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Thinking Outside the Box When Dealing With Patients With GERD and Feeding Problems

Lifschitz, Carlos

Journal of Pediatric Gastroenterology and Nutrition: October 2011 - Volume 53 - Issue 4 - p 358
doi: 10.1097/MPG.0b013e318229ace9
Invited Commentaries

Hospital Italiano, Buenos Aires, Argentina.

Address correspondence and reprint requests to Carlos Lifschitz, MD, Buenos Aires, Argentina (e-mail:

Received 8 May, 2011

Accepted 2 June, 2011

The author reports no conflicts of interest.

See “Maternal Psychopathology and Psychomotor Development of Children With GERD” by Karacetin et al on page 380.

Gastroesophageal reflux (GER) and GER disease (GERD) are common causes for consultation to general pediatricians and pediatric gastroenterologists. Neurologic impairment, repaired esophageal atresia, other congenital esophageal diseases, cystic fibrosis, hiatal hernia, repaired achalasia, or family history of GERD may increase the incidence and severity of GERD. Patients with such conditions do not constitute the majority of consultations, however.

Feeding refusal and feeding difficulty are terms used mainly to describe symptoms such as refusal to eat, uncoordinated sucking and swallowing, gagging, vomiting, or irritability during feeding (1). Although GER or GERD and feeding refusal frequently coexist, a relation between them has not been established. There is a report suggesting that reflux disease caused infant feeding difficulty; however, no prospective studies have proven causation and none have shown resolution of feeding problems with medical therapy for GERD (2). Higher incidence of poor nutrient intake, decreased feeding readiness, and food refusal in infants with abnormal pH probe tests compared with normal controls have been reported (3). Heine et al (4) found no association between GERD diagnosed by pH probe and feeding difficulty, except for infants who experienced excessive regurgitation. More recently, a double-blind placebo-controlled multicenter study showed no improvement in feeding difficulties following lansoprazole therapy compared with placebo in infants with suspected GERD (5).

Recommendations for treating infants with GER state that as long as the child is gaining weight and merely spitting up, there is no reason to intervene (6). Although this may be the correct approach for most cases, perpetuation or even worsening of symptoms may occur in the occasional infant whose parent(s) has psychopathologic issues that makes it difficult to handle the child's problem, even if clinically not relevant. How much parental psychopathology contributes to make GER progress to GERD and/or to feeding disorders in some cases is not clear. How to identify such parents early remains a challenge. Any practitioner interested in feeding disorders knows from experience that when parents repeatedly force-feed, feeding aversion is just a step away, and resolving feeding aversion is not easy.

The study by Karacetin et al (7) attempts to shed some light on the potential association or cause and effect between maternal psychopathology and children with GERD. The study presents important findings regarding the potential relation among maternal anxiety, force-feeding, children's response to force-feeding, and the like. Which is the chicken and which the egg? Our guess is that, in some cases, maternal anxiety and psychopathology may help convert GER into GERD, which in turn worsens maternal anxiety and psychopathology. In other cases, the infant's GERD triggers an abnormal response in a mother whose symptoms of anxiety would otherwise have been under relative control. One study in infants showed that large-volume feedings promote regurgitation, probably by increasing the frequency of transient lower esophageal sphincter relaxation (8). Severe reduction in feeding volume during an extended period (as an attempt to diminish regurgitation or vomiting), however, may deprive the infant of needed energy and adversely affect weight gain. Overfeeding more often than energy restriction is a technique used by parents in an attempt to secure adequate energy intake. Physicians are many times innocently responsible for inducing a feeding disorder by pressuring parents to feed their infants more often and in larger quantities to preserve growth.

ESPGHAN and NASPGHAN's excellent and thorough guidelines make no mention of maternal psychopathology in association with GERD (2). Doctors are more prone to indicate and parents are more willing to accept clinical tests and even a second round of tests, rather than psychological evaluation and treatment when such problems are identified. Before performing a second endoscopy, biopsies, pH probe, and/or multichannel intraluminal impedance and indicating a third course of double-dose proton pump inhibitors because of failure to correct feeding problems in a child with GERD, clinicians should remember this report and the few others on the topic, and consider referral to a psychotherapist for evaluation and, if necessary, treatment. After all, persistent GERD and feeding problems can be disruptive even to the most normal parents.

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