Visceral pain in infants

Benefits of massage therapy for infants with symptoms of gastroesophageal reflux disease

OBJECTIVES

This randomized controlled pilot trial was conducted to evaluate the clinical efficacy of massage therapy (MT) for relief of symptoms of gastroesophageal reflux disease (GERD). The hypothesis was that, when compared to infants who received nonmassage therapy, infants who received MT would display fewer GERD symptoms, greater weight gain, greater amount of sleep, lower cortisol levels before and after treatment, and lower daily (area under the curve [AUC]) cortisol secretion.

METHODS

Participants were 36 infants born at term, 4-10 weeks of age at enrollment, healthy except for a diagnosis of GERD by their pediatrician, and with a score of at least 16 on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R). Infants were randomized to receive either MT or a nonmassage sham treatment in their homes for 30 min twice a week for 6 weeks. Data collectors and parents were blind to study condition.

RESULTS

GERD symptoms decreased in both groups and weight increased. Pretreatment salivary cortisol levels decreased significantly over time in the massage group while increasing in the nonmassage group. Daily cortisol level also decreased in the massage group and increased in the nonmassage group, but the difference was not significant.

CONCLUSIONS

MT administered by a professional therapist did not affect symptoms of GERD differently than a sham treatment but did decrease infant stress as measured by cortisol. Research focusing on stress reduction in infants with GERD and multimodal treatments addressing GERD symptoms may yield the most effective treatment.

The diagnosis and management of gastro-oesophageal reflux in infants

Gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD) occur frequently during the first months of life. Gastro-oesophageal reflux may be a primary gastro-intestinal motility disorder, but it may also be secondary to other conditions such as cow's milk protein allergy. Objective diagnosis can be difficult because there may be absence of correlation between history, results of pH monitoring and histology. Severe GORD may cause minor symptoms, and minor GOR may cause severe symptoms. Several different therapeutic interventions exist. Simply stated, thickened formula reduces regurgitation and alginates and proton pump inhibitors can be used to decrease acid GOR, depending on the severity of the GORD. Efficacy data of prokinetic drugs are either lacking or disappointing. Regarding side-effects, interest has been focused on cisapride, although other molecules have similar effects. Long-term side-effects such as the nutritional consequence of therapeutic management have been insufficiently studied, especially for the acid-reducing molecules.

Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture

Excessive crying is the most common problem presenting to the doctor in the first months of life in western industrialised societies, affecting up to 30% of infants. There has been an exponential increase in the diagnosis of gastro-oesophageal reflux disease (GORD) in babies who cry excessively over the past few decades, and many parents believe their crying infant "has reflux". This paper proposes that culturocentric assumptions have confused interpretation of research into GORD, and re-examines the findings of GORD research from the perspective of evolutionary biology. Evolutionary biologists argue that the human infant is an exterogestate foetus for at least the first six months of life, dependent on maternal co-regulation for optimal physiological function. However, infant-care practices in western industrialised societies shifted towards an emphasis on infant autonomy at the time of the Industrial Revolution. From the perspective of evolutionary biology, a misalignment between western culture and the biological expectations of the infant developed over two million years of evolution may result in excessive crying in less adapted babies. The key biocultural factors that impact on infant distress are feeding management, parental responsiveness, sensory nourishment and sleep management. When the concept of the human infant as an exterogestate foetus is integrated with the findings of GORD research, a hypothesis and its corollary emerge. This hypothesis proposes that infant GORD is a physiological manifestation of misalignment between biology and culture, and proposes, as a corollary, that if the impact of biocultural factors upon the physiology of otherwise well crying babies is not addressed in the first months of life, populations of infants who cry excessively may be predisposed to GORD after three to four months of age. If this hypothesis is correct, an integrated clinical approach to crying babies less than three to four months of age that considers feeding management (e.g., frequent feeds, breast- or bottle-feeding technique, referral to a lactation consultant, cow's milk allergy), parental responsiveness (e.g., prompt response to infant cues), sensory nourishment (e.g., sling or backpack, walks, massage) and sleep management (e.g., nocturnal co-sleeping) should, firstly, decrease crying when applied to infants less than three to four months of age, and secondly, decrease the incidence of GORD in these infants once they are older than three to four months of age. Thirdly, if this hypothesis is correct, combining the integrated approach with pharmaceutical intervention should improve outcomes in infants diagnosed with GORD.

Gastro-oesophageal reflux disease and motility disorders

Gastro-oesophageal reflux (GOR) is a common phenomenon occurring at any age with a benign prognosis in the majority of cases, but requiring prompt evaluation and treatment when presenting with alarm symptoms or when persisting. Complications of GOR disease (GORD) may be severe. This chapter will discuss the epidemiology, natural course, pathophysiology, clinical presentation, diagnostic and therapeutic approach towards GORD and motility disorders according to different ages. Similarities and differences between infants, children and adults will be highlighted. The superior efficacy and safety of proton pump inhibitors have recently changed the diagnostic and therapeutic recommendations in adults, and possible indications in children are discussed. Only in patients unresponsive to optimal medical treatment are further investigations to exclude other aetiologies for GORD needed (e.g. eosinophilic oesophagitis in infants, scleroderma in adults). Special patient groups such as those with congenital malformations (e.g. oesophageal atresia) are not considered, whereas neurological, respiratory and allergy-affected patients as well as Helicobacter pylori infection are briefly discussed.

Gastroesophageal reflux: one reason why baby won't eat

Gastroesophageal reflux (GER) is the movement of gastric contents retrograde into the esophagus. Sometimes the refluxate is seen as emesis, but often reflux is "silent," meaning that there are no discrete symptoms during an episode. In adults, the most common symptom of GER is heartburn, whereas in infancy excessive crying and malaise are symptoms that prompt investigation for GER, with or without esophagitis. Symptoms of esophagitis in infancy may include arching (hyperextension) of the torso and refusal of feedings. Tube feedings may be required to treat infants with failure to thrive who refuse oral feedings. Paradoxically, tube feedings increase the number of GER episodes. A hypothetical explanation for refusal of food in infancy is that pain with swallowing (odynophagia) or heartburn are consequences of peptic esophagitis. As a result, infants will learn to refuse food if it hurts or if they fear that it will hurt to eat. Another possible mechanism is visceral hyperalgesia, a neuropathic condition in which prior experience changes sensory nerves so that previously innocuous stimuli are perceived as painful. Some infants may have especially sensitive sensory nerves in the upper gastrointestinal tract, which predisposes visceral hyperalgesia to develop. Thus pain occurs from luminal distension or acid reflux in the absence of tissue damage. The evaluation of babies who won't eat includes a careful history and physical examination to exclude the possibility of chronic systemic illness. Refusal to feed is an unusual manifestation of a common condition: GER disease. The initial tests for GER usually include a barium swallow study to assess the upper gastrointestinal anatomy, endoscopy and esophageal biopsy to assess esophagitis, and an intraesophageal pH study, which is useful in "silent" reflux to quantitate the duration of esophageal acid exposure and to correlate discrete symptom episodes with periods of reflux. The treatment of infants and toddlers who refuse to eat because of pain resulting from visceral hyperalgesia or reflux esophagitis involves removing the pain associated with eating and making eating a pleasurable experience. Treatment for esophagitis may include maintaining an upright posture after meals and thickened feeds, medication to improve gastrointestinal motility or to decrease acid secretion, or fundoplication.