Gastroesophageal reflux and swallowing in newborns and infants: integrative review of literature

Abstract:

The gastroesophageal reflux disease (GERD) has been found in 25% of babies and it could cause several damages in infant's development. This paper aims to realize an integrative review of literature searching publications that relates swallowing disturbances to the condition of gastroesophageal reflux in newborns and infants. The research was made consulting Bireme's (Virtual Health Library) and PubMed's websites. The catchwords used were gastroesophageal reflux, newborn and infant, both in Portuguese and in English. Descriptors were used in pairs, since their isolated use comprised many texts containing subject matters different from authors' interest. Papers from the last 10 years were selected. From the 1184 Bireme's and 1600 PubMed's articles analyzed through the application of inclusion and exclusion criteria, 23 articles left, being the majority concerned to GERD signs, symptoms and diagnosis. Two articles approached the GERD and swallowing, demonstrating that could have or not relation between the GERD and oropharyngeal dysphagia in newborns and infants, moreover, the lack of research on this subject matter shows the need of new studies focusing on the pathophysiological aspects involved.

Keywords:
Gastroesophageal Reflux; Swallowing Disturbances; Infants

Resumo:

O refluxo gastroesofágico é encontrado em 25% dos bebês e pode acarretar vários prejuízos para o desenvolvimento. O objetivo deste trabalho foi realizar uma revisão integrativa da literatura buscando verificar se há publicações relacionando alterações da deglutição com o quadro de refluxo gastroesofágico em recém-nascidos e lactentes. A pesquisa foi realizada consultando os sites da Bireme e da PubMed. Os unitermos utilizados foram refluxo gastroesofágico, recém-nascido e lactente, em português e os correspondentes em inglês. Os descritores foram utilizados pareados, pois isolados abrangia muitos textos com temáticas diferentes da de interesse. Os trabalhos selecionados foram dos últimos dez anos. Não houve limite de tempo. De 1184 artigos da Bireme e 1600 da PubMed analisados a partir da aplicação dos critérios de inclusão e exclusão, restaram 23 artigos, sendo a maioria voltada aos sinais, sintomas e diagnóstico do RGE. Dois artigos abordaram o RGE e a deglutição, demonstrando que pode haver ou não relação entre RGE e disfagia orofaríngea em recém nascidos e lactentes, sendo que a escassez de pesquisas com essa temática demonstrou a necessidade de novos estudos abordando os aspectos patofisiológicos envolvidos.

Descritores:
Refluxo Gastroesofágico; Transtornos da Deglutição; Lactente

Introduction

The gastroesophageal reflux disease (GERD) is defined as the involuntary return of the gastric content to esophagus^¹and it happens in approximately 25% of babies, being the second greatest problem regarding the most prevailing affections of the digestive tract^².

The GERD in children is classified as physiological, functional and primary and secondary pathological^³ condition. The physiological GERD is characterized by episodic reflux, in the postprandial period, and it can occur at least in three short episodes, at the first two postprandial hours^⁴. The functional GERD occurs with more frequency than the physiological one, however, without causing disease to the child. It is called functional for not having any basic dysfunction (mechanical, inflammatory, infectious or biochemical) that can lead to reflux, and it is a process of gastrointestinal maturity. Reflux still can be occult or silent, being possible that it becomes pathological^⁴.

Inasmuch as the GERD comprises extraesophageal areas, it ceases to be a problem restrict to the digestive tract. Among the GERD complications is mentioned the bronchitic asthma and the otorhinolaryngological problems, food problems^⁵, infantile colic^⁶ and dental erosion^⁷. The GERD can also be considered the factor responsible for swallowing difficulty, both in newborns and in bigger children^⁸.

In spite of feeding, as well as breathing, being a natural function, it is necessary, to it occurs, a very complex process that involves several phases, as swallowing and digestion^⁴. Interruptions or alterations in any of these phases can cause bad nutrition and growth deficit. The nutrition of a baby, especially in the first year of life, is essential to brain growth and development⁹.

The most common symptoms that suggest a food problem are sucking and swallowing difficulties, apnea, repetitive cough and/or choking, excessive irritability, behavior changes during feeding, time of nutrition higher than 30 to 40 minutes, food refusal and growth deficit^⁹.

The occurrence of vomiting, regurgitation, chokings, lack of air, esophagitis, dysphagia, odynophagia, pyrosis and retrosternal pain make the child to relate food to discomfort, pain and antipleasure¹⁰. On the other side, the GERD jeopardizes the integrity of baby's oral motricity, causing hypersensitivity in the oral cavity, anticipation of vomiting reflex and aversion to tactile stimulation, justifying the refusal of some food and textures¹¹.

Thus, the objective of this paper was realize an review of literature to verify if there is publications relating swallowing disturbances to the condition of the GERD in newborns and infants.

Methods

This paper is an integrative review, with descriptive and analytic character, being based on the analysis of articles on gastroesophageal reflux in newborns and infants.

The collection of periodicals was realized in the Bireme's website (Virtual Health Library), being consulted the LILACS and MEDLINE's database, and in the PubMed's site.

The catchwords used to the research were: gastroesophageal reflux, newborn and infant, both in English and in Portuguese. The research was carried out with descriptors in pairs, since their isolated use comprised many texts containing subject matters different from authors' interest.

All the scientific articles that approached gastroesophageal reflux, both the physiological reflux and the GERD, in newborns and infants, in the period between 2004 and 2014, were included. All duplicated articles, those that did not approach the proposed subject matter, and those that did not mention babies or were not in the limit of time were excluded.

After all information was grasped and studied, the data were analyzed considering the journal and the year of publication, the research objective, the diagnosis exams and proposed treatments, as well as the relation between the gastroesophageal reflux and swallowing disturbances. At last, the levels of evidence of each study was analyzed, according to Souza, Silva e Carvalho (2010) ¹². Subsequently this data were discussed and compared with literature.

Review of Literature

In the search carried out in the Bireme's website, using catchwords in pairs, 1.184 articles were found. According to the established criteria, 8 studies were selected in LILACS and MEDLINE's database. Yet in the search carried out in the PubMed's website, 1.600 articles were found, from which remained 15 articles after the application of inclusion and exclusion criteria. The steps of this selection are illustrated in Figure 1.

Figure 1:
Information referring to the bibliographic collection and selection of articles

Articles published in the period of 2004 to 2014 were selected, being one article published per year, mostly. The years of 2012 and 2013 presented the biggest number of publications (n=4). It was possible to observe that there was an increase in the number of publications on this subject matter in the last years, as presented in Figure 2.

Figure 2:
Presentation of the number of articles published per year according to the results found through the search in all data-bases e websites consulted

The Figure 3 presents information obtained from the analysis of each selected publication, being possible to observe that the majority of the studies had the objective of establishing the best exam to diagnose the GERD and, also, the objective of relating clinic signs to the exams. The medical journals presented the biggest number of published articles related to the subject matter (n=18), followed by the nutrition journals (n=2), speech therapist (n=1), sleep (n=1) and neonatal care (n=1).

Figure 3:
Information referring to the articles selected for the research, collected in Bireme's database, wich approached the gastroesophageal reflux disease in newborns and infants

According to the review that was realized, several exams were used to diagnose the GERD, however, the Esophageal pH monitoring was the most used (n=13) and demonstrated better sensitivity and greater reliability. The exams are presented in Figure 4.

Figure 4:
Presentation of the number of articles in relation to the diagnostic test used to detect the gastroesophageal reflux disease.

The signs and symptoms most related to the GERD were breathing problems (n=7), followed by regurgitations (n=5) and vomiting (n=4), regarding that the same article can mention t than one sign/symptom, as presents Figure 5.

Figure 5:
Presentation of the number of articles in which was mentioned the signs and symptoms - vomiting, breathing problems, chokings and others -related to the gastroesophageal reflux disease.

The most mentioned types of treatment were the postural one (n=4), drug treatment (n=3) and use of thickening formula (n=3). The treatments are presented in Figure 6.

Figure 6:
Presentation of the number of articles in which were presented treatments

Few articles related the GERD to swallowing (n=2), being one of them published in a journal that covers the area of phonoaudiology and the other the area of nutrition. The findings of these studies are disposed in Figure 7.

Figure 7:
Information referring to the articles that approached the relation between the gastroesophageal reflux disease and swallowing in babies and the findings of these studies.

Discussion

The intention of this study was to research if the GERD influence on swallowing has become evident in the scientific literature, seeing the physiological GERD is common in the neonatal period and can cause damages to baby's health and development. The GERD is considered one of the main causes of visiting a pediatric gastroenterologist^².

It was possible to observe that the number of publications is increasing over the years, corroborating Mooloy, Di Fiori, Martin (2005)³⁶, that verified an increase in researches on the GERD in the last decades due to its aspects that were not clarified yet.

The majority of the articles found sought to connect signs and symptoms with GERD verification^{14 16 22 24 27}and to identify the most sensitive exams to the GERD diagnosis. Another objective, that was also approached, was to study the effect of the postural treatment on the GERD, what proved to be efficient in both medical researches found^{13 17}, confirming the literature's findings³⁷.

The bibliographic collection demonstrated that great majority of publications found (n=18) correspond to medical field. There was a diversity of topics in the medical research found, from food thickening¹⁶, corporal posture^{13 29}, diagnosis^{14 31}, treatments^{26 32 35} to exams^{15 19 20 22 2}, among others.

The most used diagnostic test and considered effective by the studies found^{13 15 17 20 22 26 27 29 33} was the Esophageal pH monitoring, confirming Moraes-Filho that consider the pH monitoring a gold standard test due to its sensitivity to detect problems and, still, to its capacity of propitiating a connection with the symptoms found in patients³⁸.

The most mentioned signs/symptoms in the research were the breathing ones^{14 15 20 21 31 33}, including oxygen saturation drop, pneumonia, the crying baby syndrome, cyanosis, among others, followed by regurgitation^{16 18 31 32 35}and vomiting^{18 21 32 33}, confirming another research²that cited these ones as being the main clinic signs and symptoms.

In the research developed by Silva-Munhoz and Buhler²⁴, the authors related sign/symptom comparing preterm newborns with term newborns, where they ascertained that the preterm newborns presented higher desaturation, while the term newborns showed vomiting as the main symptom. Another topic found in this collection^{21 32}is the baby's nutritional state, that in most cases is altered, jeopardizing its growth, what corroborates literature².

Drent and Pinto (2007)³⁹, relating the GERD to food problems, concluded that the GERD presence results in alimentary disturbances of behavioral and myofunctional orofacial magnitude, causing malnutrition and growth deficit. Meira (1998)¹¹still mentions that the GERD can increase the intraoral sensitivity, making child to develop aversion to some stimuli and textures, justifying the food refusal.

The studies showed that the therapeutic approach focusing in corporal posture changes^{13 29}and formulae to modify food consistency^{16 18}generates positive results. Another authors approached, yet, medicinal treatment^{26 31 32}, being necessary to adopt surgical conducts only in extreme cases.

The jeopardized oral and pharyngeal phases of swallowing and feeding difficulties in GERD children was considered only by two studies^{14 24}, being one of them published in a journal that covers the area of phonoaudiology and the other, the area of nutrition. However, in an article²⁴ this relation was not observed in term babies, only in preterm babies relating swallowing difficulty to immaturity. Additionally, a study⁴⁰that found association between such aspects evidenced the high incidence of this relation in babies that presented the GERD. Few researches of medical field dealt with the possibility of oropharyngeal dysphagia in this population, being scarce the references found that approach the oral phase of swallowing or even relate food problems to the GERD, evidencing the need of new researches.

The data found in the present research demonstrated that the GERD treatment must be multi-professional, being the participation of a phonoaudiologist of fundamental importance in the supervision of the sucking and swallowing conditions, enabling to obtain best results by reducing the risk of sequelae that can affect the child's global development.

Conclusion

The review of literature realized by this paper demonstrated that can have relation between the GERD and swallowing disturbances in newborns and infants, being that the scarcity of studies on this subject matter demonstrated the need of more researches approaching the pathophysiological aspects involved.

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Publication Dates

• Publication in this collection
  Oct 2015

History

• Received
  24 Mar 2015
• Accepted
  26 June 2015