עיכול ג: Esophageal Atresia, Transesophageal Fistula, GER & GERD

Pediatric gastrointestinal disorders covering esophageal atresia, tracheoesophageal fistula, VACTERL, diagnostic investigations, preoperative and postoperative nursing care, surgical repair, GER versus GERD, clinical manifestations, feeding management, pharmacological treatment, and Nissen fundoplication.

Esophageal Atresia (EA): Definition

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Congenital interruption of the esophagus; one or both ends terminate in a blind pouch instead of forming a continuous route to the stomach. 𝗘𝗳𝗳𝗲𝗰𝘁: Swallowed milk and saliva cannot pass normally to the stomach → pooling, regurgitation, and aspiration risk.

Tracheoesophageal Fistula (TEF): Definition

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: An abnormal connection between the trachea and esophagus. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Secretions, swallowed contents, or gastric contents may enter the airway → choking and aspiration. Air may also travel from trachea into the GI tract.

EA and TEF: Embryological Cause

𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Abnormal separation of the developing foregut into trachea and esophagus. 𝗥𝗲𝗹𝗮𝘁𝗶𝗼𝗻𝘀𝗵𝗶𝗽: EA and TEF frequently occur together but can also occur separately

Ultrasound & Polyhydramnios Indicating EA/TEF

𝗡𝗼𝗿𝗺𝗮𝗹: The fetus swallows amniotic fluid, which travels through the GI tract and is absorbed. 𝗣𝗼𝗹𝘆𝗵𝘆𝗱𝗿𝗮𝗺𝗻𝗶𝗼𝘀: Esophageal obstruction impairs effective swallowing and absorption → amniotic fluid accumulates. The slide describes polyhydramnios as more than 2,000 mL. 𝗨𝗹𝘁𝗿𝗮𝘀𝗼𝘂𝗻𝗱 𝗙𝗶𝗻𝗱𝗶𝗻𝗴𝘀: Polyhydramnios and a small or absent fetal stomach bubble because swallowed fluid does not reach the stomach normally. 𝗙𝗼𝗹𝗹𝗼𝘄-𝘂𝗽: Targeted fetal anomaly scan to identify EA/TEF and associated congenital abnormalities.

EA/TEF: Further Investigation for VACTERL

𝗙𝗿𝗲𝗾𝘂𝗲𝗻𝗰𝘆: Approximately 50% of infants with EA/TEF have additional congenital abnormalities. 𝗩𝗔𝗖𝗧𝗘𝗥𝗟 𝗔𝘀𝘀𝗼𝗰𝗶𝗮𝘁𝗶𝗼𝗻 𝗩: Vertebral anomalies 𝗔: Anal anomalies, including anal atresia 𝗖: Cardiac anomalies 𝗧𝗘: Tracheoesophageal abnormalities 𝗥: Renal anomalies, including kidney malformations 𝗟: Limb anomalies 𝗜𝗻𝘃𝗲𝘀𝘁𝗶𝗴𝗮𝘁𝗶𝗼𝗻: A targeted anomaly assessment is needed to identify associated abnormalities. 𝗣𝗮𝘀𝘁 𝗘𝘅𝗮𝗺𝘀 (𝟮𝟬𝟮𝟮 𝗔𝗹𝗲𝗽𝗵 𝗤𝟳; 𝟮𝟬𝟮𝟲 𝗔𝗹𝗲𝗽𝗵 𝗣𝗶𝘀𝗴𝗮𝗵 𝗤𝟯𝟮): Know that EA/TEF can be associated with VACTERL, particularly renal abnormalities and anal atresia.

EA & TEF: Signs & Symptoms

𝗢𝗻𝘀𝗲𝘁: Typically immediately after birth or during the first feeding. 𝗧𝗵𝗲 𝗧𝗵𝗿𝗲𝗲 𝗖𝘀: Coughing, Choking, Cyanosis, especially when feeding. 𝗙𝗿𝗼𝘁𝗵𝘆 𝗦𝗮𝗹𝗶𝘃𝗮 & 𝗗𝗿𝗼𝗼𝗹𝗶𝗻𝗴: Saliva collects in the blind upper esophageal pouch → persistent frothy secretions around the mouth and nose, even after suctioning. 𝗥𝗲𝘀𝗽𝗶𝗿𝗮𝘁𝗼𝗿𝘆: Secretions or swallowed milk may enter the airway → choking, cyanosis, respiratory distress, and aspiration. 𝗔𝗯𝗱𝗼𝗺𝗶𝗻𝗮𝗹 𝗗𝗶𝘀𝘁𝗲𝗻𝘀𝗶𝗼𝗻: With a distal TEF, air passes from the trachea through the fistula into the stomach and intestines → abdominal distension.

EA/TEF: What Are the Three Cs?

𝟭: Coughing 𝟮: Choking 𝟯: Cyanosis 𝗪𝗵𝗲𝗻: Especially during feeding, due to aspiration of milk or pooled secretions into the airway.

PAST EXAM: 2024 Bet, Q8

𝗤: A newborn after birth is observed to have respiratory difficulty, frothy saliva coming from the mouth and nose, and persistent coughing. After suctioning is performed, a similar event occurs again. What is the appropriate diagnosis? 𝗘𝘅𝗮𝗰𝘁 𝗔𝗻𝘀𝘄𝗲𝗿: Tracheoesophageal fistula

EA/TEF: NG/OG Tube Diagnostic Test

𝗠𝗲𝘁𝗵𝗼𝗱: Gently insert an NG or OG tube, usually 8–10 Fr. 𝗦𝘂𝗴𝗴𝗲𝘀𝘁𝗶𝘃𝗲 𝗙𝗶𝗻𝗱𝗶𝗻𝗴: In EA, the tube meets resistance and cannot advance past the blind pouch, often around 10–12 cm from the gums. 𝗖𝗼𝗻𝗳𝗶𝗿𝗺𝗮𝘁𝗶𝗼𝗻: X-ray with tube in place shows it stopping or coiling in the upper esophagus.

PAST EXAM: 2024 Aleph, Q3

𝗤: How can a tracheoesophageal fistula be diagnosed? 𝗘𝘅𝗮𝗰𝘁 𝗔𝗻𝘀𝘄𝗲𝗿: Insertion of a nasogastric tube to confirm esophageal obstruction, followed by an X-ray with the tube in place

Following Suspected Diagnosis of EA/TEF: Immediate Priorities

𝗡𝗣𝗢: Stop all oral feeding to prevent aspiration. 𝗔𝗶𝗿𝘄𝗮𝘆: Suction pooled upper-pouch secretions and monitor breathing and oxygen saturation. 𝗦𝘂𝗽𝗽𝗼𝗿𝘁: Provide IV fluids; arrange investigations and surgical evaluation.

EA/TEF: What Does Abdominal Gas Tell You?

𝗚𝗮𝘀𝗹𝗲𝘀𝘀/𝗦𝗰𝗮𝗽𝗵𝗼𝗶𝗱 𝗔𝗯𝗱𝗼𝗺𝗲𝗻: Suggests pure EA without a distal TEF; airway air cannot reach the stomach. 𝗚𝗮𝘀 𝗶𝗻 𝗦𝘁𝗼𝗺𝗮𝗰𝗵/𝗜𝗻𝘁𝗲𝘀𝘁𝗶𝗻𝗲𝘀: Suggests a distal TEF; air passes from trachea through fistula into the GI tract.

Types of EA & TEF

𝗠𝗮𝗶𝗻 𝗗𝗶𝘀𝘁𝗶𝗻𝗰𝘁𝗶𝗼𝗻: EA = esophagus is interrupted → food cannot pass normally into the stomach. TEF = abnormal connection between airway and esophagus → air can enter the stomach if the fistula connects the trachea to the distal esophagus. 𝗧𝘆𝗽𝗲 𝗔: EA without TEF → gasless abdomen. 𝗧𝘆𝗽𝗲 𝗕: EA + proximal TEF → rare. 𝗧𝘆𝗽𝗲 𝗖: EA + distal TEF → most common (80–90%). 𝗧𝘆𝗽𝗲 𝗗: EA + proximal and distal TEF → two fistulas. 𝗧𝘆𝗽𝗲 𝗘 (𝗛-𝘁𝘆𝗽𝗲): TEF without EA → esophagus remains continuous; swallowing possible, but aspiration can occur. 𝗠𝗼𝘀𝘁 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝘁 — 𝗧𝘆𝗽𝗲 𝗖 (𝟴𝟬–𝟵𝟬%): The upper esophagus ends in a blind pouch (EA), while the lower esophagus connects to the trachea through a fistula (distal TEF). Air can reach the stomach, but swallowed food cannot pass normally from the mouth into the stomach. 𝗜𝗺𝗮𝗴𝗲: Add anatomical classification image manually in Knowt.

EA/TEF: How Is the Anatomy Further Defined?

𝗜𝗺𝗮𝗴𝗶𝗻𝗴: Chest and abdominal X-ray to assess tube position and abdominal air. 𝗔𝗱𝗱𝗶𝘁𝗶𝗼𝗻𝗮𝗹 𝗦𝘁𝘂𝗱𝗶𝗲𝘀: Fluoroscopy and/or bronchoscopy may be used to locate a fistula and guide surgery.

EA/TEF: Short Gap vs. Long Gap

𝗦𝗵𝗼𝗿𝘁 𝗚𝗮𝗽: Approximately less than 3–4 cm in the lesson → often permits tension-free primary anastomosis. 𝗟𝗼𝗻𝗴 𝗚𝗮𝗽: Approximately greater than 3–4 cm → may require delayed or staged repair. 𝗥𝗲𝗮𝘀𝗼𝗻: Excessive tension on a new anastomosis increases leak and stricture risk; feasibility depends on individual anatomy.

EA & TEF: Preoperative Nursing & Airway Management

𝗠𝗮𝗶𝗻 𝗣𝗿𝗶𝗼𝗿𝗶𝘁𝘆: Maintain a patent airway and prevent aspiration pneumonia. 𝗥𝗲𝗽𝗹𝗼𝗴𝗹𝗲 𝗧𝘂𝗯𝗲 𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Double-lumen tube placed in the blind upper esophageal pouch. 𝗠𝗮𝗶𝗻 𝗟𝘂𝗺𝗲𝗻: Continuous low-pressure suction removes pooled saliva and secretions. 𝗦𝗲𝗰𝗼𝗻𝗱 𝗟𝘂𝗺𝗲𝗻: Allows air entry/irrigation as prescribed to maintain catheter patency and prevent blockage. 𝗣𝗼𝘀𝗶𝘁𝗶𝗼𝗻𝗶𝗻𝗴: Elevate the head approximately 45° according to the lecture to reduce secretion pooling and aspiration. 𝗡𝘂𝗿𝘀𝗶𝗻𝗴 𝗠𝗼𝗻𝗶𝘁𝗼𝗿𝗶𝗻𝗴: Assess respiratory status, oxygen saturation, secretion output, and signs of aspiration or infection. 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝘁: The 45° positioning refers to monitored preoperative care, not routine infant sleep positioning.

EA & TEF: Preoperative Fluids, Electrolytes, Medications & Nutrition

𝗡𝗣𝗢: Strictly no oral intake to prevent aspiration. 𝗙𝗹𝘂𝗶𝗱𝘀: Provide IV fluids to maintain hydration and electrolyte balance. 𝗘𝗹𝗲𝗰𝘁𝗿𝗼𝗹𝘆𝘁𝗲𝘀: Saliva contains chloride; ongoing loss through suction may contribute to electrolyte disturbances → monitor blood electrolytes, fluid balance, and hydration. 𝗠𝗲𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀: Give preoperative antibiotics as prescribed, according to the lecturer. 𝗡𝘂𝘁𝗿𝗶𝘁𝗶𝗼𝗻: TPN may be required if enteral feeding cannot be established promptly.

Surgical Repair of EA & TEF

𝗣𝗿𝗶𝗺𝗮𝗿𝘆 𝗥𝗲𝗽𝗮𝗶𝗿 — 𝗦𝗵𝗼𝗿𝘁-𝗚𝗮𝗽 𝗘𝗔 𝗪𝗵𝗲𝗻: The gap between the two esophageal ends is short enough to allow a safe, tension-free connection. 𝗣𝗿𝗼𝗰𝗲𝗱𝘂𝗿𝗲: Surgeon identifies, divides, and closes the TEF if present → performs an end-to-end anastomosis, joining the upper and lower esophagus. 𝗦𝘂𝗿𝗴𝗶𝗰𝗮𝗹 𝗔𝗽𝗽𝗿𝗼𝗮𝗰𝗵𝗲𝘀 𝗧𝗵𝗼𝗿𝗮𝗰𝗼𝘀𝗰𝗼𝗽𝘆: Minimally invasive chest surgery using a camera. 𝗧𝗵𝗼𝗿𝗮𝗰𝗼𝘁𝗼𝗺𝘆: Open surgical approach through the chest. 𝗦𝘁𝗮𝗴𝗲𝗱 𝗥𝗲𝗽𝗮𝗶𝗿 — 𝗟𝗼𝗻𝗴-𝗚𝗮𝗽 𝗘𝗔 𝗪𝗵𝘆: Segments cannot be safely joined immediately because of excessive tension. 𝗜𝗻𝗶𝘁𝗶𝗮𝗹 𝗠𝗮𝗻𝗮𝗴𝗲𝗺𝗲𝗻𝘁: May involve fistula closure, upper-pouch drainage, and feeding access. 𝗟𝗮𝘁𝗲𝗿: Definitive esophageal reconstruction; occasionally esophageal replacement is required. 𝗚𝗮𝗽 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝗰𝗲: Excessive tension increases the risk of anastomotic leakage and stricture formation.

EA & TEF: Postoperative Management

𝗠𝗮𝗶𝗻 𝗣𝗿𝗶𝗼𝗿𝗶𝘁𝗶𝗲𝘀: Protect the esophageal anastomosis, prevent aspiration, and monitor for complications. 𝗦𝘂𝗰𝘁𝗶𝗼𝗻𝗶𝗻𝗴 𝗣𝗿𝗲𝗰𝗮𝘂𝘁𝗶𝗼𝗻𝘀 𝗗𝗮𝗻𝗴𝗲𝗿: Inserting a suction catheter too deeply can damage the newly repaired esophagus and cause a potentially life-threatening anastomotic leak. 𝗡𝘂𝗿𝘀𝗶𝗻𝗴 𝗥𝘂𝗹𝗲: Suction only to the prescribed depth with a premeasured catheter. 𝗣𝗼𝘀𝘁𝗼𝗽𝗲𝗿𝗮𝘁𝗶𝘃𝗲 𝗘𝘀𝗼𝗽𝗵𝗮𝗴𝗿𝗮𝗺 𝗧𝗶𝗺𝗶𝗻𝗴: Usually around postoperative day 5–7 according to the lecture; follow surgical protocol. 𝗣𝘂𝗿𝗽𝗼𝘀𝗲: Contrast study assesses the anastomosis for leakage before oral feeding begins. 𝗡𝗼𝗻-𝗡𝘂𝘁𝗿𝗶𝘁𝗶𝘃𝗲 𝗦𝘂𝗰𝗸𝗶𝗻𝗴 𝗜𝗻𝘁𝗲𝗿𝘃𝗲𝗻𝘁𝗶𝗼𝗻: Encourage pacifier use as appropriate during prolonged NPO periods. 𝗕𝗲𝗻𝗲𝗳𝗶𝘁: Helps maintain sucking skills and reduce oral hypersensitivity or aversion.

EA/TEF Repair: Anastomotic Stricture

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Scar-related narrowing at the site where the esophagus was rejoined. 𝗦𝗶𝗴𝗻𝘀: Dysphagia, choking, vomiting, or food getting stuck. 𝗧𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁: Esophageal balloon dilation, sometimes repeated.

EA/TEF: Tracheomalacia

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Weak tracheal cartilage permits excessive airway collapse during breathing. 𝗦𝗶𝗴𝗻𝘀: Barking cough, stridor, and respiratory or aspiration-related difficulties. 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝗰𝗲: Possible complication/associated condition after EA/TEF repair.

EA/TEF: Discharge Feeding Precautions

𝗙𝗼𝗼𝗱 𝗣𝗿𝗲𝗽𝗮𝗿𝗮𝘁𝗶𝗼𝗻: Cut solid food into very small pieces; avoid large meat pieces and whole sausages/hot dogs. 𝗘𝗮𝘁𝗶𝗻𝗴 𝗛𝗮𝗯𝗶𝘁𝘀: Encourage thorough chewing and careful swallowing; offer fluids with meals as appropriate. 𝗪𝗵𝘆: Prevent food becoming lodged at a narrowed/repaired esophagus.

PAST EXAM: 2026 Aleph Pisgah, Q33

𝗤: As part of parental education before discharge, what should parents do to prevent obstruction of the repaired esophagus? 𝗘𝘅𝗮𝗰𝘁 𝗔𝗻𝘀𝘄𝗲𝗿: Cut solid foods into very small pieces, teach the child to chew thoroughly, and avoid foods such as hot dogs or large pieces of mea

Gastroesophageal Reflux (GER): Definition

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Backward movement of gastric contents into the esophagus. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Usually caused by transient relaxation of the lower esophageal sphincter (LES). 𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗣𝗼𝗶𝗻𝘁: Common physiological event in infants.

Gastroesophageal Reflux (GER) in Infants

𝗥𝗲𝗮𝘀𝗼𝗻: The lower esophageal sphincter (LES) is still developing. Temporary LES relaxation permits milk and gastric contents to reflux upward. 𝗣𝗲𝗮𝗸: Around 4 months of age. 𝗥𝗲𝘀𝗼𝗹𝘂𝘁𝗶𝗼𝗻: Usually improves spontaneously; often resolves by 12–24 months. 𝗛𝗮𝗽𝗽𝘆 𝗦𝗽𝗶𝘁𝘁𝗲𝗿: An infant who spits up milk but remains comfortable, feeds adequately, and gains weight normally. 𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗜𝗺𝗽𝗹𝗶𝗰𝗮𝘁𝗶𝗼𝗻: Usually physiological GER, not GERD.

Gastroesophageal Reflux Disease (GERD): Definition

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Reflux that produces troublesome symptoms or complications. 𝗘𝘅𝗮𝗺𝗽𝗹𝗲𝘀: Feeding difficulty, esophagitis, esophageal injury, or failure to thrive. 𝗗𝗶𝘀𝘁𝗶𝗻𝗰𝘁𝗶𝗼𝗻: The disease is defined by clinical harm, not just the presence of regurgitation.

GERD in Infants: Signs & Symptoms

𝗚𝗜/𝗙𝗲𝗲𝗱𝗶𝗻𝗴: Frequent regurgitation or vomiting, feeding refusal, irritability, or back arching, particularly during or after feeds. 𝗚𝗿𝗼𝘄𝘁𝗵: Poor weight gain or failure to thrive (FTT). 𝗥𝗲𝘀𝗽𝗶𝗿𝗮𝘁𝗼𝗿𝘆: Choking, aspiration, recurrent cough, hoarseness, wheezing, or asthma-like symptoms. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Reflux-related aspiration or irritation may contribute to respiratory symptoms. 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝘁: Respiratory symptoms alone do not establish GERD.

Sandifer Syndrome: Definition

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Unusual posturing of the head, neck, or back associated with gastroesophageal reflux. 𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗖𝗹𝘂𝗲: May resemble a neurologic disorder but occurs in association with reflux.

GERD in Older Children: Signs & Symptoms

𝗦𝘆𝗺𝗽𝘁𝗼𝗺𝘀: Pyrosis (heartburn), retrosternal discomfort, abdominal pain, or dysphagia. 𝗔𝗱𝗱𝗶𝘁𝗶𝗼𝗻𝗮𝗹: Some have cough, hoarseness, or wheezing when reflux contributes.

GERD: Diagnostic Investigations

𝟭. 𝟮𝟰-𝗛𝗼𝘂𝗿 𝗘𝘀𝗼𝗽𝗵𝗮𝗴𝗲𝗮𝗹 𝗽𝗛 𝗠𝗼𝗻𝗶𝘁𝗼𝗿𝗶𝗻𝗴 — 𝗚𝗼𝗹𝗱 𝗦𝘁𝗮𝗻𝗱𝗮𝗿𝗱 𝗳𝗼𝗿 𝗔𝗰𝗶𝗱 𝗥𝗲𝗳𝗹𝘂𝘅 𝗔𝘀𝘀𝗲𝘀𝘀𝗺𝗲𝗻𝘁 𝗠𝗲𝗮𝘀𝘂𝗿𝗲𝘀: Frequency and duration of esophageal acid exposure. 𝗔𝗰𝗶𝗱 𝗥𝗲𝗳𝗹𝘂𝘅: Esophageal pH below 4 indicates acid reflux episodes. 𝗣𝘂𝗿𝗽𝗼𝘀𝗲: Compare reflux episodes with recorded symptoms; combined pH-impedance monitoring can also identify non-acid reflux. 𝟮. 𝗨𝗽𝗽𝗲𝗿 𝗚𝗜 𝗖𝗼𝗻𝘁𝗿𝗮𝘀𝘁 𝗦𝘁𝘂𝗱𝘆 (𝗕𝗮𝗿𝗶𝘂𝗺 𝗦𝘄𝗮𝗹𝗹𝗼𝘄) 𝗣𝘂𝗿𝗽𝗼𝘀𝗲: Identify or exclude anatomical abnormalities, such as malrotation or esophageal strictures. 𝗟𝗶𝗺𝗶𝘁𝗮𝘁𝗶𝗼𝗻: A contrast study alone does not diagnose GERD. 𝟯. 𝗨𝗽𝗽𝗲𝗿 𝗚𝗜 𝗘𝗻𝗱𝗼𝘀𝗰𝗼𝗽𝘆 𝘄𝗶𝘁𝗵 𝗕𝗶𝗼𝗽𝘀𝘆 — 𝗗𝗶𝗮𝗴𝗻𝗼𝘀𝘁𝗶𝗰 𝗧𝗲𝘀𝘁 𝗠𝗲𝘁𝗵𝗼𝗱: Visualize the esophageal mucosa and collect tissue samples. 𝗜𝗱𝗲𝗻𝘁𝗶𝗳𝗶𝗲𝘀: Esophagitis, strictures, other mucosal abnormalities, and complications of reflux.

Barrett Esophagus: Reflux Complication

𝗗𝗲𝗳𝗶𝗻𝗶𝘁𝗶𝗼𝗻: Metaplastic change of the esophageal lining linked to chronic acid-related injury. 𝗣𝗲𝗱𝗶𝗮𝘁𝗿𝗶𝗰 𝗥𝗲𝗹𝗲𝘃𝗮𝗻𝗰𝗲: Rare in children; may be considered in severe longstanding disease.

GER/GERD: Nursing Management & Parental Education

𝗙𝗶𝗿𝘀𝘁-𝗟𝗶𝗻𝗲 𝗧𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁: Parent education and feeding modifications rather than routine medication for uncomplicated infant reflux. 𝟭. 𝗦𝗺𝗮𝗹𝗹, 𝗙𝗿𝗲𝗾𝘂𝗲𝗻𝘁 𝗙𝗲𝗲𝗱𝗶𝗻𝗴𝘀 𝗠𝗲𝘁𝗵𝗼𝗱: Offer smaller quantities more often, without overfeeding; encourage calm, unhurried feeding. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Less gastric distension and pressure at the LES → less regurgitation. 𝟮. 𝗧𝗵𝗶𝗰𝗸𝗲𝗻𝗲𝗱 𝗙𝗲𝗲𝗱𝘀 𝗣𝘂𝗿𝗽𝗼𝘀𝗲: Increasing the viscosity of milk can reduce visible regurgitation. 𝗟𝗲𝗰𝘁𝘂𝗿𝗲𝗿 𝗔𝗺𝗼𝘂𝗻𝘁: Approximately 1 teaspoon to 1 tablespoon of rice cereal per ounce of milk. 𝗦𝗮𝗳𝗲𝘁𝘆: Thickening method and amount must be individually prescribed according to the infant’s age, feeding type, and clinical needs. 𝟯. 𝗣𝗼𝘀𝗶𝘁𝗶𝗼𝗻𝗶𝗻𝗴 𝗔𝗳𝘁𝗲𝗿 𝗙𝗲𝗲𝗱𝗶𝗻𝗴: Hold the infant upright for approximately 30 minutes while awake and supervised. 𝗗𝘂𝗿𝗶𝗻𝗴 𝗦𝗹𝗲𝗲𝗽: Always place the infant supine (on the back) on a firm, flat sleeping surface without pillows or inclined positioning. 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝘁: GER/GERD does not justify unsafe sleeping positions due to SIDS risk. 𝗣𝗮𝘀𝘁 𝗘𝘅𝗮𝗺 — 𝟮𝟬𝟮𝟲 𝗔𝗹𝗲𝗽𝗵 𝗣𝗶𝘀𝗴𝗮𝗵, 𝗤𝟯𝟭 𝗤: What is the appropriate education for a child with gastroesophageal reflux disease? 𝗔: Small, frequent feedings; feeding in an elevated position; thickening the formula.

GERD: Notes on Acid Suppression

𝗜𝗻𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻: Acid-suppressing medications are used in selected GERD cases with significant acid-related symptoms or complications, especially when conservative measures are insufficient. 𝗡𝗼𝘁 𝗙𝗼𝗿: Routine physiological infant regurgitation (GER) alone. 𝗪𝗵𝗮𝘁 𝗔𝗰𝗶𝗱 𝗦𝘂𝗽𝗽𝗿𝗲𝘀𝘀𝗶𝗼𝗻 𝗗𝗼𝗲𝘀: Reduces gastric acidity and acid-mediated esophageal mucosal injury. 𝗪𝗵𝗮𝘁 𝗜𝘁 𝗗𝗼𝗲𝘀 𝗡𝗢𝗧 𝗗𝗼: Does not necessarily stop stomach contents from physically refluxing into the esophagus.

GERD: Acid Suppression, H2 Blockers & PPIs

𝟭. 𝗛𝟮-𝗥𝗲𝗰𝗲𝗽𝘁𝗼𝗿 𝗕𝗹𝗼𝗰𝗸𝗲𝗿𝘀 𝗘𝘅𝗮𝗺𝗽𝗹𝗲: Famotidine. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Blocks histamine H2 receptors on gastric parietal cells → reduced gastric acid secretion. 𝟮. 𝗣𝗿𝗼𝘁𝗼𝗻 𝗣𝘂𝗺𝗽 𝗜𝗻𝗵𝗶𝗯𝗶𝘁𝗼𝗿𝘀 (𝗣𝗣𝗜𝘀) 𝗘𝘅𝗮𝗺𝗽𝗹𝗲𝘀: Omeprazole and lansoprazole. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Inhibit the H+/K+-ATPase proton pump in gastric parietal cells, blocking the final step of acid secretion. 𝗕𝗲𝗻𝗲𝗳𝗶𝘁: More potent acid suppression; supports healing of erosive esophagitis. 𝗣𝗣𝗜 𝗔𝗱𝗺𝗶𝗻𝗶𝘀𝘁𝗿𝗮𝘁𝗶𝗼𝗻 — 𝟯𝟬-𝗠𝗶𝗻𝘂𝘁𝗲 𝗥𝘂𝗹𝗲 𝗧𝗶𝗺𝗶𝗻𝗴: For PPIs prescribed before meals, administer approximately 30 minutes before breakfast or the first meal. 𝗪𝗵𝘆: Food stimulates proton pump activity, allowing the medication to inhibit active pumps effectively. 𝗣𝗿𝗮𝗰𝘁𝗶𝗰𝗲: Follow the prescribed medication and formulation instructions.

GERD: Nissen Fundoplication

𝗜𝗻𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻: Selected cases of severe GERD when conservative and pharmacological treatment have failed or significant complications develop. 𝗣𝗼𝘀𝘀𝗶𝗯𝗹𝗲 𝗜𝗻𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀: Recurrent aspiration, severe esophagitis, persistent reflux-related complications, or failure to thrive (FTT). 𝗣𝗿𝗼𝗰𝗲𝗱𝘂𝗿𝗲: The surgeon wraps the gastric fundus approximately 360° around the lower esophagus. 𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Reinforces the antireflux barrier → reduces backward movement of gastric contents into the esophagus. 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝘁: Not a routine treatment for uncomplicated infant GER. 𝗣𝗼𝘀𝘁𝗼𝗽𝗲𝗿𝗮𝘁𝗶𝘃𝗲 𝗡𝗼𝘁𝗲: Gas-bloat syndrome can develop because the tighter antireflux barrier may make it difficult to belch or vomit.

Nissen Fundoplication: Gas-Bloat Syndrome

𝗠𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝗺: Tighter antireflux barrier may make burping or vomiting difficult. 𝗦𝘆𝗺𝗽𝘁𝗼𝗺𝘀: Trapped gas → bloating, abdominal distension, discomfort or pain. 𝗠𝗮𝗻𝗮𝗴𝗲𝗺𝗲𝗻𝘁: A gastrostomy tube (GT) may sometimes be used to vent gas