Author: Joshua Alexander, MD
INTRODUCTION
Children with special health care needs can have many conditions that contribute to difficulties in achieving good nutrition. One of these is gastroesophageal reflux, the passage of undigested food from the stomach back into the esophagus (the tube carrying food from the throat to the stomach). While most infants will have some "spit-up" after eating, gastroesophageal reflux disease (GERD) can be a persistent, painful condition that can affect a child's ability to feed and gain weight.
CASE REPORT
CC was a 4-year-old white female with spastic diplegic cerebral palsy who presented with failure to gain weight and being a "picky eater". Her mother had brought her to her pediatrician earlier that year because of the occasional "spitting up" that she had done all her life. An upper GI test was performed to rule out GERD and was read as normal, and no treatment was given. Her symptoms had continued, and her parents, worried about her having problems with this in kindergarten, brought her in for another opinion. A complete history and physical examination were performed and she was found to have several additional symptoms associated with GERD, including:
? Complaints of intermittent chest pain not associated with activity
? Bad breath
? Excessive and loud burps
She was admitted to the hospital for a 24 hour long pH probe- a test that measures how often stomach acid flows into the esophagus and the degree of its acidity during a 24 hour period. A thin tube was gently inserted through her nose, and down into the bottom portion of her esophagus. Small, thin probes at the middle and end of the tubing measured the pH of the surrounding area and were attached to a portable computer that recorded the acidity in the esophagus on a paper tape. When the test was over, the recording was analyzed and a full report was prepared. The report showed that, while CC didn't have any episodes of spitting up in the hospital, there were many times when the stomach contents flowed backwards from the stomach and into the esophagus, even into the upper part of this tube where it could potentially spill over into her lungs. CC was started on medications to treat her reflux by speeding up stomach emptying and reducing the acid contents of her stomach and discharged home. On follow-up visits 1 and 6 months later, her mother noted that not only had her symptoms improved, but she also hadn't had an "asthma attack" since leaving the hospital.
DISCUSSION
GERD is a common cause of many nutrition-related (and some breathing!) challenges faced by children with disabilities. The first step in treating this condition is recognition and diagnosis. This is best accomplished by keeping a high index of suspicion, using a specialized history and physical examination, and recognizing the strengths and weaknesses of specific diagnostic tests.
In this case, a normal upper GI x-ray test was incorrectly interpreted as proving that GERD was not present. While reflux seen on an upper GI proves its presence, the absence of reflux at the moment in time the x-ray was taken doesn't mean it doesn't exist at other times. A 24 hour pH probe, though more time consuming and invasive, is still considered to be the gold standard diagnostic test when evaluating a child for GERD and should be used when a family or clinician's high index of suspicion has not been confirmed by other tests.
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