”The baby was born 55 days ago and suddenly coughs while sleeping, sometimes quite violently or even to the point of screaming, swallows saliva with difficulty when burping and also chokes when feeding, and spits up milk when swallowing with a large mouthful of milk” .
What this mother describes is a typical symptom of gastroesophageal reflux. This is very common, with half of all newborns having gastroesophageal reflux. The ancients considered it a normal manifestation of infancy, and the 17th century English writer Shakespeare considered it the first of seven stages of development (At first the infant, mewling and puking in the nurse’s arms).
Gastric juices, including stomach acid, return from the stomach into the esophagus, sometimes overflowing from the esophagus and affecting the respiratory tract. In severe cases, this can lead to respiratory distress, pneumonia, and failure to thrive. Generally, the situation improves considerably after the child is about 6 months old and starts to eat complementary foods. These children usually have prolonged lower esophageal sphincter relaxation and slow gastric emptying, which is thought to be due to the fact that the brain is not yet fully mature. After one or two years of age, 90% of children will heal on their own.
For now, conservative management should be tried.
1. Feeding smaller amounts of milk at a time and increasing the number of feedings to ensure the total amount
2. Sleep with the upper body padded up a bit and the body turned to the left
3. Some milk powder or milk thickening powder has been reported to slow down the symptoms.
4. Severe babies can be treated with antigastric acid medication, PPI or H2 inhibitors.
Pre-operative examination
It depends on the clinical need to determine if further testing is needed to determine the need for surgical treatment: 1.
1. upper gastrointestinal imaging to determine the presence of hiatal hernia, position of the lower esophageal sphincter, reflux, etc.
2. Gastroesophagoscopy: to detect the degree of esophagitis, ulcers, and to determine the presence of a hiatal hernia, etc.
A 24-hour pH test is considered the gold standard, and a lower esophageal pH of less than 4% of the time is considered to have reflux. I did a 24-hour pH test for one year at London Children’s Hospital (Great Ormond Street Hospital) in ’95, and I personally believe that a pH of more than 10% is considered serious.
4. Esophageal manometry: To determine if the lower esophageal sphincter relaxation (Transient lower esophageal sphincter relaxation TLESR) is too long.
Personally, I believe that a preoperative upper gastrointestinal tract imaging should be done at the very least, as it is acceptable for children. Gastroscopy certainly helps, but the child needs general anesthesia. If available, or if the diagnosis is unclear, a 24 hour pH test should of course be done, and the insertion of a manometry tube into the esophagus is somewhat uncomfortable and requires the child’s cooperation. The same is true for esophageal manometry, which also requires a tube and is not available in every hospital.
When is anti-reflux surgery necessary, in my opinion.
1. in children with recurrent pneumonia, asthma, or risk of choking due to reflux
2. When acid irritation has caused ulcers, strictures in the esophagus, or inflammation or polyps in the vocal cords or trachea.
3. Some children with developmental delays and slow weight gain. Gastrostomy or anti-reflux surgery can be considered.
4. Children who have not responded to long-term PPI anti-acid medication or who are not receiving long-term medication.
Surgical modality.
The principle of surgery is to repair a hiatal hernia of the esophagus over the diaphragm, wrapping the lower esophageal sphincter with the fundus of the stomach to reduce its relaxation. This can be a 360-degree Ni fundoplication (Nissen’s fundoplication) or a 180-degree partial encirclement of the posterior or anterior wall (Toupe or Thal’s procedure).
Traditional open surgery is now mostly taken by minimally invasive laparoscopic surgery. Minimally invasive surgery is less invasive and has a faster recovery.
Results and complications of surgery
The success rate of surgery is over 90%. Recurrence rates reported in the literature range from 2 or 5% to 10%. Depending on the repair of the esophageal hiatus hernia, the child’s development (whether he/she has cerebral palsy, etc.). A small percentage of children have difficulty eating after surgery, but this rarely happens in children who have only a partial wrap.
Sixty percent of children with esophageal atresia will have gastroesophageal reflux after surgery. The vagus nerve is poorly developed in these children, and I did a gastric electrogram in a group of post-operative patients with esophageal atresia while I was in London and found that their gastric waves (peristalsis) were disturbed. I also used a mouse model to confirm that abnormal esophageal neuropeptides in atresia are the likely cause of peristaltic disturbances.
Gastroesophageal reflux in babies can be treated conservatively or surgically by a pediatric surgeon with very satisfactory results.