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There has been a lot of talk about dysphagia lately so we wanted to repost our blog from a few months ago called “Dysphagia, GERD and Silent Aspiration”

Dysphagia, GERD and Silent Aspiration

We’ve talked about Gastroesophageal reflux disease (GERD) before, and today we wanted to talk about dysphagia and aspiration, two things that can be associated with GERD.

GERD

Dysphagia refers to the inability of food and/or liquids to pass easily from the mouth, into the throat, through the esophagus and into to the stomach during the process of swallowing.[1] In more simple terms, it means “difficulty swallowing.” Many medical conditions can cause dysphagia but in children, it is usually due to physical malformations, neurological conditions or digestive problems like GERD.

How can GERD cause dysphagia?

GERD is a condition where the muscles at the end of the esophagus do not close properly and allow stomach contents to leak back into the esophagus. The acidity of stomach contents can cause inflammation in the esophagus (esophagitis) and may lead to ulcers and scaring. The scarring can result in narrowing of the esophagus which may make swallowing more difficult. Patients with dysphagia may experience pain in the throat or chest, heartburn, regurgitation or the feeling that they have something stuck in their throat or chest.

Aspiration:

Both GERD and dysphagia are risk factors for aspiration, where foreign substances (food, liquid and/or stomach contents) are inhaled into the lungs. GERD can cause stomach contents to flow back into the esophagus and dysphagia can cause food and/or liquid to remain in the esophagus after swallowing. If these substances are inhaled and move into the lungs, it can lead to serious respiratory problems, such as aspiration pneumonia[2].

Silent Aspiration:

Silent aspiration describes aspiration without any obvious signs of swallowing difficulty, such as coughing or breathing difficulty[3]. Silent aspiration is especially common among children with dysphagia. In fact, an estimated 94% of children with dysphagia experience silent aspiration. This form can be especially dangerous because caregivers may not know that aspiration is occurring until the child becomes sick.

Because GERD and dysphagia are risk factors for aspiration and because children are more likely than adults to experience silent aspiration, you may want to do a swallow study if your child has these conditions to rule out aspiration. If it is detected, don’t worry! There are various ways to manage it so that respiratory problems don’t develop, such as altering the thickness of your child’s food and drinks.

*Update*

Eosinophilic Esophagitis

Our previous post focused on GERD as it relates to dysphagia and silent aspiration but in this post, I want to mention Eosinophilic Esophagitis (EoE), which is another condition that is linked to dysphagia and silent aspiration. Patients with EoE may have feeding problems, vomiting, dysphagia, abdominal pain or food impaction. In fact, a recent study urged professionals to screen for EoE when patients present with dysphagia. If your child has been diagnosed with EoE, you may want to discuss the possibility of silent aspiration with your health care provider since dysphagia is a risk factor for aspiration. Symptoms of EoE are often controlled by diet so dietary management may be sufficient to control dysphagia and the risk for silent aspiration. Feeding therapy and food thickeners may be considered as well.

Have any of your children with GERD or EE experienced dysphagia? How do you manage the dysphagia and the risk for silent aspiration?

-Mallory

[1] Dysphagia. Children’s Hospital Boston:
http://www.childrenshospital.org/az/Site815/mainpageS815P0.html.
[2] Palmer & Drennan et al. Evaluation and Treatment of Swallowing Impairments. Am Fam Physician 2000;61:2453-62
[3] Lee J, Blain S, Casas M, Kenny D, Berall G, Chau T. A radial basis classifier for the automatic detection of aspiration in children with dysphagia. J Neuroeng Rehabil. 2006 Jul 17;3:14.

Many of you have little ones who suffered for weeks, months or even years before finally getting a diagnosis. The diagnosis may have been a food allergy, gastroesophageal reflux disease (GERD), an eosinophilic disorder, food protein-induced enterocolitis syndrome (FPIES), multiple food protein intolerance (MFPI), or a similar allergy-related condition. The diagnosis explains your child’s symptoms and helps you manage them. Although you were likely relieved to have an answer and appropriate treatment plan, many of you were probably still left with many questions.

Research has given us many answers in recent years but there are many questions that still remain. Why did my child develop this condition? Is there any way to prevent this condition? What are the chances that siblings will develop the same condition? Is there a way to actually cure the underlying condition so that my child can eat a normal diet? The best way to get these answers is to support clinical research. There may be a research study on your child’s specific condition at a facility near you. Enrolling your children is the best way to get closer to the cause of these diseases and hopefully someday, the cure.

Finding a Clinical Trial

It’s easy to find trials on the U.S. National Institutes of Health (NIH) website: http://www.clinicaltrials.gov. Here are some clinical trials (which are seeking participants) that may apply to your child’s condition:

• Food allergies;
• Eosinophilic disorders;
• Infants and children with GERD;
• Pediatric inflammatory bowel disease;
• Short bowel syndrome in children; and
• General studies on pediatric allergic disease.

Obviously, pediatric allergic diseases are getting more and more attention from researchers. By joining a clinical study, you can help strengthen the research and do your part to help find answers. You can refine your search for a clinical trial by location so that you can find a clinical trial near you. You can even see a list of studies on a map.

Questions You Should Ask Before Enrolling in a Clinical Trial

Before you enroll your child in a clinical study, it’s important to understand exactly what a clinical trial is. Here are the answers to some questions that you might have. Chances are that you may be a little wary about signing your child up to be a “guinea pig” for science. And that’s okay; it’s your job as a parent to be careful!

You should make sure that you get all the facts before you decide to participate. The National Institutes of Health actually has a website dedicated to clinical studies for children that provides information and guidance for parents. For example, they provide a printable document (http://www.nhlbi.nih.gov/childrenandclinicalstudies/downloads/english/pdf/questions_to_ask.pdf) with questions that parents may want to ask when considering enrolling their child in a clinical study. Once you get all the information, your family can decide if participating in a clinical trial is right for you.

Have any of you participated in a clinical trial in the past? What has your experience been? Would you do it again?

- Mallory

We often get calls from parents asking about their child’s “spitting up” habits. If your little one has had vomiting problems in the past due to food allergies, it may be hard to know when it’s a regular spit up or something more serious. Every baby spits up or vomits occasionally, and some do quite often or even with every feeding. If, despite the spitting, your baby is

• Content
• In no discomfort
• Growing appropriately
• Experiencing no breathing problems from the vomiting

then your little one is what pediatricians call a "happy spitter" and no treatment is needed.

Infant Reflux and GERD

Reflux occurs when the contents of the stomach flow back up into the esophagus. When reflux is severe, it can progress to a more serious condition such as GERD (gastroesophageal reflux disease). GERD symptoms include heartburn, regurgitation of food or sour liquid, difficulty swallowing, coughing, wheezing and chest pain. Typical reflux should not be causing any pain for your baby. If you notice your little one is in discomfort, please see your pediatrician.

Reflux Remedies

Infants are especially prone to reflux because 1) their stomachs are quite small and are easily distended, and 2) the lower esophagus valve may be immature and may not tighten up when it should. Typically, the lower esophagus valve tightens up sometime in the first year, usually around 4-5 months of age, at which time the spitting up may go away. For any spitter, there are a few things that might help:

• Keep your baby upright for a half hour or so after a feeding (to let gravity help out).
• Make sure there's no pressure on the stomach after a feeding. For example, try to wait at least 30 minutes after feeding before putting baby in her car seat.

If your child has more serious reflux or GERD, your pediatrician may also prescribe some medication to help control the acid.

What remedies work for your little spitters?

- Christine

[Image Source]

We’ve talked about Gastroesophageal reflux disease (GERD) before, and today we wanted to talk about dysphagia and aspiration, two things that can be associated with GERD.

Dysphagia refers to the inability of food and/or liquids to pass easily from the mouth, into the throat, through the esophagus and into to the stomach during the process of swallowing.[1] In more simple terms, it means “difficulty swallowing.” Many medical conditions can cause dysphagia but in children, it is usually due to physical malformations, neurological conditions or digestive problems like GERD.

How can GERD cause dysphagia?

GERD is a condition where the muscles at the end of the esophagus do not close properly and allow stomach contents to leak back into the esophagus. The acidity of stomach contents can cause inflammation in the esophagus (esophagitis) and may lead to ulcers and scaring. The scarring can result in narrowing of the esophagus which may make swallowing more difficult. Patients with dysphagia may experience pain in the throat or chest, heartburn, regurgitation or the feeling that they have something stuck in their throat or chest.

Aspiration:

Both GERD and dysphagia are risk factors for aspiration, where foreign substances (food, liquid and/or stomach contents) are inhaled into the lungs. GERD can cause stomach contents to flow back into the esophagus and dysphagia can cause food and/or liquid to remain in the esophagus after swallowing. If these substances are inhaled and move into the lungs, it can lead to serious respiratory problems, such as aspiration pneumonia[2].

Silent Aspiration:

Silent aspiration describes aspiration without any obvious signs of swallowing difficulty, such as coughing or breathing difficulty[3]. Silent aspiration is especially common among children with dysphagia. In fact, an estimated 94% of children with dysphagia experience silent aspiration. This form can be especially dangerous because caregivers may not know that aspiration is occurring until the child becomes sick.

Because GERD and dysphagia are risk factors for aspiration and because children are more likely than adults to experience silent aspiration, you may want to do a swallow study if your child has these conditions to rule out aspiration. If it is detected, don’t worry! There are various ways to manage it so that respiratory problems don’t develop, such as altering the thickness of your child’s food and drinks.

Have any of you had experience with GERD, dysphagia or aspiration? Do you have any additional advice for little ones who are diagnosed with these conditions?

- Mallory

[1] Dysphagia. Children’s Hospital Boston: http://www.childrenshospital.org/az/Site815/mainpageS815P0.html.
[2] Palmer & Drennan et al. Evaluation and Treatment of Swallowing Impairments. Am Fam Physician 2000;61:2453-62
[3] Lee J, Blain S, Casas M, Kenny D, Berall G, Chau T. A radial basis classifier for the automatic detection of aspiration in children with dysphagia. J Neuroeng Rehabil. 2006 Jul 17;3:14.

Does it seem like your baby spits up all the time? Do you have to constantly change their clothes (and yours) because they have trouble keeping formula or breastmilk down? If this sounds like your little one, you might be dealing with either GER or GERD.

Gastroesophageal reflux disease (GERD) a more serious form of Gastroesophageal reflux (GER), which is very common. According to the National Institutes of Health, GER occurs when the lower esophageal sphincter (LES) opens spontaneously, for varying periods of time, or does not close properly and stomach contents rise up into the esophagus. GER is also known more commonly as acid reflux, because digestive juices (acids) rise up with the food.

Occasional GER is common, so if this sometimes happens to your baby it doesn’t necessarily mean they have GERD. If the reflux is persistent and happens more than twice a week, then it is considered GERD, which can lead to more serious health problems for babies including failure to gain weight, bleeding, respiratory problems or esophagitis.

So how can you tell if your child is spitting up a lot or has the more serious GERD? According to Dr. Samuel Nerko, MD, MPH from Children’s Hospital of Boston, gastroenterologists often look for the following symptoms to diagnose GERD in infants:

• Vomiting or spitting up frequently
• Pain associated with regurgitation
• Back arching
• Refusal to eat
• Constant or sudden crying
• Chronic hiccups
• Irritability or fussiness

If you think that your little one might have GERD, check in with your doctor or a pediatric gastroenterologist. They will probably recommend an infant dose of medications typically used to treat heartburn in adults. A hypoallergenic amino acid-based formula can often help babies with GERD too because it is sometimes caused or made worse by allergies to milk or soy protein.

What treatments have helped your little ones with GERD? Are there any tricks that you rely on to manage their reflux?

-Nita

Yesterday, I came across an interesting article in the Wall Street Journal on the increasing number of babies being diagnosed and treated for GERD (gastroesophageal reflux disease). According to the article, a few years ago, most of the symptoms were put off as colic. To read the whole article, click here.

As a nutrition specialist, I often hear from parents with these questions: Is it colic? GERD? A milk protein allergy? Sometimes, it can even be all three with 42% of infants with GERD also having a milk allergy! The article mentioned a few treatments, including Pepcid and the use of a proton-pump inhibitor, but it did not include changing the baby’s diet. Often, an allergy to milk/soy is the cause of GERD, in these cases nutritional management can help.

If this is the case, nursing moms need to remove all milk and dairy proteins from their diet if they are using nutritional management as treatment. If the baby is formula-fed, parents should switch to a milk- and soy-free elemental formula, such as Neocate. With the protein broken down to its simplest form (amino acids), babies with a milk allergy and/or GERD can easily digest the formula while getting the nutrition they need to grow and thrive.

Check out the article. It has some interesting diagnosis stories that might help your little one get better!

And for more information on this topic, click here.

As always, send any questions my way!

-Sarah

Q: Our doctor thinks that my son might have an eosinophilic gastrointestinal disorder, but I am confused about what that is and how it can be treated. Where can I find out more?

A: Eosinophilic gastrointestinal disorders (also known as EGIDs) are rare conditions that can occur when there are high levels of eosinophils in one or more parts of the digestive system, including the esophagus, stomach, small and large intestines. An eosinophil is a type of white blood cell that is involved in allergic reactions.

Symptoms of EGIDs can vary, which sometimes make them difficult to diagnose. Some of the common ones include:

• Nausea or vomiting
• Reflux
• Difficulty swallowing
• Diarrhea
• Abdominal pain
• Poor weight gain or failure to thrive

Typically your gastroenterologist will need to do a biopsy to positively diagnose an EGID and rule out any other digestive diseases (such as GERD). Once a diagnosis has been made, they will often follow up with allergy testing to help determine the appropriate treatment.

Depending on the severity of your son’s EGID and allergies, he may need to be on an elimination diet and avoid all potential allergens. Your doctor may recommend an elemental formula (like Neocate Jr. or EO28 Splash), which will ensure that he doesn’t have any allergic reactions and still gets all of the nutrients he needs. Once his digestive tract begins to heal, then the process of trialing new foods will begin to identify “safe” items that he can eat.

For more information about EGIDs, be sure to visit the American Partnership for Eosinophilic Disorders website, www.apfed.org.

Twins Clare and Shane were born two months premature. In addition to dealing with the issues of prematurity, they were diagnosed with gastroesophageal reflux disease (GERD) and the Neonatal Intensive Care Unit started them on Neosure.

Clare and Shane immediately reacted negatively to the Neosure, crying for hours on end and arching their backs.

“I didn’t know what to do,” says Laura, the twins’ mother. “I thought I was a horrible mother because I could not comfort them.”

After reacting to the Neosure, the twin’s home care nurse switched Clare and Shane to Gentlease formula, but there was no change in their symptoms.

For five months, Clare and Shane had frequent visits with their neologist pediatrician and tried everything from switching formulas multiple times, varying feeding schedules and trying Zantac and Mylicon. Nothing seemed to ease their pain.

Finally, Clare and Shane’s visiting home nurse suggested that the twins try Neocate®, a hypoallergenic formula comprised of amino acids (the building blocks of protein) instead of the full or partial protein chains in other formulas.

After the first bottle, Clare and Shane showed instant improvement. “I had two completely different babies” says Laura.

Clare and Shane After Neocate

It took five long months for Clare and Shane to receive the right treatment option for their GERD. Once on Neocate, there was an immediate difference.

“Clare and Shane now laugh and smile,” says Laura. “They burp, get sleepy and barely ever cry.”

If you want to share your before and after photos, we’d love to see them! Send us an email at FoodAllergyLiving@nutricia.com.

The first eight months of Sean’s life were grueling.  He experienced the discomfort and pain of vomiting up to three times a day, unable to tolerate his formula.  Six months of very little weight gain left Sean feeling weak, while his gastroesophageal reflux condition fuelled his asthma symptoms.

At nine months old Sean was diagnosed with failure to thrive; a description given to children whose current weight or rate of weight gain is significantly below that of other children of similar age and sex.

“We didn’t understand why he was vomiting so often and his lack of weight gain,” said Rebecca Sparks, Sean’s mother.  “It was heartbreaking on us as his parents to see him go through that all, we felt helpless.”

To combat Sean’s persistent vomiting, his parents tried Zantac and Prevacid, which seemed to soothe his symptoms for some time, but they ultimately returned.  

Since his symptoms kept reoccurring, Sean’s pediatrician referred his parents to a gastroenterologist, who tested for allergies, cystic fibrosis and eosinophilic esophagitis.  Sean tested negative, increasing his parents concerns.  With little options left, Sean’s doctors recommended a surgery, nissen fundoplication, which treats gastroesophageal reflux by stitching the upper part of the stomach around the lower end of the esophagus, reinforcing the closing function.

In an attempt to exhaust all other options, especially surgery, Rebecca turned to Neocate Junior.  After a month and a half, Sean only vomited a total of three times compared to three times a day prior to Neocate.

“I definitely wish we had switched to Neocate sooner,” says Rebecca.  “Sean is gaining weight and drinking more formula.  He was averaging 20 ounces per day and now he chows down 30!” 

Neocate has improved Sean’s life and offered him an alternative to surgery and for that his parents are grateful.

“Sean doesn’t have to experience the pain of vomiting so often and can tolerate all his formula,” says Rebecca.  “Sean has always tried to be a happy camper despite his symptoms, but with Neocate, he can be happy and healthy." 

If you want to share your before and after photos, we’d love to see them! Send us an email at FoodAllergyLiving@neocate.com. 

Sean After Neocate 

We often get calls from parents who are interested in thickening Neocate. In today’s post, we’ll explore the reasons for thickening formulas (or bottle-fed breast milk) and some tips for those of you considering it.

There are  two main reasons for wanting to thicken your child’s infant formula.

1) Reflux:

One reason is for gastroesophageal reflux. If your child suffers from reflux, the physician may recommend thickening their formula or breast milk by adding a small amount of rice cereal. This practice is somewhat controversial. Some physicians recommend it and others feel that it can actually worsen reflux for some infants. Thickening feeds is shown to reduce vomiting but there are mixed results in terms of its effect on reflux itself. Every baby is unique and for some babies, thickening with rice cereal is helpful.

If you are considering trying to thicken your baby’s formula, be sure to discuss it with the physician first. If your baby has food allergies, make sure the ingredients in the rice cereal are appropriate. We have heard from several parents that their child reacted to a brand of rice cereal that contains soy. As always, read the food labels carefully. It is possible for babies with multiple food protein allergies to be intolerant to rice proteins.

We don’t recommend thickening Neocate, nor do we recommend NOT thickening Neocate. It really depends on the circumstances and it is something for the physician and the parent to decide. That said, the nutrition in Neocate will not be harmed by the addition of a thickener so as long as the doctor or dietician recommends it, there is no problem with thickening Neocate. Keep in mind that thickening formula may make it difficult for the baby to drink it so you may have to adjust the nipple size accordingly.

2) Swallowing Problems; Dysphagia:

Swallowing problems, also known as “dysphagia”, is the other reason for thickening infant formula (or bottle-fed breastmilk). According to the Children’s Hospital of Boston, dysphagia describes the inability of food or liquids to pass easily from the mouth, into the throat, and down into the esophagus to the stomach during the process of swallowing. Swallowing problems can be dangerous because of the risk for aspiration, where food or liquids are inhaled into the windpipes and lungs, which can lead to pneumonia.

When a child has swallowing problems, the physician or feeding specialist may recommend altering the consistency of the diet to make swallowing easier. Sometimes the physician may recommend thickening with rice cereal and other times they will recommend a commercial thickener such as Thick-It. In the case of dysphagia, there is no problem using a thickener with Neocate, so long as it is recommended by a healthcare provider and it contains no ingredients that the child is intolerant to. 

Do you thicken your child’s infant formula or bottle-fed breast milk?