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Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI
--Colic: A Parent’s (and Pediatrician’s) Nightmare
--Milk Intolerance vs. Milk Allergy

  

Spitting vs. GE Reflux: What is the Difference?

Introduction: Most babies spit up. (67% at 4 mos; 21% at 7 mos)  Some spit up more than others did.  When should we consider a diagnosis of reflux?  When should we do a workup for this condition, what should the workup consist of, and what medications should we use?

When should we consider the diagnosis of GE Reflux: A workup should be considered particularly if excessive spitting is associated with any of the following:

  1. apnea and/or bradycardia; relationship with near-miss, ALTE and SIDS uncertain
  2. recurrent pneumonia, wheezing, chronic cough
  3. failure to thrive
  4. bleeding from esophagitis with occult blood in the stool and iron deficiency anemia
  5. when associated with opisthotonus, abnormal head posturing (Sandifer’s Syndrome)
  6. prematurity or neurological abnormalities such as CP

Incidence of moderate-severe reflux requiring treatment: 1:300- 1:1000 varying with population

What workup should we consider?

  1. Barium swallow: if do this test, and child spits up all the time it will be positive.  The reason to do this test is to rule out hiatal hernia, strictures, esophagitis, etc.
  2. pH probe: scoring system to diagnose condition; surgeons need to have this test before consider surgery.  If do this test, can correlate apnea, cough, etc. with the reflux event.

What treatment of reflux should we consider?

1. Mild GE Reflux without one of six conditions listed above: keep child prone, thicken feedings with cereal, burp frequently (every 1/2 - 3/4 oz), keep upright for 1/2 hour after each feeding, consider sling to keep child’s head elevated 30 degrees.  Most of these ineffective < 6 mos.

2. Moderate or severe GE Reflux: Most commonly used now: Reglan and Zantac: Other medications used: Tagamet (Cimetidine); Antacids (15-ml/sq meter); Omeprazole; Bethanechol or Metoclopramide (prokinetic agents)

  Metoclopramide (Reglan) Ranitidine (Zantac)
Mechanism Stimulates mobility Decreases acid produced by stomach

H2- receptor antagonist
Side Effects Drowsiness, dystonic reactions,

tremor, anxiety

 Unusual: headache, CNS rxn rare

Can increase theophylline levels
How supplied PO: 10 mg tablet; syrup: 5 mg/5 ml Syrup: 15 mg/ml
Dosage 0.1 mg/kg/dose up to QIP 2-4 mg/kg divided q 12h

3. If severe reflux is unresponsive to the above combination of methods and a pH probe test confirms the presence of reflux, surgery may be indicated.  Nissen fundoplication or a variation of it will control reflux in 90% of cases.  This procedure can be combined with G-tube placement in certain patients.  This procedure does not need to be done commonly.

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004