way.

    So, what about endoscopy? So, we do endoscopy in kids when we suspect some kind of a complication of gastroesophageal reflux, or some other diagnosis. For example, if there's bleeding, if there's dysphagia, something like that, we would look in there. I have to admit, the main reason I look in there now is because I think they may have eosinophilic esophagitis, which is this disease, and we diagnose this by esophageal biopsy. And you can see all of these little eosinophils in here. And these are allergic cells, and they're drawn in here because this isn't actually a disease, mostly a food allergy disease, but it may be an environmental allergy disease from swallowed environmental allergens. Either way, there's something causing allergic inflammation in this esophagus. And so, we think about this disease in older kids when they have dysphagia, because the eosinophilia attracts mast cells. The mast cells cause inflammation in the esophageal nerves, and they screw up the peristalsis, and the esophagus will go into spasm.

    So, these people will present with food impactions, esophageal spasm, and crampy esophageal pain. And it's commonly seen in older children and adults. In little kids, sometimes, this is asymptomatic, or it could present with just discomfort or vomiting and so forth. It's a little bit different than what you see in the older kids. So, a lot of times, if I think a kid may have this, if there's a feeding refusal issue, or the child tends to eat real slowly or cut up their food small or something like that, and they're losing weight, I'll do an upper GI endoscopy to look for this disease. Now, we actually do this quite a lot anymore, and that's something that we really didn't used to do very much.

    So, how do you treat gastroesophageal reflux disease? And there are basically three things that we can do. We can treat them with dietary treatment and positioning, we can treat them with medical treatment, or we can treat them with surgical treatment. So, what's positioning? Positioning is basically elevating the head of bed at night. And, you know, they used to do this with adults a lot, and I think they still do. You put a couple of six-inch blocks under the head of the bed, and they'd sleep on an incline, and people would tend to sleep a lot better. And that in fact works in kids too, if you elevate the head of the crib. What you don't do is put them in a car seat and let them sit up all day long, because that actually interferes with gastric emptying, and causes more reflux than it does when you let them lay down. So, basically, what you're doing is you're just letting them sleep on an incline.

    So, what about dietary feeding? So, what can you do in dietary management of infants with reflux? Well, small and more frequent feedings, because gastric distension increases intragastric pressure. And if you increase intragastric pressure so that it exceeds pressure in the lower esophageal sphincter, that causes reflux. Another thing that people do sometimes is they thicken the feedings, usually about 5 grams of either rice or oat cereal in 30 milliliters of formula or breast milk. And sometimes that will thicken it up a little bit, so that they don' that, you know, the food doesn't make it through the sphincter so easily, and there's a lot nice data that show that that actually works.

    Rice cereal mixes a lot better. Unfortunately, it's kind of a common allergen, and it also, it's kind of hard to get rice without arsenic in it. So, people have started to use more oats, but the oats don't mix nearly as well, and they're harder to get through the nipple. Avoiding overfeeding, and then... That's a big one because, again, gastric distension is a bad thing. And pre-thickened formulas is another thing we could talk about a little bit. They don't work great, but sometimes they help a little bit.

    So, Susan Orenstein was the old guru of gastroesophageal reflux disease. I think that mantle or torch has been passed to Rachel Rosen. But Susan was the one who I said did all these studies where she'd always put everybody on an extensively hydrolyzed formula for two weeks before she ever studied the kid, because she knew that a lot of these kids were allergic. And so, what she would do...what she showed in this study is that if you fed babies pre-thickened formula, they refluxed a lot less, and their stomachs actually emptied a little bit better. So, that was kind of an interesting phenomenon. And she really popularized this whole thickened feeding thing.

    And so, when I was [inaudible 00:30:48] the infant formula industry, we always worried about if you thicken the formula, it works, but some problems happen. And one is that you increase the caloric density of the formula. And babies don't eat to volume, they eat to calories. So, a baby will eat however many calories it needs to maintain its weight, so if you thicken his formula, he'll just eat less. And so, if you put a bunch of extra calories in his formula, with cereal, then they'll just simply cut their volume intake down, and that'll make them better, but they won't get enough fluid, they won't get enough protein, and they won't get enough micronutrients and minerals. And if they do happen to eat more, they'll get fat.

    And so, the idea, the concept came up was what if you'd made a formula that was thicker? And one of the best ideas that's come up with is you could get certain rice cereals that will complex with casein in the presence of acid, and form a gel in the stomach. And that was done with this particular formula, that was called AR. And this was actually done before I ever got involved in this industry. But I did have the opportunity to do the clinical studies with it back when I was at the University of Nebraska, and it fixed this nutrition problem. And the stuff was nice, because it went down the same viscosity through the nipple, and then it thickened in the stomach. And sure enough, if you looked at pH and viscosity curves, it did the same thing as putting rice cereal in the formula, and it did cause some decrease in the reflux symptoms.

    Now, I have to tell you that the folks that did the analysis on these data when we wrote this paper had to torture it a bit, because it wasn't really real obvious that this stuff worked all that well, although it did work. But it wasn't quite as effective as what Susan did with the rice cereal. But at least it didn't screw up the nutrition balance, and even the babies tended to sleep a little bit better with it. And so, it's still out there, and there have been some other ones that have come out since then by other manufacturers. They've taken a different approach. They've usually used gums rather than rice starch in them. And so they go through the nipple thick, and then they stay thick in the stomach. And I think from an efficacy standpoint, they're probably fairly similar.

    So, what about medications? Years ago, we had a drug that actually worked for this disease, or this problem. And that was... Well, wait, wait. Before I get into that, let me just tell you about Susan's study here, a more recent paper that basically looked at the effect of conservative therapy, which would be seating positioning, and thickening with rice cereal, not with a special formula, but adding rice cereal to the formula. And basically, what she showed was it worked. And it was a significant improvement. And so her solution was this is what you ought to do for most babies with reflux. Now, having said that, I will tell you that most babies I see who are spitting up and otherwise growing fine and not having problems, I didn't treat those babies. I don't treat them with anything. I just tell the mother, "This is normal. Have your carpets cleaned when the baby starts to walk, and carry your towel around. The baby will get better. It's growing fine. Don't worry about it." If you need to treat them, what Susan would say is this should be your first line of therapy.

    Now, Vasu Tolia in Detroit... I don't know if you remember Stuie Kaufman, but she was Stuie's chief resident when Stuie was an intern in Detroit. And Vasu did this little study with metoclopramide, and actually showed that it worked. And unfortunately, it didn't work very well. And cisapride came along, and that worked really well, but it sort of fell off when it was taken off the market. So, now what do we have left? Is we have acid suppression. And that takes away the acid, but it doesn't do anything to the sphincter. So, if it doesn't do anything to the sphincter, it's not gonna really do anything. It doesn't do anything to gastric emptying. So, if the patient has esophagitis, or even eosinophilic esophagitis, acid suppression is something to do. Otherwise, don't do it. Other prokinetics. There's a new one out on the market, but it's not approved for this disease, and it's not approved for babies. And antispasmodics, peppermint oil, all of the, bentyl and whatever, they all decrease lower esophageal sphincter pressure, so they actually are something that you shouldn't do, because they'll make this disease worse.

    So, here's some studies that go back to Susan. And these are really classics, and I think this is really an important study, where she took these kids that had reflux, and randomized them to either a placebo or a lansoprazole, a proton pump inhibitor, that really took away all the acid, to see if she could make crying, fussiness, and irritability go away. And these were babies who were non-allergic. These were babies that she had already put on an extensively hydrolyzed formula to prove that they were not allergic, and then randomized.

    And sure enough, what she found is that crying, spitting up, no difference. Arching of back, feeding problems, no difference. Adverse respiratory events, a big difference. And it was a big difference because it was more in the kids that got the lansoprazole than the placebo. She actually saw an increase in both respiratory and GI infections in these kids that were on lansoprazole. Why would that be? Because the acid in the stomach is what protects you against viral infections in both the lungs and the gut. And if you take that acid away, the baby's gonna get more infections, and in addition to that, because you're gonna screw up his microbiome, you're going to increase his potential for getting allergies. So, Susan's point, "Don't do this."

    Another study, this was done by a German, published in a British journal. And basically showed that if you looked at the duration of crying for 24 hours, and compared it to how much babies refluxed, using a pH study, there was no correlation. It was just a random bunch of dots. And so they were unable to demonstrate any association between crying and reflux. And then there was this poster that I found at ESPGHAN, the European PDGI meetings one year, and took a picture of it. It was just another paper that showed no effect of proton pump inhibitors on irritability in infants, a systemic review of randomized controlled studies, all of which showed the same thing. Now, on the other hand, there's never been a paper that showed a benefit to putting a reflux baby on a PPI. No studies showing a benefit. Several studies showing no benefit, and some studies showing complication. Yet we still see this all the time.

    Should we treat bradycardia with reflux medications? And we talked a little bit about apnea events and reflux before. And sure enough, here's a group of patients that were treated, bradycardia patients. No improvement in drugs versus a placebo on that. So, what do you do when you don't have any good medical therapy, and the kid's failing to thrive, or has protracted esophagitis and doesn't respond to the medicines that you got? And what can you do? Well, you can send them to your friendly neighborhood pediatric surgeon, and they'll be more than happy to do a Nissen fundoplication. They can do them laparoscopically. There are some post-operative problems associated with it. And for that reason, we really reserve this to the complicated patients. And the one thing that I would tell you about is whenever you think about doing this, this is the time to make absolutely sure you don't have an allergic baby, because let me tell you, if you fundoplicate an allergic baby and you feed that baby, you're gonna hear screaming like you've never heard before in your life. So, be very careful of that.

    This is how the operation is done, and basically, what you do is just wrap the stomach around the lower and the intra-abdominal esophagus, to basically create a one-way valve. And there's a fairly low incidence of problems, and it works pretty well. The biggest problem you have is recurrent retching and gas bloat. And I think a lot of this can be controlled if you're very careful about selecting your patient population and you're very careful about not doing any fundoplication on allergic kids. Ends up that a lot of the reflux procedures we do are in neurologically impaired kids, and as you might guess, these are also the ones that seem to get the most complications.

    So, let me just give you some conclusions here. Reflux is common. Most of the time, I don't treat it. When it's GERD, then I might treat it. And what we do is thicken the formula, use positioning therapy, maybe use an enhanced viscosity formula, probably not use any medicine, and occasionally we'd send a patient like this to a surgeon. Important clinical considerations. Make sure you have the right diagnosis. Don't treat an allergic kid for GERD, because it won't work, and, well, it just doesn't help the kid. And don't over-treat the kids. This is where I get into the PPIs or excessive positional therapy, or screwing up the kid's diet if it's an otherwise healthy kid. I mean, it's not gonna hurt that kid to spit up a little bit.

    And it's a messy problem for the parents, but it's not bothering the kid, and it goes away when they walk. Don't over-study them. You don't have to do tests on these kids unless there's a problem. And avoid surgery if you can. If the baby's fussy and cries all the time, the problem's usually not reflux. It's usually an allergic problem or something else going on. I think maybe at one point in time I gave a little talk on colic and how to treat that, and it's time to take all those little tools and put them to use, and work along those lines, because that's a whole different deal in trying to treat a fussy baby for reflux when that's not the problem, is not the right answer. So, we got some questions coming up. If you have time, I got 5 or 10 minutes I can answer some questions, and that would be great. And if not, you folks all have a great day.

    Woman: Dr. Vanderhoff, we'd like to thank you for your time and expertise, as always. We encourage you all to stay connected with us and take advantage of our free monthly CME opportunities. Watch for follow-up email communications announcing our upcoming presenters with the Boys Town Physician Education Series, or visit our website at Thank you, and have a great afternoon.


Physician Education Pediatric Gastroenterology