Materiały źródłowe

• #1 Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2001/1201/p1853.html

  Gastroesophageal reflux is a common, self-limited process in infants that usually resolves by six to 12 months of age. […] Gastroesophageal reflux disease (GERD) is a less common, more serious pathologic process that usually warrants medical management and diagnostic evaluation. […] The term GER implies a functional or physiologic process in a healthy infant with no underlying systemic abnormalities. […] GER is a common condition involving regurgitation, or spitting up, which is the passive return of gastric contents retrograde into the esophagus. […] Gastroesophageal reflux disease (GERD) is a pathologic process in infants manifested by poor weight gain, signs of esophagitis, persistent respiratory symptoms, and changes in neurobehavior. […] Abnormal signs and symptoms that warrant a diagnosis of GERD occur in approximately one in 300 infants.

• #2 Infant Regurgitation (Gastroesophageal Reflux) Explained

  https://www.dr-tummy.com/gastroesophageal-reflux

  Gastroesophageal reflux means the backward movement of stomach contents up the oesophagus (the „swallowing tube”). This can take place only in the lower part of the oesophagus or reach up to the mouth or even the nose. Reflux often includes the release of the material from the mouth, as in infants who „spit up.” […] Reflux is a normal phenomenon, occurs when the muscle between the oesophagus and stomach relaxes (as it does during burping), allowing stomach content to leak up the oesophagus. […] Reflux is normal and very common. Up to 70% of healthy babies spills regularly with a peak around the age of 4 months. This happens because infant’s gastroesophageal sphincter is not fully developed, and their meals are mostly liquid. […] Gastroesophageal Reflux Disease (GORD) refers to a condition where tissue damage or harmful symptoms happen because of the reflux. GORD is not common in otherwise healthy infants. GORD is more common in preterm birth and in infants with otherwise chronic diseases.

• #3 Reflux in Babies and Toddlers | ParentData by Emily Osterframe_1-svgframe_2-svgframe_3-svg

  https://parentdata.org/reflux-in-babies-and-toddlers/

  Gastroesophageal reflux (GER) is when stomach contents flow backward into the esophagus. To some extent, it is physiologically normal in babies: some studies suggest it is seen in about half of all babies under 3 months. It also may get worse around 4 months before it begins to improve. This is because the band of muscle separating the esophagus and stomach — which is designed to limit backwashing — is underdeveloped and loosens intermittently and randomly in babies. So any changes in position, expansion of the stomach, or pressure on the abdomen will more easily push stomach contents in the wrong direction. Think of it like squeezing a loose-lidded plastic bottle in the middle. […] Reflux symptoms usually begin in the first 3 months of life, sometimes worsen around 4 months, and then gradually improve; most infants have outgrown physiologic reflux by the age of 1 year. If symptoms begin after 6 months, there may be something more going on.

• #4 Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2001/1201/p1853.html

  Gastroesophageal reflux is a common, self-limited process in infants that usually resolves by six to 12 months of age. […] Gastroesophageal reflux disease (GERD) is a less common, more serious pathologic process that usually warrants medical management and diagnostic evaluation. […] The term GER implies a functional or physiologic process in a healthy infant with no underlying systemic abnormalities. […] GER is a common condition involving regurgitation, or spitting up, which is the passive return of gastric contents retrograde into the esophagus. […] Gastroesophageal reflux disease (GERD) is a pathologic process in infants manifested by poor weight gain, signs of esophagitis, persistent respiratory symptoms, and changes in neurobehavior. […] Abnormal signs and symptoms that warrant a diagnosis of GERD occur in approximately one in 300 infants.

• #5 Pediatric Gastroesophageal Reflux: Practice Essentials, Background, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/930029-overview

  In pediatric gastroesophageal reflux disease (GERD), immaturity of lower esophageal sphincter function is manifested by frequent transient lower esophageal relaxations, which result in retrograde flow of gastric contents into the esophagus. […] The distinction between this „physiologic” gastroesophageal reflux and „pathologic” gastroesophageal reflux in infancy and childhood is determined not merely by the number and severity of reflux episodes (when assessed by intraesophageal pH monitoring), but also, and most importantly, by the presence of reflux-related complications, including failure to thrive, erosive esophagitis, esophageal stricture formation, and chronic respiratory disease. […] Transient lower esophageal sphincter relaxation (tLESR) – This is currently believed to be the main mechanism of gastroesophageal reflux, accounting for 94% of reflux episodes in children and adults; poor basal LES tone was previously thought to be a cause.

• #6 Gastroesophageal reflux disease in neonates and infants : when and how to treat – PubMed

  https://pubmed.ncbi.nlm.nih.gov/23322552/

  Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. […] The predominant mechanism causing GERD is transient lower esophageal sphincter (LES) relaxation, which is defined as an abrupt decrease in LES pressure to the level of intragastric pressure, unrelated to swallowing and of relatively longer duration than the relaxation triggered by a swallow. […] Sandifer syndrome, apnea and apparent life-threatening events are the extraesophageal manifestations of GERD in infants. […] Although Nissen fundoplication is now well established as a treatment option in selected cases of GERD in children, its role in neonates and young infants is unclear and is only reserved for selective infants who did not respond to medical therapy and have life-threatening complications of GERD.

• #7 Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1773397/

  Transient lower oesophageal sphincter relaxation (TLOSR) is the predominant mechanism of gastro-oesophageal reflux (GOR) in healthy infants but the mechanisms of GOR in infants with GOR disease (GORD) are poorly understood. […] TLOSR was the predominant mechanism of GOR, triggering 50100% of GOR episodes (median 91.5%). […] In infant GORD, acid reflux associated TLOSRs are abnormally common and likely to be a major contributing factor to the pathophysiology of GORD. […] While TLOSR was the predominant mechanism of GOR in infants with GORD, the number of TLOSRs was similar to normal infants but GORD infants had a higher proportion associated with acid reflux. […] These data demonstrate that TLOSR is likely to be a major contributing factor to the pathophysiology of GORD in these babies.

• #8 Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1773397/

  Transient lower oesophageal sphincter relaxation (TLOSR) is the predominant mechanism of gastro-oesophageal reflux (GOR) in healthy infants but the mechanisms of GOR in infants with GOR disease (GORD) are poorly understood. […] TLOSR was the predominant mechanism of GOR, triggering 50100% of GOR episodes (median 91.5%). […] In infant GORD, acid reflux associated TLOSRs are abnormally common and likely to be a major contributing factor to the pathophysiology of GORD. […] While TLOSR was the predominant mechanism of GOR in infants with GORD, the number of TLOSRs was similar to normal infants but GORD infants had a higher proportion associated with acid reflux. […] These data demonstrate that TLOSR is likely to be a major contributing factor to the pathophysiology of GORD in these babies.

• #9 Pediatric Gastroesophageal Reflux: Practice Essentials, Background, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/930029-overview

  In pediatric gastroesophageal reflux disease (GERD), immaturity of lower esophageal sphincter function is manifested by frequent transient lower esophageal relaxations, which result in retrograde flow of gastric contents into the esophagus. […] The distinction between this „physiologic” gastroesophageal reflux and „pathologic” gastroesophageal reflux in infancy and childhood is determined not merely by the number and severity of reflux episodes (when assessed by intraesophageal pH monitoring), but also, and most importantly, by the presence of reflux-related complications, including failure to thrive, erosive esophagitis, esophageal stricture formation, and chronic respiratory disease. […] Transient lower esophageal sphincter relaxation (tLESR) – This is currently believed to be the main mechanism of gastroesophageal reflux, accounting for 94% of reflux episodes in children and adults; poor basal LES tone was previously thought to be a cause.

• #10 Pediatric Gastroesophageal Reflux: Practice Essentials, Background, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/930029-overview

  The major mechanism in infants and children has now been demonstrated to involve increases in tLESRs. Factors that may promote gastroesophageal reflux during tLESRs include increased intragastric liquid volume and supine and „slumped” seated positioning. […] Decreased gastric compliance is believed to lead to LES relaxation at lower intragastric volumes in infants. This aspect, in conjunction with abdominal wall muscle contraction (if it occurs during periods of LES relaxation) propels refluxate into the esophagus, with subsequent regurgitation. […] An association between gastroesophageal reflux and delayed gastric emptying is recognized. This is more common in premature infants.

• #11 Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1773397/

  Abdominal straining was also an important factor increasing the likelihood of TLOSRs to trigger acid GOR episodes. […] Our data clearly show that GE was not delayed in GORD patients and challenge the logic of acceleration of GE for the treatment of acid reflux. […] In conclusion, like older children and adults, TLOSR is an important factor in the pathophysiology of GORD in preterm and term infants while delayed GE does not appear to be.

• #12 Pediatric Gastroesophageal Reflux: Practice Essentials, Background, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/930029-overview

  The major mechanism in infants and children has now been demonstrated to involve increases in tLESRs. Factors that may promote gastroesophageal reflux during tLESRs include increased intragastric liquid volume and supine and „slumped” seated positioning. […] Decreased gastric compliance is believed to lead to LES relaxation at lower intragastric volumes in infants. This aspect, in conjunction with abdominal wall muscle contraction (if it occurs during periods of LES relaxation) propels refluxate into the esophagus, with subsequent regurgitation. […] An association between gastroesophageal reflux and delayed gastric emptying is recognized. This is more common in premature infants.

• #13 Reflux in Infants: MedlinePlus

  https://medlineplus.gov/refluxininfants.html

  There is a muscle (the lower esophageal sphincter) that acts as a valve between the esophagus and stomach. […] In babies who have reflux, the lower esophageal sphincter muscle is not fully developed and lets the stomach contents back up the esophagus. This causes your baby to spit up (regurgitate). […] In babies who have GERD, the sphincter muscle becomes weak or relaxes when it shouldn’t.

• #14 Infant acid reflux – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408

  If the muscle between the esophagus and the stomach relaxes when the stomach is full, food might flow up the baby’s esophagus. The muscle is called the lower esophageal sphincter. […] Infant reflux is when a baby spits up liquid or food. It happens when stomach contents move back up from a baby’s stomach into the esophagus. The esophagus is the muscular tube that connects the mouth to the stomach. […] In infants, the ring of muscle between the esophagus and the stomach is not yet fully developed. This muscle is called the lower esophageal sphincter, also known as LES. When the LES is not fully developed, it allows stomach contents to flow back up into the esophagus. Over time, the LES typically matures. It opens when a baby swallows and remains tightly closed at other times, keeping stomach contents where they belong.

• #15 Infant acid reflux – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408

  If the muscle between the esophagus and the stomach relaxes when the stomach is full, food might flow up the baby’s esophagus. The muscle is called the lower esophageal sphincter. […] Infant reflux is when a baby spits up liquid or food. It happens when stomach contents move back up from a baby’s stomach into the esophagus. The esophagus is the muscular tube that connects the mouth to the stomach. […] In infants, the ring of muscle between the esophagus and the stomach is not yet fully developed. This muscle is called the lower esophageal sphincter, also known as LES. When the LES is not fully developed, it allows stomach contents to flow back up into the esophagus. Over time, the LES typically matures. It opens when a baby swallows and remains tightly closed at other times, keeping stomach contents where they belong.

• #16 Infant Reflux – Children’s Medical Group – Pediatricians in Atlanta, Decatur, Johns Creek

  https://www.cmg-pc.com/infant-reflux.php

  Most infants will visibly spit up a small amount of breast milk or formula after their feedings for the first several weeks or months of life. This occurs because the muscle sphincter at the bottom of the esophagus is immature. This sphincter is designed to keep liquids and solids which have entered the stomach from regurgitating back into the esophagus. […] However, in some reflux can cause significant pain due to the irritation of the esophagus from stomach acid. Babies who experience substantial pain with feedings may begin refusing to eat well enough to maintain normal growth and nutrition. […] Most infants with gastroesophageal reflux will get better by their first birthday; however, reflux disease can affect children, adolescents, and adults. […] Usually treatment for reflux disease is approached in a step wise fashion. The goal of therapy is for the baby to eat with a minimum of discomfort and gain weight properly with the least possible amount of intervention. […] For those who continue to experience significant symptoms, a trial of acid suppressant therapy may be prescribed.

• #17 Gastro-Oesophageal Reflux Disease – Management – TeachMePaediatrics

  https://teachmepaediatrics.com/gastroenterology/upper-gi/gastro-oesophageal-reflux-disease/

  Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus and is normal in infants if it is asymptomatic. […] Gastro-oesophageal reflux disease (GORD) is the term used to describe this process in the presence of symptoms or complications from the reflux, which will be discussed further here. […] In cases of GORD the tone of this muscular portion of the lower oesophagus is too low, resulting in uncontrolled reflux of stomach contents. Infants have a number of anatomical and physiological features that can contribute to this mechanism: Short, narrow oesophagus, Delayed gastric emptying, Shorter, lower oesophageal sphincter that is slightly above the diaphragm, Liquid diet and high calorie requirement, distending the stomach and increasing pressure gradient between stomach and oesophagus, Larger ratio of gastric volume to oesophageal volume, Spending significant periods recumbent.

• #18 Addressing Reflux in Babies – Le Bonheur Children’s Hospital

  https://www.lebonheur.org/blogs/practical-parenting/addressing-reflux-in-babies

  Reflux in babies is a common occurrence, but many parents find it to be a challenging issue to navigate. […] When a person eats, food moves from the mouth through the esophagus, then into the stomach. […] At the lower end of the esophagus, where it joins the stomach, is a circular ring of muscle called the lower esophageal sphincter. […] Occasionally, the lower esophageal sphincter does not stay closed completely, or it can relax at the wrong time. This allows the liquids in the stomach to wash back into the esophagus causing an episode of reflux. […] Infants consume large amounts of milk and food relative to their small size and the small size of their stomachs. Their stomachs have poor compliance or stretchiness, explains Dr. Vickers. When presented with these large volumes, some of the gastric content will then reflux back into the esophagus.

• #19 Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2001/1201/p1853.html

  Transient lower esophageal sphincter relaxations unassociated with swallowing may be the major mechanism allowing the gastric refluxate to return into the esophagus. […] Delayed gastric emptying is another mechanism in infants and older children that predisposes them to gastric distension, increased acid secretion, and esophagitis. […] In the respiratory tract, complex reflex responses to the gastric refluxate occur in children by three mechanisms. […] Aspiration stimulates the chemical release of inflammatory mediators that cause further respiratory luminal obstruction. […] In infants, activation of laryngeal chemoreflexes associated with regurgitation of gastric contents into the pharynx may be associated with episodic prolonged apnea. […] Infants with GER regurgitate without any secondary signs or symptoms of inadequate growth, esophagitis, or respiratory disease.

• #20 Pediatric Gastroesophageal Reflux: Practice Essentials, Background, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/930029-overview

  The major mechanism in infants and children has now been demonstrated to involve increases in tLESRs. Factors that may promote gastroesophageal reflux during tLESRs include increased intragastric liquid volume and supine and „slumped” seated positioning. […] Decreased gastric compliance is believed to lead to LES relaxation at lower intragastric volumes in infants. This aspect, in conjunction with abdominal wall muscle contraction (if it occurs during periods of LES relaxation) propels refluxate into the esophagus, with subsequent regurgitation. […] An association between gastroesophageal reflux and delayed gastric emptying is recognized. This is more common in premature infants.

• #21 Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1773397/

  Abdominal straining was also an important factor increasing the likelihood of TLOSRs to trigger acid GOR episodes. […] Our data clearly show that GE was not delayed in GORD patients and challenge the logic of acceleration of GE for the treatment of acid reflux. […] In conclusion, like older children and adults, TLOSR is an important factor in the pathophysiology of GORD in preterm and term infants while delayed GE does not appear to be.

• #22 Gastroesophageal Reflux in Children – Children’s Health Issues – MSD Manual Consumer Version

  https://www.msdmanuals.com/home/children-s-health-issues/gastrointestinal-disorders-in-children/gastroesophageal-reflux-in-children

  Cigarette smoke (as secondhand smoke) and caffeine (in beverages or breast milk) relax the lower esophageal sphincter, allowing reflux to occur more readily. […] A food allergy, most commonly cow’s milk allergy, or food intolerance also can contribute to reflux, but these are less common causes. […] Another less common cause of reflux is a slowly emptying stomach (gastroparesis). In gastroparesis, food remains in the stomach for a longer period of time, which causes pressure in the stomach to remain high. High pressure in the stomach leads to reflux. […] Gastroesophageal reflux becomes known as gastroesophageal reflux disease (GERD) when it interferes with feeding and growth, damages the esophagus (esophagitis), leads to breathing difficulties (such as coughing, wheezing, or stopping breathing), or continues beyond infancy into childhood.

• #23 Pediatric Gastroesophageal Reflux: Practice Essentials, Background, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/930029-overview

  The major mechanism in infants and children has now been demonstrated to involve increases in tLESRs. Factors that may promote gastroesophageal reflux during tLESRs include increased intragastric liquid volume and supine and „slumped” seated positioning. […] Decreased gastric compliance is believed to lead to LES relaxation at lower intragastric volumes in infants. This aspect, in conjunction with abdominal wall muscle contraction (if it occurs during periods of LES relaxation) propels refluxate into the esophagus, with subsequent regurgitation. […] An association between gastroesophageal reflux and delayed gastric emptying is recognized. This is more common in premature infants.

• #24 Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2001/1201/p1853.html

  Transient lower esophageal sphincter relaxations unassociated with swallowing may be the major mechanism allowing the gastric refluxate to return into the esophagus. […] Delayed gastric emptying is another mechanism in infants and older children that predisposes them to gastric distension, increased acid secretion, and esophagitis. […] In the respiratory tract, complex reflex responses to the gastric refluxate occur in children by three mechanisms. […] Aspiration stimulates the chemical release of inflammatory mediators that cause further respiratory luminal obstruction. […] In infants, activation of laryngeal chemoreflexes associated with regurgitation of gastric contents into the pharynx may be associated with episodic prolonged apnea. […] Infants with GER regurgitate without any secondary signs or symptoms of inadequate growth, esophagitis, or respiratory disease.

• #25 Episodic apnea: gastroesophageal reflux associated with gastric organo-axial malrotation: a case report | Journal of Medical Case Reports | Full Text

  https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-022-03367-x

  It is hypothesized that pharyngeal penetration of reflux may activate local vagal stretch and trigger induction of apnea through pathways mediated by the brain stem. […] Gastric malrotation is one of the anatomical conditions that may cause severe reflux and life-threatening complications. […] Organo-axial type of malrotation occurs when the stomach rotates along its long axis and becomes obstructed, with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen. […] Data are insufficient concerning the respiratory symptoms directly associated with gastric malrotation. […] Malrotation associated with occult GER could probably be responsible for recurrent respiratory problems, and further prospective observations are needed to demonstrate the respiratory manifestations.

• #26 Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2001/1201/p1853.html

  Transient lower esophageal sphincter relaxations unassociated with swallowing may be the major mechanism allowing the gastric refluxate to return into the esophagus. […] Delayed gastric emptying is another mechanism in infants and older children that predisposes them to gastric distension, increased acid secretion, and esophagitis. […] In the respiratory tract, complex reflex responses to the gastric refluxate occur in children by three mechanisms. […] Aspiration stimulates the chemical release of inflammatory mediators that cause further respiratory luminal obstruction. […] In infants, activation of laryngeal chemoreflexes associated with regurgitation of gastric contents into the pharynx may be associated with episodic prolonged apnea. […] Infants with GER regurgitate without any secondary signs or symptoms of inadequate growth, esophagitis, or respiratory disease.

• #27 Respiratory illness in children with gastroesophageal reflux: Are acid blockers part of the problem? – Boston Children’s Answers Respiratory illness in kids with reflux: Questioning acid blockers

  https://answers.childrenshospital.org/respiratory-illness-in-children-with-gastroesophageal-reflux-are-acid-blockers-part-of-the-problem/

  But there was a significant relationship between the amount of non-acid reflux in the esophagus and bacterial concentrations. “This supports the idea that non-acidic reflux can travel through the length of the esophagus and change the bacteria of the lungs,” says Rosen. […] Eight bacterial species found in the children’s stomach and lung fluid were not found in the oropharynx at all, suggesting that stomach contents were being directly aspirated into the lungs. […] Two of these eight species were highly correlated with full-column reflux (fluid backup all the way to the top of the esophagus), further evidence that reflux is a viable mechanism for lung disease in children with GERD. […] While more research is needed to further connect the dots, acid suppression therapy clearly alters the stomach’s bacterial profile and may impact lung microflora through full-column reflux, the researchers write.

• #28 Respiratory illness in children with gastroesophageal reflux: Are acid blockers part of the problem? – Boston Children’s Answers Respiratory illness in kids with reflux: Questioning acid blockers

  https://answers.childrenshospital.org/respiratory-illness-in-children-with-gastroesophageal-reflux-are-acid-blockers-part-of-the-problem/

  But there was a significant relationship between the amount of non-acid reflux in the esophagus and bacterial concentrations. “This supports the idea that non-acidic reflux can travel through the length of the esophagus and change the bacteria of the lungs,” says Rosen. […] Eight bacterial species found in the children’s stomach and lung fluid were not found in the oropharynx at all, suggesting that stomach contents were being directly aspirated into the lungs. […] Two of these eight species were highly correlated with full-column reflux (fluid backup all the way to the top of the esophagus), further evidence that reflux is a viable mechanism for lung disease in children with GERD. […] While more research is needed to further connect the dots, acid suppression therapy clearly alters the stomach’s bacterial profile and may impact lung microflora through full-column reflux, the researchers write.

• #29 Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2001/1201/p1853.html

  Patients with GERD may manifest persistent regurgitation with secondary poor weight gain and failure to thrive. […] A subset of infants may demonstrate significant reflux by esophageal pH monitoring but will not have symptoms of regurgitation, known as silent GERD. […] Finally, abnormal hyperextension of the neck with torticollis (Sandifer’s syndrome) may be seen solely in infants with more severe GERD. […] After infancy, more classic symptoms of esophagitis predominate, including lower chest pain, heartburn (pyrosis), odynophagia, dysphagia, and signs of anemia and esophageal obstruction from stricture formation. […] Complications of reflux esophagitis may be seen, including signs of peptic stricture and Barrett’s esophagus, which is the progressive replacement of distal eroded squamous mucosa with metaplastic gastric epithelium.

• #30 Pediatric Gastroesophageal Reflux Clinical Presentation: History, Physical Examination

  https://emedicine.medscape.com/article/930029-clinical

  The symptoms of gastroesophageal reflux are most often directly related to the consequences of emesis (eg, poor weight gain) or result from exposure of the esophageal epithelium to the gastric contents. […] Pediatric patients with gastroesophageal reflux typically cry and report sleep disturbance and decreased appetite. […] ALTEs that involve apnea associated with bradycardia, pallor, and/or cyanosis have been linked to gastroesophageal reflux, especially in premature infants. In these events, reflux into the hypopharynx is postulated to lead to laryngospasm and subsequent obstructive apnea. […] Gastroesophageal reflux is a complicating factor in asthma. The mechanism may include microaspiration, which leads to reflex bronchoconstriction. […] Esophagitis may manifest as crying and irritability in the nonverbal infant. Failure to thrive can result from insufficient caloric intake secondary to repeated vomiting and nutrient losses from emesis. […] Hiccups, sleep disturbances, and Sandifer syndrome (arching) have also been shown to be associated with gastroesophageal reflux and esophagitis.

• #31 Pediatric Gastroesophageal Reflux Clinical Presentation: History, Physical Examination

  https://emedicine.medscape.com/article/930029-clinical

  The symptoms of gastroesophageal reflux are most often directly related to the consequences of emesis (eg, poor weight gain) or result from exposure of the esophageal epithelium to the gastric contents. […] Pediatric patients with gastroesophageal reflux typically cry and report sleep disturbance and decreased appetite. […] ALTEs that involve apnea associated with bradycardia, pallor, and/or cyanosis have been linked to gastroesophageal reflux, especially in premature infants. In these events, reflux into the hypopharynx is postulated to lead to laryngospasm and subsequent obstructive apnea. […] Gastroesophageal reflux is a complicating factor in asthma. The mechanism may include microaspiration, which leads to reflex bronchoconstriction. […] Esophagitis may manifest as crying and irritability in the nonverbal infant. Failure to thrive can result from insufficient caloric intake secondary to repeated vomiting and nutrient losses from emesis. […] Hiccups, sleep disturbances, and Sandifer syndrome (arching) have also been shown to be associated with gastroesophageal reflux and esophagitis.

• #32 Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2015/1015/p705.html

  Gastroesophageal reflux is defined as the passage of stomach contents into the esophagus with or without accompanied regurgitation (spitting up) and vomiting. […] Gastroesophageal reflux disease (GERD) is reflux that causes troublesome symptoms or leads to medical complications. […] The lower esophageal sphincter is the primary barrier to gastroesophageal reflux. Most reflux events are caused by transient lower esophageal sphincter relaxation triggered by postprandial gastric distention. […] Frequent large-volume feedings, short esophagus, and supine positioning predispose infants to regurgitation or vomiting induced by transient lower esophageal sphincter relaxation. […] The following conditions are associated with increased risk of GERD (listed from highest to lowest odds ratio): hiatal hernia (including congenital diaphragmatic hernia), neurodevelopmental disorders, cystic fibrosis, epilepsy, congenital esophageal disorders, asthma, and prematurity.

• #33 Preterm infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux in the first 6 months of life than infants born at later gestational ages – Pados – Pediatric Medicine

  https://pm.amegroups.org/article/view/6184/html

  Infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux (GER) than infants born at later gestational ages across the first 6 months of life. […] The pathophysiologic mechanisms for the increased symptoms of GER in these populations of infants are not well understood, but may be related to several factors known to be related to prematurity. […] There may be developmental alterations in the gastrointestinal tract related to early exposure of the immature gut to microbes or changes related to gastrointestinal injury (e.g., necrotizing enterocolitis) that impact later gastrointestinal functioning. […] Infants born preterm are also known to experience alterations to the gut microbiome that may impact their symptoms of GER. […] Chronic, toxic stress related to prolonged hospitalization and the frequent, painful events associated with interventions common to newborn intensive care of the infant born prior to 32 weeks, may contribute to inflammation along the gastrointestinal tract and epigenetic changes to glucocorticoid receptor function that may impact the infants inflammatory response.

• #34 Preterm infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux in the first 6 months of life than infants born at later gestational ages – Pados – Pediatric Medicine

  https://pm.amegroups.org/article/view/6184/html

  Infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux (GER) than infants born at later gestational ages across the first 6 months of life. […] The pathophysiologic mechanisms for the increased symptoms of GER in these populations of infants are not well understood, but may be related to several factors known to be related to prematurity. […] There may be developmental alterations in the gastrointestinal tract related to early exposure of the immature gut to microbes or changes related to gastrointestinal injury (e.g., necrotizing enterocolitis) that impact later gastrointestinal functioning. […] Infants born preterm are also known to experience alterations to the gut microbiome that may impact their symptoms of GER. […] Chronic, toxic stress related to prolonged hospitalization and the frequent, painful events associated with interventions common to newborn intensive care of the infant born prior to 32 weeks, may contribute to inflammation along the gastrointestinal tract and epigenetic changes to glucocorticoid receptor function that may impact the infants inflammatory response.

• #35 Preterm infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux in the first 6 months of life than infants born at later gestational ages – Pados – Pediatric Medicine

  https://pm.amegroups.org/article/view/6184/html

  Infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux (GER) than infants born at later gestational ages across the first 6 months of life. […] The pathophysiologic mechanisms for the increased symptoms of GER in these populations of infants are not well understood, but may be related to several factors known to be related to prematurity. […] There may be developmental alterations in the gastrointestinal tract related to early exposure of the immature gut to microbes or changes related to gastrointestinal injury (e.g., necrotizing enterocolitis) that impact later gastrointestinal functioning. […] Infants born preterm are also known to experience alterations to the gut microbiome that may impact their symptoms of GER. […] Chronic, toxic stress related to prolonged hospitalization and the frequent, painful events associated with interventions common to newborn intensive care of the infant born prior to 32 weeks, may contribute to inflammation along the gastrointestinal tract and epigenetic changes to glucocorticoid receptor function that may impact the infants inflammatory response.

• #36 Preterm infants born prior to 32 weeks gestation experience more symptoms of gastroesophageal reflux in the first 6 months of life than infants born at later gestational ages – Pados – Pediatric Medicine

  https://pm.amegroups.org/article/view/6184/html

  Infants born prior to 32 weeks also frequently experience respiratory disease and growth faltering, which may require increased feeding volumes and nutritional changes, that may contribute to GER symptoms. […] Understanding these mechanisms will allow for development of targeted management strategies. […] Additionally, research is needed to understand why full-term infants improve in terms of GER symptoms, but preterm infants do not. […] Understanding the mechanisms for these differences in trajectories of symptoms will not only allow for targeted treatment, but improve our understanding of the ideal time to implement management strategies in preterm infants.

• #37 Cow’s Milk Allergy or Gastroesophageal Reflux Disease—Can We Solve the Dilemma in Infants?

  https://www.mdpi.com/2072-6643/13/2/297

  Gastroesophageal reflux (GER) and cow milk allergy (CMA) occur frequently in the first year of life. The pathogenesis of these two conditions is complex and involves multiple mechanisms of nutrition, motility, immunology and hypersensitivity. […] GER and other persistent gastrointestinal symptoms in allergic patients are predominantly associated with cellular immune mechanisms and delayed reactions. In non-IgE mediated CMA, activated mast-cells, eosinophils and Th2 lymphocytes, release histamine, tryptase, IL-4, IL-5, IL-13, eotaxin and other chemokines that lead to increased permeability, epithelial dysfunction, inflammatory infiltration in the mucosal, submucosal and, in some cases, muscle layers and nociception. […] GER and regurgitation are commonly related to overfeeding, short length of the (intra-abdominal) esophagus, obtuse His angle, horizontal position of the infant. Inappropriate relaxations of the lower esophageal sphincter (LES), ineffective clearance and the impaired resistance of the esophageal mucosa contribute to GERD. […] GER and CMA can coexist in the same patient and it has been reported that CMA can induce GER and also be a predisposing factor for gastrointestinal functional disorders. Conversely, treatment with acid inhibitors for GERD increase the risk of allergy later in life.

• #38 Cow’s Milk Allergy or Gastroesophageal Reflux Disease—Can We Solve the Dilemma in Infants?

  https://www.mdpi.com/2072-6643/13/2/297

  Gastroesophageal reflux (GER) and cow milk allergy (CMA) occur frequently in the first year of life. The pathogenesis of these two conditions is complex and involves multiple mechanisms of nutrition, motility, immunology and hypersensitivity. […] GER and other persistent gastrointestinal symptoms in allergic patients are predominantly associated with cellular immune mechanisms and delayed reactions. In non-IgE mediated CMA, activated mast-cells, eosinophils and Th2 lymphocytes, release histamine, tryptase, IL-4, IL-5, IL-13, eotaxin and other chemokines that lead to increased permeability, epithelial dysfunction, inflammatory infiltration in the mucosal, submucosal and, in some cases, muscle layers and nociception. […] GER and regurgitation are commonly related to overfeeding, short length of the (intra-abdominal) esophagus, obtuse His angle, horizontal position of the infant. Inappropriate relaxations of the lower esophageal sphincter (LES), ineffective clearance and the impaired resistance of the esophageal mucosa contribute to GERD. […] GER and CMA can coexist in the same patient and it has been reported that CMA can induce GER and also be a predisposing factor for gastrointestinal functional disorders. Conversely, treatment with acid inhibitors for GERD increase the risk of allergy later in life.

• #39 Cow’s Milk Allergy or Gastroesophageal Reflux Disease—Can We Solve the Dilemma in Infants?

  https://www.mdpi.com/2072-6643/13/2/297

  Gastroesophageal reflux (GER) and cow milk allergy (CMA) occur frequently in the first year of life. The pathogenesis of these two conditions is complex and involves multiple mechanisms of nutrition, motility, immunology and hypersensitivity. […] GER and other persistent gastrointestinal symptoms in allergic patients are predominantly associated with cellular immune mechanisms and delayed reactions. In non-IgE mediated CMA, activated mast-cells, eosinophils and Th2 lymphocytes, release histamine, tryptase, IL-4, IL-5, IL-13, eotaxin and other chemokines that lead to increased permeability, epithelial dysfunction, inflammatory infiltration in the mucosal, submucosal and, in some cases, muscle layers and nociception. […] GER and regurgitation are commonly related to overfeeding, short length of the (intra-abdominal) esophagus, obtuse His angle, horizontal position of the infant. Inappropriate relaxations of the lower esophageal sphincter (LES), ineffective clearance and the impaired resistance of the esophageal mucosa contribute to GERD. […] GER and CMA can coexist in the same patient and it has been reported that CMA can induce GER and also be a predisposing factor for gastrointestinal functional disorders. Conversely, treatment with acid inhibitors for GERD increase the risk of allergy later in life.

• #40 Taking a Swing at „Reflux”: Evidence-based Information From a Pediatric PT — Boost Babies, LLC

  https://www.boostbabiesaustin.com/blog/2020/7/21/taking-a-swing-at-reflux-evidence-based-information-from-a-pediatric-pt

  The more time that passes after a feed, the higher the stomach acidity levels which is what damages the esophagus. When infants feed in smaller and more frequently feeds, they decrease stomach content acidity with spitting up and may decrease reflux occurrence. (Please consult your pediatrician regarding changes to feeding schedules/volumes) (1,2) […] Supported sitting positions increase reflux more than other positions. […] Based on anatomy, the esophagus enters the stomach on the back (posterior) side. Supported sitting places more liquid near the gastro-esophageal junction (where the tube of the esophagus enters the stomach) increasing the incidence of reflux (5). […] Poor postural control in infants younger than 6 months contributes to a slumped posture in supported sitting. This posture submerges the gastro-esophageal junction further with stomach contents and increases abdominal pressure contributing to reflux (5).

• #41 Taking a Swing at „Reflux”: Evidence-based Information From a Pediatric PT — Boost Babies, LLC

  https://www.boostbabiesaustin.com/blog/2020/7/21/taking-a-swing-at-reflux-evidence-based-information-from-a-pediatric-pt

  Overuse of seating positions like swings, bouncers, and car seats exacerbates reflux and limits infant exposure to movements delaying optimal gross motor development (5,6) […] In prone, the stomach contents move towards the bottom of the stomach allowing more air to be near the junction between the esophagus and stomach decreasing reflux (2,5) […] Anatomically speaking, when an infant is on the left side, gas is again nearer to gastro-esophageal junction than when on the right side decreasing reflux occurrence (2, 7). […] Left sidelying almost doubles digestion time compared to right sidelying which lowers acidity in the stomach decreasing reflux incidence and vomiting (2,7). […] Infants show the biggest decrease or least amount of reflux during sleep versus awake times. […] Stress hormones, (cortisol) are low during sleep. Thus, good sleep helps decrease reflux. Soothing your baby with swaddling, a pacifier, or positive touch like infant massage may be effective in decreasing cortisol and improving infant sleep. Note: There is no strong clinical evidence supporting infant massage as a treatment for GERD; however, I like the science behind linking massage to better sleep and lower stress hormones (7,8).

• #42 Reflux & Baby Sleep | Taking Cara Babies

  https://takingcarababies.com/reflux-baby-sleep?srsltid=AfmBOorBRXezU6SZscfASGYWYaGU5Q7Vu20YflC_-T8Z1wuwe6RUbaU_

  Reflux means that the stomach contents are being pushed into the esophagus. For most babies, this is not associated with pain; for some, there is pain involved. […] However, for some babies, the acid from the stomach can cause pain in the esophagus. This is called Gastroesophageal reflux disease (GERD). Babies with GERD need to be seen by a doctor for the appropriate diagnosis and support. […] Not all babies who show reflux symptoms need treatment. Doctors get concerned when babies begin to suffer from severe pain, have trouble gaining weight, show blood in their stool, refuse to eat, or begin to experience respiratory issues. […] The American Academy of Pediatrics does not recommend elevating a baby’s head for sleep. The AAP reports that elevating the head of the infant’s crib is not effective in reducing reflux. It may result in the infant sliding to the foot of the crib into a position that may compromise respiration and therefore is not recommended. […] Some babies with reflux need medication. If your baby does need treatment, you will need to work closely with your pediatrician/pediatric GI specialist to find the correct medication and dosage for your baby.

• #43 Why Infant Reflux Matters – La Leche League International

  https://llli.org/news/why-infant-reflux-matters/

  What are the causes of the symptoms often associated with reflux? […] 1. Normal baby physiology – Babies have little core strength and many spend a lot of time horizontal. They have a liquid diet and can have an immature valve closing the top of the stomach, so it is leaky. […] 2. Too much milk too quickly – Babies are designed to drink small amounts frequently. A baby feeding every three hours needs to drink twice as much at each feed as a baby drinking every one hour and a half. Overfilling the stomach causes it to stretch, loosening the valve at the top of the stomach – allowing the overflow to escape. Frequent feeding can reduce reflux episodes. […] 3. Aerophagia – This just means swallowing air. A baby who is gulping or spluttering may be taking in more air than they should. A poor latch, scheduled feeds, oral restrictions or difficulty managing flow can all cause excess air to be swallowed. The stomach valve will then open to allow it to escape. As air comes back up, milk escapes too. Correcting the feeding issue so that air isn’t swallowed can reduce or eliminate reflux.

• #44 Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie) | Siegel | International Journal of Clinical Pediatrics

  https://www.theijcp.org/index.php/ijcp/article/view/246/189

  Infants with tongue and possible lip tie often have a poor latch in which there is often an inadequate seal around the breast and disorganized swallowing. As a result, many of these infants swallow air during breastfeeding. Many of these infants suffer from symptoms of reflux. […] This study shows a correlation between aerophagia in infants with short maxillary labial frenula (maxillary lip tie) and ankyloglossia and reflux. A new term has been created to describe this entity: aerophagia induced reflux (AIR). […] There appears to be a relationship between maxillary lip tie (ankyloglossia and shortened maxillary labial frenula) and AIR. Treatment of these infants with a relatively simple frenotomy procedure may reduce or eliminate reflux. […] Aerophagia induced reflux (AIR) represents a different pathophysiologic mechanism compared to that of GER and/or GERD.

• #45 The Pathophysiology of Gastroesophageal Reflux | SpringerLink

  https://link.springer.com/chapter/10.1007/978-3-642-18906-7_3

  Understanding the pathophysiology of gastroesophageal reflux (GER) is important in choosing the best diagnostic and therapeutic approach to adopt in children with GER. GER is due to multiple factors which result in incompetence of the esophageal cardia, and allow reflux of gastric content into the esophagus. Competence of the esophageal cardia is due to both anatomical and physiological factors which form an antireflux barrier. GER is associated with the failure of these mechanisms against reflux.

• #46 Gastroesophageal reflux disease in children: What’s new right now?

  https://www.wjgnet.com/1948-5190/full/v15/i3/84.htm

  Gastroesophageal reflux (GER) in children is very common and refers to the involuntary passage of gastric contents into the esophagus. This is often physiological and managed conservatively. In contrast, GER disease (GERD) is a less common pathologic process causing troublesome symptoms, which may need medical management. Apart from abnormal transient relaxations of the lower esophageal sphincter, other factors that play a role in the pathogenesis of GERD include defects in esophageal mucosal defense, impaired esophageal and gastric motility and clearance, as well as anatomical defects of the lower esophageal reflux barrier such as hiatal hernia. […] The main pathogenesis of GERD in children, as in adults, is abnormal transient lower esophageal sphincter relaxation (TLESR). Other factors implicated in the pathogenesis of GERD include the anatomy and integrity of the antireflux barrier, as well as those affecting esophageal peristalsis and clearance.

• #47 Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1773397/

  Transient lower oesophageal sphincter relaxation (TLOSR) is the predominant mechanism of gastro-oesophageal reflux (GOR) in healthy infants but the mechanisms of GOR in infants with GOR disease (GORD) are poorly understood. […] TLOSR was the predominant mechanism of GOR, triggering 50100% of GOR episodes (median 91.5%). […] In infant GORD, acid reflux associated TLOSRs are abnormally common and likely to be a major contributing factor to the pathophysiology of GORD. […] While TLOSR was the predominant mechanism of GOR in infants with GORD, the number of TLOSRs was similar to normal infants but GORD infants had a higher proportion associated with acid reflux. […] These data demonstrate that TLOSR is likely to be a major contributing factor to the pathophysiology of GORD in these babies.

• #48 Gastroesophageal reflux in premature infants – UpToDate

  https://www.uptodate.com/contents/gastroesophageal-reflux-in-premature-infants

  Gastroesophageal reflux (GER), the passage of gastric contents into the esophagus, occurs commonly in newborn infants and is especially common in those born prematurely. Physiologic GER typically is a developmental process that resolves with maturation. GER generally resolves on its own by one year of age. In infants who have no symptoms other than regurgitation, no further evaluation or intervention is typically required. […] In contrast, gastroesophageal reflux disease (GERD) is clinically significant GER that causes morbidity. Putative morbidities of GERD in preterm infants include frequent vomiting, aspiration pneumonia, irritability, failure to thrive, and exacerbation of respiratory symptoms, including chronic lung disease. However, it is likely that in many infants with these symptoms, the GER is not the underlying cause.

• #49 Medical management of gastro-esophageal reflux in healthy infants | Canadian Paediatric Society

  https://cps.ca/en/documents/position/gastro-esophageal-reflux-in-healthy-infants

  Clinical symptoms attributed to gastro-esophageal reflux disease (GERD) in healthy term infants are non-specific and overlap with age-appropriate behaviours. […] Gastroesophageal reflux disease (GERD) occurs when GER leads to symptoms that affect daily functioning or to complications. […] In the infant who is growing well, symptoms are unlikely to be improved by therapy aimed at GERD. […] The incorrect attribution of symptoms leads to frequent overtreatment of GERD by physicians. […] The management of severe disease or GERD associated with comorbidities is beyond the scope of this document. […] The natural history of symptom resolution in GER, the limited evidence that pharmacological management of GERD in infants improves symptoms, and the serious side-effect profile of medications, all indicate that their routine use in infants who are otherwise healthy should be avoided.

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