When we looked at our own data at Boston Children's and we looked at rates of hospitalization, once the gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.
When we looked at our own data at Boston Children's and we looked at rates of hospitalization, once the gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.
When we looked at our own data at Boston Children's and we looked at rates of hospitalization, once the gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.
You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has allergic esophagitis or eosinophilic esophagitis, and I can't stress that enough.
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, and wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 1 · 3:23
quoteThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 1 · 3:23
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, and wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 1 · 3:23
quoteThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 1 · 5:26
clinicalProton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid.↗
▶Ep 1 · 5:26
clinicalProton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid.↗
▶Ep 1 · 5:39
clinicalIn infants fed every 2 to 3 hours, milk remains in the stomach for up to 2–3 hours; acid production only begins after 3 hours, so infants reflux non-acidic gastric content.↗
▶Ep 1 · 5:39
clinicalIn infants fed every 2 to 3 hours, milk remains in the stomach for up to 2–3 hours; acid production only begins after 3 hours, so infants reflux non-acidic gastric content.↗
▶Ep 1 · 5:53
quoteProton pump inhibitors just aren't going to help in this age group where they're really refluxing non-acid reflux.↗
▶Ep 1 · 5:53
quoteProton pump inhibitors just aren't going to help in this age group where they're really refluxing non-acid reflux.↗
▶Ep 1 · 7:21
epidemiologicalStudies have shown that both H2 blockers and PPIs increase the risk of sepsis, UTIs, necrotizing enterocolitis, pneumonia, pharyngitis, upper respiratory infections, GI bugs, and C. diff in infants.↗
▶Ep 1 · 7:21
epidemiologicalStudies have shown that both H2 blockers and PPIs increase the risk of sepsis, UTIs, necrotizing enterocolitis, pneumonia, pharyngitis, upper respiratory infections, GI bugs, and C. diff in infants.↗
▶Ep 1 · 9:41
clinicalIn children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive.↗
▶Ep 1 · 9:41
clinicalIn children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive.↗
▶Ep 1 · 9:53
epidemiologicalEosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms.↗
▶Ep 1 · 9:53
epidemiologicalEosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms.↗
▶Ep 1 · 10:08
clinicalIn older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia.↗
▶Ep 1 · 10:08
clinicalIn older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia.↗
▶Ep 1 · 10:54
quoteYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has allergic esophagitis or eosinophilic esophagitis, and I can't stress that enough.↗
▶Ep 1 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 1 · 10:54
quoteYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has allergic esophagitis or eosinophilic esophagitis, and I can't stress that enough.↗
▶Ep 1 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 1 · 12:02
epidemiologicalAbout 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy.↗
▶Ep 1 · 12:02
epidemiologicalAbout 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy.↗
▶Ep 1 · 16:28
clinicalMacrolides (erythromycin) are motilin agonists that make the antrum of the stomach contract and can help with vomiting; they also have an anti-inflammatory effect on the airway and lungs.↗
▶Ep 1 · 16:28
clinicalWe use a lot of erythromycin in babies who have respiratory symptoms; macrolides are motilin agonists and also have an anti-inflammatory effect for the airway and lungs.↗
▶Ep 1 · 16:28
clinicalMacrolides (erythromycin) are motilin agonists that make the antrum of the stomach contract and can help with vomiting; they also have an anti-inflammatory effect on the airway and lungs.↗
▶Ep 1 · 16:28
clinicalWe use a lot of erythromycin in babies who have respiratory symptoms; macrolides are motilin agonists and also have an anti-inflammatory effect for the airway and lungs.↗
▶Ep 1 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, so the best use of a probe is to correlate symptoms with reflux episodes.↗
▶Ep 1 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, so the best use of a probe is to correlate symptoms with reflux episodes.↗
▶Ep 1 · 28:21
clinicalThe majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.↗
▶Ep 1 · 28:21
quoteThe majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.↗
▶Ep 1 · 28:21
clinicalThe majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.↗
▶Ep 1 · 28:21
quoteThe majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.↗
▶Ep 1 · 28:42
epidemiologicalIn kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy.↗
▶Ep 1 · 28:42
epidemiologicalIn kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy.↗
▶Ep 1 · 29:37
quoteWhen we looked at our own data at Boston Children's and we looked at rates of hospitalization, once the gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 1 · 29:37
epidemiologicalWhen we looked at our own data at Boston Children's, once a gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 1 · 29:37
quoteWhen we looked at our own data at Boston Children's and we looked at rates of hospitalization, once the gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 1 · 29:37
epidemiologicalWhen we looked at our own data at Boston Children's, once a gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 1 · 35:28
quoteThe kids who are the most miserable post Nissen, it's the kids that were retching pre-op because they retch a lot post-op too.↗
▶Ep 1 · 35:28
clinicalThe kids who are the most miserable post-Nissen are the kids that were retching pre-op, because they retch a lot post-op too.↗
▶Ep 1 · 35:28
clinicalThe kids who are the most miserable post-Nissen are the kids that were retching pre-op, because they retch a lot post-op too.↗
▶Ep 1 · 35:28
quoteThe kids who are the most miserable post Nissen, it's the kids that were retching pre-op because they retch a lot post-op too.↗
▶Ep 1 · 40:54
guidelineThere are three Rome IV diagnostic categories for older children with chest pain or heartburn: non-erosive reflux disease (NERD, abnormal acid burden with normal scope), reflux hypersensitivity (normal acid burden but symptom correlation with reflux), and functional heartburn (normal scope, normal acid, no symptom correlation).↗
▶Ep 1 · 40:54
guidelineThere are three Rome IV diagnostic categories for older children with chest pain or heartburn: non-erosive reflux disease (NERD, abnormal acid burden with normal scope), reflux hypersensitivity (normal acid burden but symptom correlation with reflux), and functional heartburn (normal scope, normal acid, no symptom correlation).↗
▶Ep 1 · 43:42
guidelineNew GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months, then attempting to wean; if unable to wean, restart the drug, but the goal should be to try to wean ideally 2 times a year.↗
▶Ep 1 · 43:42
guidelineNew GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months, then attempting to wean; if unable to wean, restart the drug, but the goal should be to try to wean ideally 2 times a year.↗
▶Ep 1 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 1 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 1 · 49:02
clinicalWhen you look at kids that tend to do the worst after Nissen, it's the kid who had a Nissen for pulmonary reasons; if they're aspirating during swallowing, their saliva pools in the esophagus over the Nissen and they continue to aspirate, so they gag, retch, and cough all the time.↗
▶Ep 1 · 49:02
clinicalWhen you look at kids that tend to do the worst after Nissen, it's the kid who had a Nissen for pulmonary reasons; if they're aspirating during swallowing, their saliva pools in the esophagus over the Nissen and they continue to aspirate, so they gag, retch, and cough all the time.↗
▶Ep 1 · 52:39
clinicalBeing able to use blenderized food instead of formula has really changed our rates of needing to think about fundoplication, because everything we're putting through the gastrostomy tube is so heavy and migrates to the antrum away from the LES and cardia.↗
▶Ep 1 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication because now everything we're putting through the gastrostomy tube is so heavy.↗
▶Ep 1 · 52:39
clinicalBeing able to use blenderized food instead of formula has really changed our rates of needing to think about fundoplication, because everything we're putting through the gastrostomy tube is so heavy and migrates to the antrum away from the LES and cardia.↗
▶Ep 1 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication because now everything we're putting through the gastrostomy tube is so heavy.↗
▶Ep 1 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 1 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 1 · 54:26
clinicalCyproheptadine (periactin) helps with gastric accommodation and can control retching in kids.↗
▶Ep 1 · 54:26
clinicalCyproheptadine (periactin) helps with gastric accommodation and can control retching in kids.↗
▶Ep 1 · 1:02:02
clinicalWhen you're looking at the post-fundoplication patient, if they have a G tube, you have to image them both ways: putting barium through the G tube and also giving them barium from above via a nasoesophageal tube to see if the esophagus is emptying.↗
▶Ep 1 · 1:02:02
clinicalWhen you're looking at the post-fundoplication patient, if they have a G tube, you have to image them both ways: putting barium through the G tube and also giving them barium from above via a nasoesophageal tube to see if the esophagus is emptying.↗
▶Ep 1 · 1:03:07
clinicalA study out of Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 1 · 1:03:07
clinicalA study out of Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 1 · 1:11:39
clinicalWhen you look at rates of reflux post-Nissen, it's somewhere between 10 and 20 reflux episodes per 24-hour period on impedance probe, and if I see that, I'm pretty happy that the Nissen is still doing its job.↗
▶Ep 1 · 1:11:39
clinicalWhen you look at rates of reflux post-Nissen, it's somewhere between 10 and 20 reflux episodes per 24-hour period on impedance probe, and if I see that, I'm pretty happy that the Nissen is still doing its job.↗
▶Ep 1 · 1:18:58
clinicalPatients who ruminate describe vomiting 50 to 100 times a day, typically within minutes of starting a meal or for the hour after a meal; esophageal motility study shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 1 · 1:18:58
clinicalPatients who ruminate describe vomiting 50 to 100 times a day, typically within minutes of starting a meal or for the hour after a meal; esophageal motility study shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 1 · 1:19:31
clinicalIf you wrap patients who ruminate, they continue to do this even with a wrap in place, so fundoplication does not help.↗
▶Ep 1 · 1:19:31
quoteIf you wrap these patients, what we find is they continue to do this even with a wrap in place.↗
▶Ep 1 · 1:19:31
quoteIf you wrap these patients, what we find is they continue to do this even with a wrap in place.↗
▶Ep 1 · 1:19:31
clinicalIf you wrap patients who ruminate, they continue to do this even with a wrap in place, so fundoplication does not help.↗
Gastroesophageal Reflux Disease
▶Ep 8 · 3:23
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 8 · 3:35
quoteThe number one masquerader that we see in kids this age who have respiratory symptoms and vomiting is aspiration.↗
▶Ep 8 · 4:18
epidemiologicalThe peak age of reflux is between 4 and 6 months of age.↗
▶Ep 8 · 5:26
clinicalIn children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk).↗
▶Ep 8 · 5:39
quoteWhen you think about what babies reflux, babies reflux milk. They're fed basically every 2 to 3 hours.↗
▶Ep 8 · 5:45
clinicalNormal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty.↗
▶Ep 8 · 7:21
clinicalStudies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children.↗
▶Ep 8 · 8:04
quoteLast thing you want to do is push them over the edge with more respiratory symptoms by prescribing a proton pump inhibitor.↗
▶Ep 8 · 9:27
clinicalIn kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough.↗
▶Ep 8 · 9:53
epidemiologicalWhen you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids.↗
▶Ep 8 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 8 · 11:14
quoteI can't stress that enough. You do the initial endoscopy, you see that there's eosinophils there.↗
▶Ep 8 · 11:57
epidemiologicalIn about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy.↗
▶Ep 8 · 16:28
clinicalMacrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs.↗
▶Ep 8 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult.↗
▶Ep 8 · 19:18
opinionReflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants.↗
▶Ep 8 · 28:06
quoteReflux doesn't cause a problem unless you can't protect your airway.↗
▶Ep 8 · 28:21
clinicalThe majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN.↗
▶Ep 8 · 28:42
epidemiologicalIn Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy.↗
▶Ep 8 · 29:37
epidemiologicalIn kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 8 · 35:28
clinicalKids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this.↗
▶Ep 8 · 40:54
guidelineRome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux).↗
▶Ep 8 · 43:42
guidelineThe new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly.↗
▶Ep 8 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 8 · 45:55
quoteMy bias is I'll take a PPI over a fundo any day.↗
▶Ep 8 · 49:02
clinicalKids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva.↗
▶Ep 8 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication.↗
▶Ep 8 · 52:39
clinicalBlenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia.↗
▶Ep 8 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 8 · 54:26
clinicalCyproheptadine (Periactin) helps with gastric accommodation and can control retching in children.↗
▶Ep 8 · 1:03:11
clinicalA study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 8 · 1:08:04
opinionGastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility.↗
▶Ep 8 · 1:08:18
clinicalBotox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism.↗
▶Ep 8 · 1:11:44
clinicalPost-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning.↗
▶Ep 8 · 1:18:40
clinicalPatients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal.↗
▶Ep 8 · 1:19:13
clinicalOn esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 8 · 1:19:31
clinicalIf you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place.↗
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 24 · 3:35
quoteThe number one masquerader that we see in kids this age who have respiratory symptoms and vomiting is aspiration.↗
▶Ep 24 · 4:18
epidemiologicalThe peak age of reflux is between 4 and 6 months of age.↗
▶Ep 24 · 5:26
clinicalIn children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk).↗
▶Ep 24 · 5:39
quoteWhen you think about what babies reflux, babies reflux milk. They're fed basically every 2 to 3 hours.↗
▶Ep 24 · 5:45
clinicalNormal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty.↗
▶Ep 24 · 7:21
clinicalStudies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children.↗
▶Ep 24 · 8:04
quoteLast thing you want to do is push them over the edge with more respiratory symptoms by prescribing a proton pump inhibitor.↗
▶Ep 24 · 9:27
clinicalIn kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough.↗
▶Ep 24 · 9:53
epidemiologicalWhen you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids.↗
▶Ep 24 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 24 · 11:14
quoteI can't stress that enough. You do the initial endoscopy, you see that there's eosinophils there.↗
▶Ep 24 · 11:57
epidemiologicalIn about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy.↗
▶Ep 24 · 16:28
clinicalMacrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs.↗
▶Ep 24 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult.↗
▶Ep 24 · 19:18
opinionReflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants.↗
▶Ep 24 · 28:06
quoteReflux doesn't cause a problem unless you can't protect your airway.↗
▶Ep 24 · 28:21
clinicalThe majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN.↗
▶Ep 24 · 28:42
epidemiologicalIn Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy.↗
▶Ep 24 · 29:37
epidemiologicalIn kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 24 · 35:28
clinicalKids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this.↗
▶Ep 24 · 40:54
guidelineRome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux).↗
▶Ep 24 · 43:42
guidelineThe new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly.↗
▶Ep 24 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 24 · 45:55
quoteMy bias is I'll take a PPI over a fundo any day.↗
▶Ep 24 · 49:02
clinicalKids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva.↗
▶Ep 24 · 52:39
clinicalBlenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia.↗
▶Ep 24 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication.↗
▶Ep 24 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 24 · 54:26
clinicalCyproheptadine (Periactin) helps with gastric accommodation and can control retching in children.↗
▶Ep 24 · 1:03:11
clinicalA study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 24 · 1:08:04
opinionGastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility.↗
▶Ep 24 · 1:08:18
clinicalBotox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism.↗
▶Ep 24 · 1:11:44
clinicalPost-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning.↗
▶Ep 24 · 1:18:40
clinicalPatients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal.↗
▶Ep 24 · 1:19:13
clinicalOn esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 24 · 1:19:31
clinicalIf you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place.↗
quoteThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 1 · 3:23
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, and wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 1 · 5:26
clinicalProton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid.↗
▶Ep 1 · 5:39
clinicalIn infants fed every 2 to 3 hours, milk remains in the stomach for up to 2–3 hours; acid production only begins after 3 hours, so infants reflux non-acidic gastric content.↗
▶Ep 1 · 5:53
quoteProton pump inhibitors just aren't going to help in this age group where they're really refluxing non-acid reflux.↗
▶Ep 1 · 7:21
epidemiologicalStudies have shown that both H2 blockers and PPIs increase the risk of sepsis, UTIs, necrotizing enterocolitis, pneumonia, pharyngitis, upper respiratory infections, GI bugs, and C. diff in infants.↗
▶Ep 1 · 9:41
clinicalIn children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive.↗
▶Ep 1 · 9:53
epidemiologicalEosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms.↗
▶Ep 1 · 10:08
clinicalIn older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia.↗
▶Ep 1 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 1 · 10:54
quoteYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has allergic esophagitis or eosinophilic esophagitis, and I can't stress that enough.↗
▶Ep 1 · 12:02
epidemiologicalAbout 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy.↗
▶Ep 1 · 16:28
clinicalWe use a lot of erythromycin in babies who have respiratory symptoms; macrolides are motilin agonists and also have an anti-inflammatory effect for the airway and lungs.↗
▶Ep 1 · 16:28
clinicalMacrolides (erythromycin) are motilin agonists that make the antrum of the stomach contract and can help with vomiting; they also have an anti-inflammatory effect on the airway and lungs.↗
▶Ep 1 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, so the best use of a probe is to correlate symptoms with reflux episodes.↗
▶Ep 1 · 28:21
clinicalThe majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.↗
▶Ep 1 · 28:21
quoteThe majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.↗
▶Ep 1 · 28:42
epidemiologicalIn kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy.↗
▶Ep 1 · 29:37
epidemiologicalWhen we looked at our own data at Boston Children's, once a gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 1 · 29:37
quoteWhen we looked at our own data at Boston Children's and we looked at rates of hospitalization, once the gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 1 · 35:28
clinicalThe kids who are the most miserable post-Nissen are the kids that were retching pre-op, because they retch a lot post-op too.↗
▶Ep 1 · 35:28
quoteThe kids who are the most miserable post Nissen, it's the kids that were retching pre-op because they retch a lot post-op too.↗
▶Ep 1 · 40:54
guidelineThere are three Rome IV diagnostic categories for older children with chest pain or heartburn: non-erosive reflux disease (NERD, abnormal acid burden with normal scope), reflux hypersensitivity (normal acid burden but symptom correlation with reflux), and functional heartburn (normal scope, normal acid, no symptom correlation).↗
▶Ep 1 · 43:42
guidelineNew GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months, then attempting to wean; if unable to wean, restart the drug, but the goal should be to try to wean ideally 2 times a year.↗
▶Ep 1 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 1 · 49:02
clinicalWhen you look at kids that tend to do the worst after Nissen, it's the kid who had a Nissen for pulmonary reasons; if they're aspirating during swallowing, their saliva pools in the esophagus over the Nissen and they continue to aspirate, so they gag, retch, and cough all the time.↗
▶Ep 1 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication because now everything we're putting through the gastrostomy tube is so heavy.↗
▶Ep 1 · 52:39
clinicalBeing able to use blenderized food instead of formula has really changed our rates of needing to think about fundoplication, because everything we're putting through the gastrostomy tube is so heavy and migrates to the antrum away from the LES and cardia.↗
▶Ep 1 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 1 · 54:26
clinicalCyproheptadine (periactin) helps with gastric accommodation and can control retching in kids.↗
▶Ep 1 · 1:02:02
clinicalWhen you're looking at the post-fundoplication patient, if they have a G tube, you have to image them both ways: putting barium through the G tube and also giving them barium from above via a nasoesophageal tube to see if the esophagus is emptying.↗
▶Ep 1 · 1:03:07
clinicalA study out of Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 1 · 1:11:39
clinicalWhen you look at rates of reflux post-Nissen, it's somewhere between 10 and 20 reflux episodes per 24-hour period on impedance probe, and if I see that, I'm pretty happy that the Nissen is still doing its job.↗
▶Ep 1 · 1:18:58
clinicalPatients who ruminate describe vomiting 50 to 100 times a day, typically within minutes of starting a meal or for the hour after a meal; esophageal motility study shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 1 · 1:19:31
quoteIf you wrap these patients, what we find is they continue to do this even with a wrap in place.↗
▶Ep 1 · 1:19:31
clinicalIf you wrap patients who ruminate, they continue to do this even with a wrap in place, so fundoplication does not help.↗
Gastroesophageal Reflux Disease
▶Ep 7 · 3:23
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 7 · 3:35
quoteThe number one masquerader that we see in kids this age who have respiratory symptoms and vomiting is aspiration.↗
▶Ep 7 · 4:18
epidemiologicalThe peak age of reflux is between 4 and 6 months of age.↗
▶Ep 7 · 5:26
clinicalIn children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk).↗
▶Ep 7 · 5:39
quoteWhen you think about what babies reflux, babies reflux milk. They're fed basically every 2 to 3 hours.↗
▶Ep 7 · 5:45
clinicalNormal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty.↗
▶Ep 7 · 7:21
clinicalStudies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children.↗
▶Ep 7 · 8:04
quoteLast thing you want to do is push them over the edge with more respiratory symptoms by prescribing a proton pump inhibitor.↗
▶Ep 7 · 9:27
clinicalIn kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough.↗
▶Ep 7 · 9:53
epidemiologicalWhen you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids.↗
▶Ep 7 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 7 · 11:14
quoteI can't stress that enough. You do the initial endoscopy, you see that there's eosinophils there.↗
▶Ep 7 · 11:57
epidemiologicalIn about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy.↗
▶Ep 7 · 16:28
clinicalMacrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs.↗
▶Ep 7 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult.↗
▶Ep 7 · 19:18
opinionReflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants.↗
▶Ep 7 · 28:06
quoteReflux doesn't cause a problem unless you can't protect your airway.↗
▶Ep 7 · 28:21
clinicalThe majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN.↗
▶Ep 7 · 28:42
epidemiologicalIn Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy.↗
▶Ep 7 · 29:37
epidemiologicalIn kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 7 · 35:28
clinicalKids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this.↗
▶Ep 7 · 40:54
guidelineRome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux).↗
▶Ep 7 · 43:42
guidelineThe new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly.↗
▶Ep 7 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 7 · 45:55
quoteMy bias is I'll take a PPI over a fundo any day.↗
▶Ep 7 · 49:02
clinicalKids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva.↗
▶Ep 7 · 52:39
clinicalBlenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia.↗
▶Ep 7 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication.↗
▶Ep 7 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 7 · 54:26
clinicalCyproheptadine (Periactin) helps with gastric accommodation and can control retching in children.↗
▶Ep 7 · 1:03:11
clinicalA study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 7 · 1:08:04
opinionGastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility.↗
▶Ep 7 · 1:08:18
clinicalBotox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism.↗
▶Ep 7 · 1:11:44
clinicalPost-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning.↗
▶Ep 7 · 1:18:40
clinicalPatients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal.↗
▶Ep 7 · 1:19:13
clinicalOn esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 7 · 1:19:31
clinicalIf you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place.↗
clinicalThe vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.↗
▶Ep 33 · 3:35
quoteThe number one masquerader that we see in kids this age who have respiratory symptoms and vomiting is aspiration.↗
▶Ep 33 · 4:18
epidemiologicalThe peak age of reflux is between 4 and 6 months of age.↗
▶Ep 33 · 5:26
clinicalIn children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk).↗
▶Ep 33 · 5:39
quoteWhen you think about what babies reflux, babies reflux milk. They're fed basically every 2 to 3 hours.↗
▶Ep 33 · 5:45
clinicalNormal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty.↗
▶Ep 33 · 7:21
clinicalStudies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children.↗
▶Ep 33 · 8:04
quoteLast thing you want to do is push them over the edge with more respiratory symptoms by prescribing a proton pump inhibitor.↗
▶Ep 33 · 9:27
clinicalIn kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough.↗
▶Ep 33 · 9:53
epidemiologicalWhen you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids.↗
▶Ep 33 · 10:54
guidelineYou really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.↗
▶Ep 33 · 11:14
quoteI can't stress that enough. You do the initial endoscopy, you see that there's eosinophils there.↗
▶Ep 33 · 11:57
epidemiologicalIn about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy.↗
▶Ep 33 · 16:28
clinicalMacrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs.↗
▶Ep 33 · 17:48
clinicalThere are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult.↗
▶Ep 33 · 19:18
opinionReflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants.↗
▶Ep 33 · 28:06
quoteReflux doesn't cause a problem unless you can't protect your airway.↗
▶Ep 33 · 28:21
clinicalThe majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN.↗
▶Ep 33 · 28:42
epidemiologicalIn Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy.↗
▶Ep 33 · 29:37
epidemiologicalIn kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.↗
▶Ep 33 · 35:28
clinicalKids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this.↗
▶Ep 33 · 40:54
guidelineRome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux).↗
▶Ep 33 · 43:42
guidelineThe new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly.↗
▶Ep 33 · 45:31
clinicalIf you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.↗
▶Ep 33 · 45:55
quoteMy bias is I'll take a PPI over a fundo any day.↗
▶Ep 33 · 49:02
clinicalKids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva.↗
▶Ep 33 · 52:39
quoteBeing able to use food instead of formula has really changed our rates of needing to think about fundoplication.↗
▶Ep 33 · 52:39
clinicalBlenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia.↗
▶Ep 33 · 54:19
clinicalPyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.↗
▶Ep 33 · 54:26
clinicalCyproheptadine (Periactin) helps with gastric accommodation and can control retching in children.↗
▶Ep 33 · 1:03:11
clinicalA study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.↗
▶Ep 33 · 1:08:04
opinionGastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility.↗
▶Ep 33 · 1:08:18
clinicalBotox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism.↗
▶Ep 33 · 1:11:44
clinicalPost-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning.↗
▶Ep 33 · 1:18:40
clinicalPatients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal.↗
▶Ep 33 · 1:19:13
clinicalOn esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus.↗
▶Ep 33 · 1:19:31
clinicalIf you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place.↗
