Indian Pediatrics 1998;35:665-668 

Gastroesophageal Reflux and  Pulmonary Complication in a Neonate

Kanya Mukhopadhyay
Anil Narang
Praveen Kumar
Shantavanu Chakraborty
Bhagwant Rai Mittal*

From the Division of Neonatology, Department of Pediatrics and *Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh 160 012, India.

Reprint requests: Dr. Anil Narang, Additional Professor & Head, Division of Neonatology, Department of Pediatrics, PGIMER, CKandigarh 160 012, India.

Manuscript Received: June 10, 1997; Initial review completed: September 9,1997;
Revision Accepted: October 24,1997.
 

In preterm babies gastroesophageal reflux (GER) can be present in as high as 80% of cases(1) but most of the time it remains clinically inapparent. In symptomatic cases, GER may lead to either acute or chronic pulmonary diseases(2). It has also been implicated in the etiology of apnea(3) and apparent life threatening events (ALTE)(4). GER as an etiology of recurrent collapse is quite often missed. We report a case of symptomatic GER who had repeated pulmonary aspiration leading to recurrent collapses and improved possibly due to multimodality therapy along with increase in postnatal age.

Case Report

The baby was born at 32 weeks period of gestation, with a birth weight of 1790 grams, by normal vaginal delivery. There was no perinatal asphyxia. The baby had respiratory distress soon after birth and settled within 48 hours of life and it was attributed due to transient tachypnea of newborn. The chest X-ray was normal. On 3rd day of life the baby was started on tube feed but had regurgitation of feeds and 12 hours later again vomited milk and developed respiratory distress. The child was managed with nil orally, oxygen, intravenous fluid and antibiotics with suspicion of, aspiration pneumonia. Chest X-ray revealed right upper lobe collapse (Fig: 1) and then right mid zone collapse. On 10th day, the baby had 2-3 episodes of apnea and chest showed bilateral crepitations and rhonchi and mild tachypnea continued for next 2 weeks. Chest X-ray showed persistent right upper lobe collapse. Baby was restarted on feeds after 15 days when tachypnea settled down but again developed respiratory distress and X-ray revealed left lung collapse and right sided hyperinflation (Fig. 2). Gastroesophageal reflux was strongly suspected and barium swallow followed by fluoroscopy revealed multiple reflux upto oral cavity. Radionuclide scintigraphy also showed reflux upto oral cavity and subsequent aspiration into lungs (Fig. 3). Metoclopramide was started 0.5 mg/kg/ day in 6 hourly doses and after 7 days cisapride was also added 0.3 mg/kg/ dose 8 hourly in view of persistence of mild tachypnea and intermittent crepitation and rhonchi. Feeds were gradually increased and thickened by adding cereals along with raising baby's head end upto 30. Inspite of the above measures baby had intermittent vomiting till 6 weeks of age. By 8 weeks the baby became asymptomatic and started gaining weight appropriately. Chest X-ray became normal and repeat radionuclide scan revealed reflux upto mid-esophagus. Baby was discharged at 21h months of age on cisapride and metoclopramide. On follow up at 3 months, baby was asymptomatic, gaining weight and radionuclide scan revealed no reflux (Fig. 4).

 

Fig. 1. Chest X-ray shows right upper lobe collapse.

 
 

Fig. 2. Chest X-ray shows left lung collapse with right sided hyperinflation.

 

Fig. 3. Radionucleide scan shows reflux of radioisotope upto oral cavity and also in the lungs.

 

Fig. 4. Radionucleide scan shows 110 reflux on follow up.

 
 
Discussion

Although hypotonia of lower esophageal sphincter (LES) was previously thought to be a major factor responsible for GER(5), recent evidence suggests that inappropriate transient LES relaxation (TLESR) of multifactorial etiology is the more probable cause for symptomatic GER(6). Prokinetic drugs have been used with variable success as exact pathogenesis of this inappropriate relaxation is not known. Though most of the infants improve during first year of-life, the babies with significant GER need supportive therapy and rare cases may even need surgical fundoplication. There is no direct correlation between postconceptional age and GER. though LES tone increases with maturity(1,7).

Gastroesophageal reflux scintigraphy first introduced in 1976(8) is a good alternative modality to pH monitoring or fluoroscopy to diagnose GER(9) as it is a convenient, relatively noninvasive and quantitative test. Scintigraphic milk scan has been shown to be a sensitive test to detect GER in infants suspected to have pulmonary aspiration of gastric contents(10). Prolonged, 24-hour intraesophageal pH monitoring is presently considered the best test for diagnosing GER disease and correlating gastroesophageal reflux episodes to symptoms. However, during early postprandial period when the pH of gastric contents is buffered by meals (pH> 4), the GER may not be detected(11). With simultaneous pH probe and scintigraphic studies, the sensitivity of radionuclide evaluation hag been reported to be 79% and the specificity 93%(12). Severity of the reflux can be easily quantitated using a reflux index(13). It also helps in detection of rates of gastric emptying which may be helpful if surgical interventions are required. However, this test is not as sensitive as barium study in ruling out obstruction.

Our baby had prolonged respiratory illness in the form of recurrent collapses and such cases should be investigated for GER. This baby improved with multimodality therapy like keeping the head up, thickening of feeds and prokinetic drugs along with advancement in age. Scintigraphy significantly helped in following up the case.
 

 References