GASTROESOPHAGEAL REFLUX

What is gastroesophageal reflux disease (GERD or GER)

The gastroesophageal reflux, although it is a real condition, is "fashion". It is demonstrated by the flourishing of milk called AR, reflux, than vice versa, as we shall see, are not true indications in the treatment of this condition. For gastroesophageal reflux means, just as its name implies, the flow down the back into the esophagus, the material contained in the stomach, milk, mucus, acids. This situation is mainly due to inappropriate relaxation of the LES (lower esophageal sphincter) that is the mechanism that "stage" the stomach and prevent, under normal conditions, the return to the top of the substances contained in it. It is a frequent phenomenon and nearly normal in the small infant but, in certain situations, may be responsible for a disease condition.
E 'must, therefore, first of all, clearly distinguish the RGE functional, normal, and disease gastroesophageal reflux disease (GERD or GERD).
RGE The child with the so-called functional regurgitant happy (happy spitter) which has only a delayed maturation of SLE. The regurgitant happy is lattantino regurgitating, sometimes quite abundant, even after the meal, but the state of health is good and growth is normal. It is the children who spit a lot, often belching and hiccups, often seems, when they are lying, that the milk back to the mouth and they almost "chew". But, and this is the fundamental fact, these children are well, grow sufficiently, they are not suffering, they have crying spells than those customary for young infants. Remember that the normal child is crying and normally can do, even in the absence of disease, even 2-3 hours a day. However, often in these cases there is a state of suffering and anxiety in parents, who play regurgitation and other phenomena as signs of "indigestion", and require an intervention of the pediatrician. Frequent in these cases are the changes of the milk, the frequent use of drugs normally poorly effective.
In reflux disease, vice versa, are the most important symptoms that express the presence of complications in the digestive system and the respiratory system. Such complications are determined by the reflux of acid into the esophagus and into the airways. The acid can cause injury in the lower part of the esophagus, the immediately overlying the stomach (gastroesophageal reflux esophagitis) or "irritation" and even most of the streets of breath.

Are indicative of the presence of reflux disease:

- The crying much more intense than usual. It 'sa crying "angry", violent, long-lasting, inconsolable;
- dysphagia, namely that the child feels pain when swallowing milk. The child often begins to suck from a bottle but after some swallowing stands out crying vigorously and often crying is arched backwards and arching the neck back. This way of crying, that tears into "opisthotonos" with the buckle of the trunk and neck is called Sandifer's syndrome and is an expression of esophagitis and esophageal pain;
- refusal of food,
- growth retardation,
- an increase in the frequency and intensity of vomiting,
- the crisis of apnea and "near-death" or HIGH. The crisis of "obstructive apnea" are crises stop breathing when the child behaves as if "something" lock up your breath is agitated, often moves vigorously. It 'sa terrific event for the parent and frequent reason for despair ran to the hospital. Similarly terrible for the parent, and dangerous, is the experience of "near-death". The mother is the child in the cradle practically lifeless, motionless and apparently lifeless, and can only resume operations excited to do so;
- asthma, cough at night and when the child is lying down, breathing problems to the so-called bronchopneumonia by inhalation refluxed material.

Gastroesophageal reflux is due to milk allergy?

The relationship between the two entities is certain: there are cases of RGE healed only with the dieta.Il EJN and food allergy, especially cow's milk, the milk that is usually used for the infant that cow's milk are obtained, are both common in the first year of life and have common symptoms such as:

- Vomiting,
- regurgitation,
- the poor growth,
- the pain, that is the crying characteristics, intensity and duration, other than crying "trivial" of the infant
- apneas,
- the bronchopneumonia.
It is a species of snake that bites its own tail: on the one hand it is possible that food allergy may help with allergic gastritis and abnormal movements of the stomach, gastroesophageal reflux, reflux can on the other, in turn, promote the allergy through the lower esophageal erosions of the region and the absorption of protein molecules in the milk.
According to some statistics in the very young child, 42% of cases of GERD is induced by PLV (cow's milk protein).
suggest the RGE induced by PLV:
a) family history of allergic diseases,
c) growth retardation,
d) failure to conduct adequate response to therapy (ranitidine or omeprazole and other "pump inhibitors.")
It is not necessary to perform allergy testing because, as mentioned in the paragraph relating to cow's milk in gastroesophageal reflux disease as well as in most diseases from milk allergy affecting the digestive system, the tests are often negative, and those performed on the skin than those performed on blood. The real test is, as always in these cases, the elimination test (test of elimination) of cow's milk and its readministration, after it has obtained a significant improvement. This, so to speak, rebuttal (provocation test) should, if the milk was really responsible for the symptoms, induce the reappearance of the symptoms of reflux disease.
then occur when those conditions that suggest a role of allergy to milk is to be carried out directly test elimination of PLV, preferably with total hydrolyzate ( Neocate or Pregomin AS ) or even pushed hydrolyzate. RGE In that does not respond to proper treatment, medication, postural and thickening of the diet, or in cases with poor growth, is should always do a test of elimination of PLV.

How is it diagnosed

For the diagnosis of gastroesophageal reflux disease, it is not necessary in the first instance, any finding or laboratory or instrumental, nor are they necessary inquiries allergy. The diagnosis is clinical and reflux from all of the symptoms that your child has, the doctor should decide if it is trivial reflux or reflux disease and this is evident from the ailments that your child has.
diagnosis of GER in is abused vice versa instrumental tests, there is an exaggerated invasiveness and above all at the level of specialist facilities. An examination often executed very popular to the point that they are the same parents often ask for it, is an ultrasound scan of the region-gatrica esophagus. It drastically it can be said that you should never ask for and do the ultrasound in the diagnosis of reflux because it has no utility from the operational point of view. Ultrasonography in the diagnosis of GER has several limitations:
- it is operator-dependent, ie it depends very much on the ability of interpretation of the doctor who performs it,
- is a test temporary, limited in time. It assesses, in other words, the presence of reflux from the stomach into the esophagus only in the limited period of time in which it performs the examination. The reflux, vice versa, is not constant and is not present at all times and it is possible that in the few minutes of observation with ultrasound does not occur if they have none. It may happen that the examination is negative and maybe, as soon as the baby regurgitates and vomiting, demonstrating practically that the reflux from the stomach there and how!,
- but even if the test is positive, that is, observe the presence of reflux in the period in which it runs it for the doctor has no utility. The physician need not demonstrate the presence of reflux, which is already evident from the behavior of the child, the regurgitation, the belching, etc. to rumination., Your doctor should decide if it is trivial reflux or reflux disease and This, on the contrary, the ultrasound is not discriminating, it is not useful.

So the ultrasound is not useful because its negativity does not exclude the presence of pathological GER as well as its positive adds nothing to what the doctor already knows based on the history of the child and its symptoms.
Ultrasound junction esophagogastric may be useful in some cases, to distinguish the RGE from hypertrophic pyloric stenosis, other disease of the very young child who, in common with reflux, vomiting as a dominant symptom or for evidence of hernia of the stomach above the diaphragm (hiatal hernia).
Among the other tests, can only be performed in specialized facilities,
- the computerized pH monitoring can not be used in young children, the pH monitoring must also be reserved for cases of disease RGE important, complicated.
- with the 'endoscopic examination (gastroesofagoscopia) certainly are displayed the characters of esophagitis, but endoscopy can not be used in the first instance and in all cases.

These more detailed investigations at higher-level structures should be reserved for cases that really matter and not responding to therapy, children with serious complications.
In ambulatory practice is authorized in concrete suspicion of reflux disease, an attempt ex juvantibus (test trial) with antisecretory (see below), without further examination.
juvantibus The former criterion may therefore be useful. To make the diagnosis, however, must use the drugs mixed acid secretion (ranitidine and so-called proton pump inhibitors) and not the prokinetic as Plasil or Peridon, which regulate the movements of the stomach wall. The disease is not cured by the RGE prokinetics: is hyperacidity in the stomach that keeps the reflux, which gives esophagitis and other symptoms of the disease.
So, in the event of suspected reflux disease is useless to waste time with prokinetics, the indication is for

_ Ranitidine (Zantac 10mg/Kg/die Ranidil or in 2 divided doses)
_ or a proton pump inhibitor: omeprazole (Losec), lansoprazole (Lansox), esomeprazole (shiny,).
The improvement of symptoms, disappearance of crying, refusal of milk, treatment confirm the suspicion of gastroesophageal reflux disease. It should be noted with this treatment disappear or reduce the symptoms of reflux disease but not necessarily the same reflux: the child can continue to regurgitate, etc. to erupt. but the treatment is good and cries like a baby can cry "normal."

How is it treated

In functional reflux in regurgitant happy, you should not make any treatment or medication or with the so-called milk RA, reflux. AR milks are not valid from the nutritional point of view, are low in fat and polyunsaturated fat, and the calcium / phosphorus ratio is not adequate to the needs of lattante.Si milk is not adequate to the ideal nutritional treatment is purely cosmetic , which reduces an event, regurgitation, completely normal, but that is worse than the normal power.
reflux in children with functional, abounding with "happy", they're fine, do not have crying abnormal and grow well everything the pediatrician should do is reassure and reassure parents. It is a completely normal phenomenon, destined to disappear with age and that does not mean that the child does not "digest" the milk.

In sickness RGE vice versa treatment should be done and treatment with antisecretory is continued for at least three months. These drugs have significant side effects.
If the symptoms of GERD is associated with poor growth must think of the allergy PLV: if there is poor growth in RGE's milk allergy assumed. The increase therefore discriminates between cases to be followed immediately by diet alone or not.
Another factor that must be interpreted as implying the presence of a milk allergy is the lack of adequate response to treatment or the symptoms recur after a period improvement induced by the therapy. In all these cases, in addition to treatment with antisecretory be added to the diet without protein of cow's milk that at a later time may be, by suspending the drugs, the primary treatment.
The diet will make use then the use of one of the specialty milk for children allergic, preferably hydrolysates rather than soy milk. They have no indication therefore, even in this case, the AR milks, which are basically always cow's milk, "worked" but cow's milk. In their conclusions, the AR milks are just a gimmick that should not have space in diet of the infant with reflux disease or not.
might want to thicken the milk, special or unless it is to make it more dense and therefore less easily refluxing from the stomach into the esophagus and respiratory system. This can be achieved with appropriate cleaning products, such as Medigel, or adding the appropriate quantities of milk creams (rice, rice, maize and tapioca etc..). For this purpose, reduce reflux as such, may be used prokinetics, without prejudice to the concept that they are not drugs of reflux disease.
Finally the child should not be placed in the supine position but on an oblique plane (postural therapy ) and in this sense may be useful "eggs" in which children may very well be put to sleep.