Gastro-esophageal reflux |
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Refluxes
of the stomach content into the esophagus are common in babies.
They present as a protracted problem, with unexplained crying,
recurring malaise, pallor, sometimes respiratory arrests. They don't
always occur during meals, nor are obviously associated with
spitting up or vomiting. Whenever an acid reflux causes the esophagus to become inflamed, the child typically stops sucking and cries, well before having finished the feeding. This results from pain in the inflamed esophagus exposed to the transit of food. Refluxes associated with esophagitis lead to slow growth and sometimes failure to thrive.
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* * Medications
are usually effective but cannot replace other measures, always
useful and sometimes effective enough alone, sparing the use of
drugs. Refluxes can result from a stomach too full or filled too fast. A breast fed baby usually drinks fairly often (8 to 12 x a day) which offer some protection, but this frequency is unusual in bottle fed babies, who take more at each feeding. It is therefore logical to fraction the child's intake into more and smaller bottles. A thickened formula may help : these are the so-called "AR" (anti-reflux) milks, available in pharmacies. Another advice is to keep the child as upright as possible, half sitting or at least with a raised head, which can be obtained by lifting one end of the bed. When these measures fail to control symptoms, medications should be prescribed. The
drug of choice, the first to try, is ranitidine (Zantac) (15
mg/ml) given twice a day. The officially recommended dosage is
often too low. Paediatric gastroenterlogists usually prescribe more :
10 to 15 mg / kg body weight / day, sometimes up to 20 mg. It is commonly necessary to combine this treatment with Gaviscon, one teaspoonful at the end of the meal, 4 x a day, or a little less with each meal. Gaviscon creates a sort of plug floating on top of the stomach content, and preventing its reflux into the esophagus. When
this double treatment fails, omeprazole (Losec, usually 10 mg once a
day) is often prescribed to replace ranitidine, and
sometimes both medications are combined. Anti-vomiting
medications such as domperidone (Motilium) 0.25 mg (=
0.25 ml) for each kg body weight up to 4 times a day may seem logical
but are less dependable and very seldom used alone.
Cisapride (Prepulsid) and metoclopramide (Primperan) are
potentially more toxic.
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* * These
treatments are commonly started empirically to alleviate
a significant malaise, but it is unreasonable to maintain them,
especially for a long time, without attempting to confirm
the diagnosis and/or to discontinue medications which may
have become unnecessary. Obviously quite a few children
take those drugs for too long without enough
justification. *
* * useful addresses : esophageal pH measurement : Madame Danielle Arnold, Clinique Universitaire Saint-Luc, phone 02 - 764 1927 Scintigraphy : Service de médecine nucléaire, Hôpital Brugmann, tél. 02 - 477 2649 (appointments), 02 - 477 2650 (results) |
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