Gastroesophageal Reflux in Infants

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02.11.2020
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The paper describes gastroesophageal reflux condition in infants, its causes, diagnostic tests involved, and treatment modalities. It is a condition that has onset between 0 and three months of age when it is considered as normal; however, it sometimes persists to 12 months of age. Persistence beyond 12 months results in a disease called gastroesophageal reflux disease. It is a condition that mostly affects males with a decreasing incidence as infants mature into childhood. The paper utilizes eight research findings to explain various aspects of the disease. Hence, it describes the occurrence rate of the disease, possible diagnostic tests used in infants, and treatment modalities documented to be effective. Though symptoms are usually presented vaguely, research findings state that there are some significant symptoms that raise the alarm. The paper also critically assesses different authors for consistency of research findings and discussed results. Abstract, paper introduction, methodology, result presentation, and discussion are analyzed to assess validity and research credibility. Finally, importance of the research findings to my pediatric nurse responsibility is explained.

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Gastroesophageal Reflux in Infants

Introduction

Gastroesophageal reflux is among gastroenterological diseases affecting the global pediatric population. It refers to a condition that happens when the stomach contents come back to the esophagus causing acid indigestion. Prolonged reflux of gastric contents results in corrosion of epithelial lining in the upper gastrointestinal tract. Continued corrosion of the esophagus leads to a serious and long-lasting condition called gastrointestinal reflux disease, which alters infants’ feeding patterns and at times prevents them from feeding. Affected infants spit up liquid made of saliva and stomach acid recurrently. Although it is common for children in the first few months after birth, it may persist up to ages between 12 and 14 months. A diagnosis is made following predictive symptoms such as vomitus and refusal to breastfeed. The paper analyzes six research findings to describe gastroesophageal reflux in infants, while explaining its implications to my pediatric nurse role.

Prevalence of Gastroesophageal Reflux

Although the condition is common within the first three months after birth, pathology sets in when acid regurgitation is prolonged past 12 to 14 months of age. According to Winter (2016), parents reporting this condition explain that it resolves with infants’ maturation. Typically, the resolving period is the age of 12 months. According to Marseglia et al. (2015), the global occurrence of the GER is estimated at 85 percent and affects males more than females by 1.6 times. Since it is a physiological condition, it is not attributed to any external factors because it is triggered and resolves when the lower esophageal sphincter matures and intra-abdominal muscles of the esophagus lengthen within the first few months after birth. Marseglia et al. (2015) explain that the prevalence rate decreases to less than 18 percent in childhood in case of normal development. American Academy of Otolaryngology-Head and Neck Surgery (2016) argues that at least 50 percent of children below the age of three months experience a daily episode of regurgitation though the rate peaks at 67 percent at four months. Children’s ability to sit and control muscles aid in a spontaneous resolution of symptoms.

Description of Gastroesophageal Reflux

Global statistics indicates that it affects more than two-thirds of children between birth and 12 months. They are affected because of underdeveloped muscular functions. According to Marseglia et al. (2015), gastroesophageal reflux is classified into primary, secondary, and acquired forms of the GER. In the main form, there is a functional disorder of the upper digestive tract such as loose sphincters that let off food into the esophagus. The secondary form of the disease may often arise from other disorders such as infections, metabolic derangements, and neurological and allergic disorders of infants, causing the passage of gastric contents into the esophagus. In turn, the acquired form of gastroesophageal reflux entails acid indigestion due to body alignment patterns. For example, a majority of women make their children lie flat on a surface after breastfeeding, causing a flow back of gastric contents due to sphincter muscle incompetency (Loots et al., 2014). Winter (2016) reiterates that it is an effortless reflux up to the oropharynx that may involve the mouth. Some infants will have persisted spitting arising from congenital disabilities, complicating into related gastrointestinal disorders beyond the age of 12 months.

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Diagnosis of Gastroesophageal Reflux

Babies within 0 to 3 months will not show the symptoms explicitly. The mother notes the change in behavior that is a preliminary indication in the alteration of feeding patterns. For instance, children will be fine when having a small amount of reflux; however, ongoing spitting due to frequent vomiting that may be seen as normal irritates the esophagus, making the infant fussy (Czinn & Blanchard, 2013). Other symptoms include troublous swallowing, poor feeding patterns, colic, arching of the back during or after feeding, and difficulty in breathing. Prolonged reflux causes weight loss and may cause other infections that will affect the child’s general well-being. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (2015) points out that the health care provider will identify large amounts of infant vomits with a regular projectile, irritability, poor growth, signs of dehydration, breathing problems, and vomitus being green or yellow in color, reminding coffee ground, or containing blood. In the identification of these symptoms, the physician performs a physical examination before opting for more tests for an appropriate diagnosis.

Diagnostic tests are definitive in eliminating other diseases with similar symptoms. For instance, the ultrasound test is used in detecting pyloric stenosis, while laboratory investigations like blood and urine tests help identify pathology and possible causes of recurrent vomiting and poor weight gain (NIDDK, 2015). Another method is esophageal pH monitoring that measures the acidity in the baby’s esophagus by inserting thin tubing through the nose or mouth and into the esophagus. The tubing is attached to a device that monitors acidity necessitating a continued stay in the hospital while physicians do the monitoring. Besides, an endoscope that is a special tube equipped with a camera and light may be passed through any upper GIT opening to the stomach and the first part of the small intestine under general anesthesia to take tissue samples for analysis. Another method uses an X-ray whereby a child is given barium before testing to detect obstructions of the digestive tract. Some other methods are invasive for infants. Randel’s research (2014) states that diagnostic tests should be well thought out and performed in a way that helps establish a causal relationship between reflux and symptoms. It identifies that some methods are not safe for children and the primary and most reliable method is upper endoscopy with esophageal biopsy (Randel, 2014).

Treatment

According to Petrochko (2013), the first-line treatment for infants and older children involves an alteration in lifestyle. In case of children, it involves changing daily feeding volume, time, and frequency. Mothers that breastfeed are advised to consider changing their diet that includes whole grains, proteins, and vegetables. In turn, those mothers who use formula are told to start using a protein hydrolysate formula that is thickened with a tablespoon of rice cereal per ounce. Changes in feeding are documented to improve the gastroesophageal reflux outcome. Randel (2014) reports similar findings, stating that it can involve a trial period of a maternal exclusion diet. Another change in lifestyle is positioning therapy. In this method, the infant is kept in an upright posture or prone position during feeding. It is because positions like the semi-supine one exacerbate reflux and, as a result, breastfeeding mother are cautioned to avoid it during and after a feeding procedure (Petrochko, 2013). These positions are taken when the infant is awake and under an older person’s supervision and are thought to improve outcomes though they are not adequately studied.

Another method described is the use of pharmacotherapy. Although Rosen (2014) acknowledges that nonpharmacologic measures need to be used whenever possible because most incidences of infant GER resolve without intervention, use of drugs is necessary in severe forms of the disease. Acid suppressants are often used to treat gastroesophageal reflux disease in infants. They include antacids, histamine H2 antagonists, and proton pump inhibitors. Randel (2014) points out that they are more efficient in comparison to prokinetic agents. Though useful, their over-prescription and dispensation over the counter raise the alarm. Physicians recommend seeking specialized medical attention to reveal causative factors of gastroesophageal reflux. Besides, chronic antacid therapy is risky and not recommended in treating the GEF in infants. Caution is required while using H2 antagonists as they predispose to contacting community-acquired diseases. Prokinetic agents often decrease symptoms by improving contractility of the body of the esophagus, increasing lower esophageal sphincter pressure, and increasing the rate of gastric emptying (Randel, 2014). Even though it has medicinal advantages, its adverse effects outweigh the benefits.

Another rarely used method is surgery that entails wrapping the gastric fundus around the distal esophagus to prevent reflux in infants and children. Fundoplication and total esophagogastric dissociation are rarely used due to associated morbidity. However, the lack of improvement in the process of pharmacological treatment of patients with a severe aspiration of gastric contents calls for a surgical intervention (Randel, 2014).

Critical Assessment of Research

Research studies by various authors indicate satisfactory results consistent to one another. All studies explain related aspects of the condition, pointing out similar results. The abstracts are intelligible in describing study objectives, while stating the results obtained. For instance, the study by Czinn and Blanchard (2013) represents its primary purpose of finding when and how to initiate treatment of infantile esophageal reflux. They state the problem explicitly and describe the essence of starting treatment early in time. They point out effective strategies used in achieving better outcomes such as parental reassurance and use of pharmacological agents in treating the condition. Similarly, Lightdale’s and Gremse’s study (2013) states the objective and gives results relating to the management guidance for the pediatrician. For instance, the research offers regional prevalence, as well as signs and symptoms defining the condition. The abstract gives guidelines that distinguish between reflux in infant age and after 12 months. Data presented in the abstract are similar to those in the main paper with the only difference being that it is summarized in the former.

Marseglia et al.’s (2015) study elaborates on the reason why their study has been conducted. For instance, they state that most of the persisting gastroesophageal reflux conditions are associated with congenital disabilities and congenital anomalies. The study explains that several mechanisms play a role in disease progression and that its associated pathology is evident in a significant number of patients, which is seen from extensive literature review results. The background information provided in their study is adequate as it points out existing gaps in research, while stating its aims. In their study, their aim has been to summarize known knowledge on pathological and clinical characteristics of gastroesophageal reflux in patients with gastrointestinal malformations.

Other studies like the one by Randel (2014) give a brief background and state the aim briefly. For instance, its purpose is to facilitate appropriate treatment and determine patients requiring gastroenterologist’s checkup (Randel, 2014). Baird, Harker, and Karmes (2015) provide discussion of a broad background, stating the problem with a little focus on the aim of the study. The purpose of the study is to recommend various medical therapies; nonetheless, the article presents a direction of the topic and research objectives. Winter’s research (2016) is aimed at elaborating the difference between gastroesophageal reflux and gastroesophageal reflux disease and its specific manifestations. The goal of the study by Loot et al.’s (2014) is pointing out appropriate body positions that relieve acid regurgitation. Davidson et al.’s (2013) research aim elaborates on the objective of determining efficacy and safety levels of daily Omeprazole intake.

Studies used in the paper have described the methodologies used in the abstract. Some use a random method of selecting respondents recruited in the survey. In the methods section, all the authors point out the study method used, as well as the study population and the number of those interviewed. However, some research findings indicate that fewer individuals were recruited in their studies, which may imply bias as then the study does not give a fair representation of the vast population. Others do not have a particular methodology such as in Lightdale and Gremse’s (2013) research. Randel’s (2014) study also lacks methodology. Loot et al. (2014) and Marselgia et al. (2015) indicate specific procedures used and reasons they were used with potential problems. Other studies lack limitations and statistical methods used. Rosen (2014) explains tools utilized in the research.

A majority of the articles include results obtained from the research. In a research evaluating the gastroesophageal function and mechanisms underlying gastroesophageal reflux in infants, results from a manometry study were included, showing differences in percentages between adults and infants (van Wijk, Knuppe, Omari, de Jong, & Benninga, 2013). Rosen (2014) also describes study findings in a table form. Davidson et al. (2013) present data using statistics obtained from correlation and chi-square analysis. The analyzed information explains levels of significance used to determine efficacy levels of proton pump inhibitors. Results elaborate on two groups chosen to participate in the study to determine drug efficacy levels, which make the research valid. Loot et al.’s study (2014) also presents data in a table with significance levels and P intervals. Marseglia et al. (2015) present data using tables with a clear analysis. Data presentation indicates that data were collected appropriately in line with the study objectives, while tables are included to show statistical methods used to analyze the data.

The discussion of the study results elaborates on the findings relating to gastroesophageal reflux. All eight researches indicate that their objectives have been met. The authors discuss the findings concerning the background information and other researches conducted by other authors on the same topic. For instance, Marseglia et al. (2015) use various findings that support their research topic and objectives. Czinn and Blanchard (2013) incorporate literature review from different authors to explain their results. Information explained in the discussion section is well interpreted to correlate with statistical data in order to support the findings without digressing to other topics with similar information. Authors’ analysis entails all the variables in the study, factors limiting the study, and criteria used to collect data. Problem mitigation in research explaining the absence of limitations indicates success.

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Impact of the Findings on My Role as a Pediatric Nurse

Based on the results of research, it is the responsibility of the pediatric nurse to perform routine examinations of the infant to note any change in feeding behavior (Loots et al., 2014). The pediatric nurse’s responsibility is early detection of the disease in the child to prevent further organ involvement. For instance, in identifying the deficit of the infant such as altered feeding, I will intervene early to prevent weight loss and malnutrition. Having knowledge concerning child’s behavior relating to gastroesophageal reflux such as crying, I will work to restore normal patterns that increase mother-child bonding. Besides, findings concerning treatment options provide knowledge essential for decision making. For instance, in relieving the infant’s pain and decreasing the occurrence of regurgitation, awareness of the drug action and side effects is crucial. As a nurse, I would prescribe proton pump inhibitors rather than antacids and prokinetic agents due to their associated side effects.

Moreover, the prevalence of gastroesophageal reflux indicates the probability of an infant developing it. Its natural occurrence in infants in the age between 0 to 3 months and due to altered maternal feeding patterns forms the basis for allaying anxiety of infants’ mothers. For instance, when a woman comes complaining that a child is vomiting, I will explain the condition to the woman and emphasize that it resolves and that there is no need to worry unless gastroesophageal reflux condition is prolonged beyond the age of 10 to 12 months. Information regarding diagnostic procedures will help educate the patient’s mother on the appropriate diagnostic method in case the condition worsens. Having knowledge of the condition and other conditions with similar symptoms, predisposing factors, and home-based treatment modality is essential for patient education and awareness. Therefore, findings from the reviewed gastroesophageal reflux literature help retrieve knowledge gained throughout the years to apply it to problem-solving while elaborating on the points of change such as new treatment and other diagnostic methods. Based on the research findings, I will provide education concerning the occurrence of the condition. I will provide health education concerning the disease in its entirety, including information about other disorders leading to reflux, risk factors such as infant positioning, and treatment modes. The resource that is of significance is information concerning gastroesophageal reflux.

Conclusion

Gastroesophageal reflux is a condition leading to regurgitation of gastric content to the esophagus and at times to the mouth. It is a common condition in infants due to undeveloped muscular muscles and lower esophageal sphincters. Persistence of the condition results in gastrointestinal reflux disease, which alters infant feeding patterns. As a natural phenomenon in children development, it is not attributed to any external factors because it resolves when the lower esophageal sphincter matures. Its global occurrence is estimated at 85 percent and affects more males than females. Diagnosis follows symptoms describing the extent of the effect such as green vomitus, baby crying, alteration in feeding, and loss of weight. Diagnostic tests used to ascertain the disease include esophageal pH monitoring, endoscopy, and X-ray. Once the diagnosis is determined, treatment is initiated. The infant’s mother is advised on changing lifestyle and at times the use of drugs is indicated. Research findings from various authors suggest consistency of information described. The articles have abstracts explaining objectives, introductions explaining why the research was conducted, elaborates on the methods used in the study, documents results, and discusses findings. The information gained from the studies will assist with the provision of education concerning the disease. Gastroesophageal reflux is a naturally occurring condition that ends when infants mature.

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