Pediatric Physical Therapy and Reflux

reflux in children

As Pediatric Therapists we encounter many young children with Gastroesophageal Reflux.  Some cases are mild and some have more clinical implications.  We are usually not brought in to directly treat the reflux, but it affects the child as a whole and our interventions can make a difference.  In this post I will break down the most recent research and provide some helpful tips for therapists and families to provide the child with less discomfort throughout the day and allow for more productive therapy sessions.

Let’s begin with the basics…What is Gastroesophageal Reflux?

According to Dr. Samuel Nurko, a specialist in Pediatric Gastrointestinal Motor Disorders at the Children’s Hospital of Boston,

“Gastroesophageal reflux (GER) is the backward flow of stomach contents up into the esophagus or the mouth. It happens to everyone. In babies, a small amount of GER is normal and almost always goes away by the time a child is 18 months old. This must be differentiated from Gastroesophageal reflux disease (GERD), which occurs when complications from GER arise, such as failure to gain weight, bleeding, respiratory problems or esophagitis.”


Other Symptoms of GERD can include:

  • crying/irritability
  • poor appetite/feeding and swallowing difficulties
  • failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting)
  • stomach aches (dyspepsia)
  • abdominal/chest pain (heartburn)
  • sore throat, hoarseness, apnea, laryngeal and tracheal stenoses,
  • asthma/wheezing, chronic cough and throat clearing
  • chronic sinusitis, ear infections/fluid, and dental caries.

When a child is experiencing symptoms associated with reflux, treatment sessions can be taxing on both the child, the parents and the therapist.  In order to address other concerns that may or may not be related to the reflux we must ensure that the child is as comfortable as possible.  The writhing motions, the tendency to arch and difficulty sustaining certain positions can greatly impact how we are able to intervene.

According to the American Academy of Otolaryngology-Head and Neck Surgery the prognosis for GER is good,

“In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at four months old.  An infant’s improved muscle control and the ability to sit up will lead to a spontaneous resolution of significant GER in more than half of infants by 10 months old, and four out of five at age 18 months. Researchers have found that 10 percent of infants younger than 12 months with GER develop significant complications.”

As Pediatric Physical Therapists we are looking for ways to minimize the discomfort, allow the child to elongate, relax the contracted muscles and to participate in activities of daily living which will enable them to develop strength, coordination, balance and achieve gross motor milestones.Reflux in Infants

Here is a breakdown of the current evidence related to the most widely held recommendations:

POSITIONING

  1. Head of Bed elevation to 30 degrees

imageimageHead of bed elevation is one of the first treatments recommended when infants display symptoms of GER.  It is suggested in many texts and articles, but lacks concrete evidence.  In fact according to a 2009 Cochrane Review by Craig et al,

“Head of bed elevation has shown no reduction in incidence or severity of symptoms.  Elevated pH in the esophagus was the same for infants positioned flat and with the head of bed elevated.  Prone and left lateral positioning was significantly superior to supine or right lateral positioning.  Comparing positioning greater than 30 degrees, for instance in a car seat or with wedges or other aides, found prone and left lateral position superior to elevation.” 

2. Positioning upright seated in car seat

imageTwo articles from the Journal of Pediatrics by Orenstein suggest that, “placing the infant upright in a car seat in fact exacerbated the symptoms of GER because the lower esophageal sphincter is more likely to be submerged in the 60 degree head elevated position.” Both length of GER episodes and duration were increased in the infants who were placed upright in car seat.

 3. Left Sidelying and Prone Position

sidelying baby

A study from the British Medical Journal studied prone, left sidelying and right sidelying position in terms of reflux severity, number of reflux episodes and duration of longest episode to assess effect of position on GER.  The results demonstrate that reflux severity, number of episodes and duration of episodes were significantly lower in prone and left sidelying position than right.  

The authors state, “The identification of a non-pharmacological treatment which reduces the severity of GER in this group-position-therefore has important implications for the management of these infants.”   

A study by Corvaglia in 2007 corroborated this finding, “the least occurrences of reflux found in prone and left lateral position”, and called these options “a simple way to limit GER”. 

Read more about helpful tips to encourage Tummy Time and toys to promote children to maintain and enjoy Tummy Time!

FEEDING

Another common recommendation is that thickened breast milk or formula may alter the stomach contents from fluid based to more solid based and thereby decrease the occurrence of regurgitation into the esophagus. A study by Corvaglia et al found that no reduction of GER has been noted from thickening breast milk or formula with a starch additive. In fact, a possible relationship between necrotizing enterocolitis and starch thickened breast milk was noted.  The Manual of Neonatal Care defines, “Necrotizing enterocolitis is an acute intestinal necrosis syndrome,  it is one of the most common surgical conditions in premature neonates and is a leading cause of premature neonatal death.”

MEDICATION

no-more-reflux-medicationAnti-reflux medications, known as Proton Pump Inhibitors or PPIs, are commonly prescribed for infants with GERD. PPIs inhibit gastric acid secretion.  The effectiveness of PPIs remains under debate, but doctors continue to prescribe these medications for infants and children with GERD An article from the 2009 Journal of Pediatrics, noted a lack of efficacy in clinical studies despite the widespread use of anti-reflux medications. The article states, “even though metoclopramide and ranitidine are not approved by the Food and Drug Administration for use in neonates, they are ranked first and fourth, respectively, among the medications most frequently used in the NICU”. 

According to a recent systemic review published in 2011, again from the Journal of Pediatrics, “PPIs may increase susceptibility to acute gastroenteritis and community acquired pneumonia, respiratory infections, gastric polyps, and bacterial overgrowth”.  The review interprets data from relevant studies and reveals, “PPIs are not effective in reducing GERD symptoms in infants.”  The authors recommend,

“If the primary aim is to treat GERD symptoms in infants, PPIs should not be prescribed.  There is insufficient evidence to support the effectiveness and safety of PPIs in the treatment of GERD in children and adolescents.  Physicians should be careful when prescribing PPIs, medications that are not approved for infants and have potential adverse effects.”

A wonderful review of the current research by Susan Pfister on Gastroesophageal Reflux sums it up well “For infants with symptomatic GER, a stepwise approach, based mainly on conservative interventions is the best therapeutic choice.”  Many clinical studies have been published that demonstrate no statistical benefit from medications or thickening of breast milk in the reduction of GER symptoms, yet these interventions continue to be prescribed in NICUs. Head of bed elevation has shown no reduction in incidence or severity of symptoms yet the practice has widespread prevalence. Finally the use of PPIs, the most commonly prescribed medication for children with GERD, has not shown positive outcomes and can cause extremely dangerous side effects.

Based on the up to date research review, interventions shown to demonstrate clinical significance to diminish symptoms of GER include:

Holding the infant upright after feedings to help eliminate some of the air from the stomach.  If caregiver can hold the infant for up to 30 minutes, the symptoms will be diminished and caregiver can help transition child to sleep state.  Initially position child in left lateral position for at least 30 minutes.  We will continue to monitor the research, to help the children and the families that we work with and care about so that they can achieve relief without exposing them to potential harm.

Learn more about Dinosaur Physical Therapy!

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References
  1. Corvalgia L, Monari C, Martini C, Aceti A, and Faldella G. Pharmacological Therapy of Gastroesophageal Reflux in Preterm Infants.  Gastroenterology Research and Practice. 2013.
  2. Craig, W. R.Hanlon-Dearman, A.Sinclair, C.Taback, S. & Moffatt, M. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two yearsCochrane Database Systematic ReviewsIssue 5.
  3. Ewer A.  Prone and left lateral positioning reduce Gastroesophaegel reflux in preterm infants. British Medical Journal. 1999.
  4. Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr. 1987; 110: 181-186.
  5. Orenstein SR, Orenstein D. Gastroesophageal reflux and respiratory disease in children. Journal Pediatr. 1988;112: 847-858.
  6. Pfister, Susan M. A Critical Review of the Literature Regarding Positioning for the Treatment of Gastroesophageal Reflux in Neonates. 2011.
  7. van der Pol RJ, et al. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics 2011;127: 925-935.
  8. Wheatley E, Kennedy K. Cross-over trial of treatment for bradycardia attributed to gastroesophageal reflux in preterm infants. Journal Pediatric. 2009; 155: 516-521.

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  • I worked as an Infant Teacher for a Child Care Center where some of our infants had reflux problems. State Regulations often prohibit some of the positioning recommendations due to licensing issues unless medically approved and documented. I encouraged parents to obtain specific positioning instructions from their Pediatrician and/or Therapist to ensure documentation was available in the event of a state licensing visit. Additionally, the positioning requirement was posted on each infant’s crib using a visible, laminated tag to read “Special Permission for Positioning Adaptations by Pediatrician/Therapist on File.” A copy of Pediatrician’s/Therapist’s guidelines was also attached to the back of each child’s chart. Parents need to know that there are always options if child is enrolled in a Child Care Program. Make sure staff understand the protocol and encourage them to contact you at any time if concerns arise.