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
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Pearl Toh, 15 Jul 2019
In addition to the known evils of maternal smoking during pregnancy on the son’s semen quality, prenatal exposure to paternal smoking can also be harmful, according to data from the large Danish National Birth Cohort (DNBC) presented at the ESHRE 2019 Meeting.
15 Jul 2019
Fluticasone, swallowed from a multidose inhaler, and oral viscous budesonide slurry have comparable efficacies as initial treatment for eosinophilic oesophagitis, a recent study has found.
2 days ago
Health-related quality of life (HRQoL) among patients with kidney stone is worse in those who are young and female than those who are older and male, according to a recent study. Non-Caucasian patients also have a lower HRQoL.
Tristan Manalac, 3 days ago
In patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI), admission Killip classification and creatinine and troponin levels are important cardiac mortality predictors, according to a recent Singapore study.