gastroesophageal%20reflux%20disease%20in%20children
GASTROESOPHAGEAL REFLUX DISEASE IN CHILDREN

Gastroesophageal reflux is categorized as a disease [gastroesophageal reflux disease (GERD)] when reflux is associated with warning signs &/or complications, & requires further evaluation.

It is more common in formula-fed infants than in purely breastfed infants.

There is increased incidence in infants at 4 months of age.

Management Based on Symptomatology

  • There is no gold standard for the diagnosis of gastroesophageal reflux disease
  • Duration of treatment with proton pump inhibitors or histamine-2 receptor agonists depend on patient's symptoms

Regurgitation & Vomiting

  • Thorough history & physical examination may be sufficient to distinguish uncomplicated from complicated gastroesophageal reflux in infants & children with recurrent regurgitation
  • Infants with recurrent regurgitation but with poor weight gain should undergo thorough history & physical exam with lab exams (CBC, serum electrolytes, BUN, serum creatinine) to rule out other possible etiologies of the symptoms
    • Dietary modifications (extensively hydrolyzed formula, amino acid-based formula) to test for cow's milk allergy may also be considered 
  • Infants in unexplained state of distress with constant crying bouts should be investigated for diseases other than gastroesophageal reflux disease, as reflux is not a common cause for these symptoms

Heartburn

  • Conservative therapies (lifestyle changes, avoidance of trigger factors) are encouraged prior to initiation of drug treatments
  • Proton pump inhibitors may be given for 2-4 weeks to test for responsiveness to this treatment & for patients with moderate to severe heartburn
    • Gradual discontinuation of proton pump inhibitor & continuation of conservative therapies are recommended after positive results with proton pump inhibitors
  • As needed use of proton pump inhibitors, antacids, & H2RAs may also be considered for symptomatic relief

Reflux Esophagitis

  • 3 months of proton pump inhibitor therapy is recommended as initial therapy in patients with erosive esophagitis
    • Dose may be increased if patient is unresponsive after 4 weeks  
  • Endoscopic monitoring may be used to assess for treatment response in patients with atypical signs & symptoms, persistent symptoms despite appropriate therapy, or those with esophageal stricture or moderate-severe esophagitis
  • Long-term proton pump inhibitor therapy or surgery may be considered for chronic or relapsing reflux esophagitis

Dysphagia, Odynophagia, & Food Refusal

  • Odynophagia & dysphagia has been associated with the presence of esophagitis
  • Feeding refusal may be related to GER/GERD but further studies are needed to establish this association
    • Some studies incorporated abnormal pH probe findings with infants & children with feeding difficulty, except in infants with excessive regurgitation  
  • May suggest upper gastrointestinal barium contrast radiography in infants with feeding refusal &/or feeding difficulty, & for older children with dysphagia
  • Pharmacological therapy may only be considered in patients with symptoms highly suggestive of gastroesophageal reflux disease

Apnea

  • Presence of prolonged apnea has been associated with acid reflux in premature infants
    • Combined esophageal pH monitoring & multichannel intraluminal impedance (MMI) monitoring may help establish the relationship between the presence of apnea & regurgitation in a patient 
  • Infants with regurgitation complicated by apparent life-threatening events (ALTEs) may benefit from milk mixed with thickeners
  • Symptoms are most likely to resolve as the child ages, therefore pharmacological therapies are not recommended

Reactive Airways Disease

  • Studies have shown that gastroesophageal reflux may produce airway hyperresponsiveness & airflow obstruction leading to asthma exacerbation in asthmatic patients
  • Asthma may in turn be a factor in the development of gastroesophageal reflux disease due to reduced resting lower esophageal reflux pressure
  • Studies have shown that 60-80% of children with asthma have abnormal pH or MII/pH findings
  • Proton pump inhibitor therapy may be considered in asthmatic patients with persistent heartburn or regurgitation

Recurrent Pneumonia

  • Reflux of gastric contents have been associated with recurrent pneumonia & interstitial lung disease
  • Pharmacological therapy (proton pump inhibitors, H2RAs, prokinetic agents) may be considered in patients with minimal lung disease associated with gastroesophageal reflux disease & should be advised about the importance of prompt follow-up
  • Antireflux surgery should be considered in patients with severely impaired lung function to prevent further pulmonary damage

Upper Airway Symptoms

  • Upper respiratory tract manifestations such as chronic cough, hoarseness, sinusitis, otitis media, & laryngoscopic features such as edema, erythema, & nodularity have been linked to the presence of gastroesophageal reflux disease
  • Other etiologies should be taken into consideration prior to starting therapy for gastroesophageal reflux disease
    • Children may undergo laryngoscopy to rule out possible functional or anatomical abnormalities

Dental Erosions

  • Several studies found the association of gastroesophageal reflux disease & dental erosions secondary to acidic pH exposure
  • Referral to a pediatric dentist is recommended

Sandifer Syndrome

  • A rare disorder associated with gastroesophageal reflux disease  characterized by spasmodic torsional dystonia with arching of the neck, head, eyes & trunk
  • Antireflux medications & specialist referral are recommended

Barrett Esophagus

  • Diagnosis for Barrett esophagus should be established prior to initiation of therapy
  • Following proton pump inhibitor therapy, histological examination is recommended to be able to characterize Barrett esophagus & to rule out presence of dysplasia
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