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Newborn esophageal reflux
ICD10CM code
#### Name of the Condition
- Newborn esophageal reflux (Gastroesophageal reflux in newborns)
#### Summary
Newborn esophageal reflux, also known as gastroesophageal reflux (GER), occurs when stomach contents flow back into the esophagus in infants. This condition is common among newborns and typically resolves on its own as the baby grows.
#### Causes
GER in newborns is often due to an underdeveloped lower esophageal sphincter (LES), which allows stomach contents to flow back into the esophagus. This can be a normal physiological process as the baby's digestive system matures.
#### Risk Factors
- Premature birth
- Feeding position and volume (overfeeding)
- Certain types of infant formulas
- Conditions affecting muscle tone, such as cerebral palsy
#### Symptoms
- Frequent spit-ups or vomiting
- Irritability during feeding
- Arching of the back while feeding
- Coughing, especially after feeding
- Poor weight gain in severe cases
#### Diagnosis
- Clinical evaluation based on symptoms
- pH probe test to measure acid levels in the esophagus
- Upper GI series x-ray to examine the digestive tract
- Endoscopy in more severe cases
#### Treatment Options
- Adjusting feeding practices (smaller, more frequent feedings)
- Positioning the baby upright during and after feedings
- Thickening bottle feeds under healthcare provider guidance
- Medications (e.g., proton pump inhibitors) for severe cases to reduce stomach acid
#### Prognosis and Follow-Up
Most infants outgrow esophageal reflux by their first birthday. Regular pediatric check-ups ensure monitoring of growth and symptom resolution. In rare instances, medical intervention might be necessary if symptoms persist beyond a year.
#### Complications
- Gastroesophageal reflux disease (GERD) if symptoms persist
- Risk of esophageal irritation or inflammation
- Aspiration pneumonia from inhaling refluxed material
#### Lifestyle & Prevention
- Elevate the head of the baby's crib slightly
- Keep the baby upright after feedings
- Avoid overfeeding
- Burp the baby frequently during feedings
#### When to Seek Professional Help
- Persistent vomiting or refusal to eat
- Blood in vomit or stool
- Chronic coughing or wheezing
- Signs of weight loss or failure to thrive
#### Additional Resources
- American Academy of Pediatrics: [HealthyChildren.org](https://www.healthychildren.org)
- North American Society for Pediatric Gastroenterology, Hepatology and Nutrition: [NASPGHAN.org](https://www.naspghan.org)
#### Tips for Medical Coders
- Ensure accurate documentation of the baby's symptoms and diagnostic findings.
- Avoid confusing newborn esophageal reflux (P78.83) with similar adult conditions.
- Be aware of co-existing conditions that might also need coding, such as prematurity.