Overview
Definition:
Gastroesophageal reflux disease (GERD) in children is a chronic condition characterized by troublesome symptoms or complications resulting from the retrograde flow of gastric contents into the esophagus
While physiological reflux is common and benign in infants, GERD is diagnosed when reflux causes significant morbidity.
Epidemiology:
GERD symptoms are reported in up to 40% of healthy infants, but only a small percentage require medical intervention
Incidence varies with age and presentation
it is most common in infants aged 0-12 months, with symptoms often decreasing by 18-24 months
In older children, GERD prevalence is similar to adults, affecting approximately 2-5%
Risk factors include prematurity, neurological impairment, obesity, and certain congenital anomalies.
Clinical Significance:
Undiagnosed or inadequately treated pediatric GERD can lead to failure to thrive, esophagitis, esophageal strictures, Barrett esophagus (rare in children), aspiration pneumonia, and a significant impact on quality of life for both the child and family
Accurate diagnosis and management are crucial for preventing long-term complications and improving patient outcomes.
Clinical Presentation
Infantile Gerd:
Vomiting or regurgitation (often effortless)
Poor weight gain or failure to thrive
Irritability, fussiness, or arching back during or after feeds
Esophagitis: hematemesis, dysphagia, feeding refusal
Respiratory symptoms: cough, wheezing, apnea, recurrent pneumonia.
Older Child Gerd:
Heartburn
Epigastric pain
Nausea
Dysphagia or odynophagia
Vomiting
Cough or hoarseness
Chest pain mimicking cardiac pain
These symptoms may be difficult for younger children to articulate, leading to behavioral changes or feeding issues.
Diagnostic Criteria:
The 2018 GERD Consensus Statement defines GERD as "recurrent episodes of reflux that cause troublesome symptoms or complications"
Diagnosis is primarily clinical
Confirmation of reflux via objective testing may be indicated in specific scenarios, particularly when symptoms are atypical, refractory to treatment, or when complications are suspected.
Diagnostic Approach
History Taking:
Detailed history of feeding patterns, frequency and nature of regurgitation/vomiting, growth parameters, associated symptoms (irritability, respiratory issues, pain), response to empirical treatment (e.g., thickened feeds, positioning, proton pump inhibitors)
Red flags: poor weight gain, hematemesis, dysphagia, recurrent vomiting, significant respiratory symptoms, neurological deficits.
Physical Examination:
Assess growth parameters (weight, height, head circumference)
Examine for signs of malnutrition or dehydration
Perform a thorough cardiopulmonary examination to rule out other causes of respiratory symptoms
Abdominal examination for distension or tenderness
Neurological assessment for underlying conditions.
Investigations:
Upper GI series (barium swallow): assesses anatomy, identifies significant reflux, malrotation, or obstruction
Esophageal pH monitoring (24-hour): gold standard for quantifying acid reflux events
pH-impedance monitoring: measures both acid and non-acid reflux events, as well as bolus transit, providing more comprehensive data
Esophageal manometry: assesses esophageal motility and lower esophageal sphincter (LES) pressure, useful in patients with suspected motility disorders or prior to surgery
Endoscopy with biopsy: used to assess for esophagitis, erosions, or Barrett esophagus
typically reserved for children with alarm symptoms or those unresponsive to therapy.
Differential Diagnosis:
Physiological reflux, overfeeding, cow's milk protein allergy, eosinophilic esophagitis, infectious esophagitis, anatomical abnormalities (e.g., pyloric stenosis, malrotation), neurological disorders with dysphagia, functional abdominal pain, cyclic vomiting syndrome, allergic proctocolitis.
PH Impedance Monitoring
Indications For Testing:
Confirmation of GERD in children with troublesome symptoms not responding to empirical therapy
Evaluation of refractory symptoms despite acid suppression
Differentiation between acid and non-acid reflux
Assessment of distal esophageal clearance
Evaluation of suspected extraesophageal manifestations of reflux (e.g., cough, laryngitis).
Interpretation Of Results:
pH monitoring quantifies the number of reflux episodes (acidic < pH 4.0), their duration, and percentage of time esophagus is acidic
Impedance monitoring adds detection of non-acid reflux (which can also be symptomatic) and bolus clearance
A high number of reflux events, especially those associated with symptoms recorded by the patient/parent (event markers), supports the diagnosis of GERD
Values are compared to normative data for age.
Limitations Of Testing:
pH-impedance is most useful in children able to communicate symptoms or when clear symptom correlation can be made with reflux events
It does not assess the presence or severity of mucosal damage directly
False positives or negatives can occur depending on patient cooperation and symptom reporting.
Management
Lifestyle And Dietary Modifications:
For infants: thickening feeds (consult with pediatrician), smaller more frequent feeds, upright positioning after feeds
For older children: avoid trigger foods (fatty, spicy foods, chocolate, caffeine, mint), weight management if obese, avoid lying down after meals
For all ages: avoid tight clothing around abdomen.
Pharmacological Management:
Proton Pump Inhibitors (PPIs): Standard of care for moderate to severe GERD or esophagitis
Dosing varies by age and weight
Examples: Omeprazole, Pantoprazole, Lansoprazole
H2 Receptor Antagonists (H2RAs): Less potent than PPIs, may be used for mild GERD or as adjunctive therapy
Examples: Ranitidine (if available, note recall history), Famotidine
Antacids: Provide short-term relief for older children, not for chronic management
Prokinetics: Generally not recommended due to limited efficacy and potential side effects.
Surgical Management:
Fundoplication is considered for severe, refractory GERD with significant complications (e.g., failure to thrive, recurrent aspiration pneumonia) in children who fail medical management
Indications are carefully selected, especially in neurologically impaired children
Nissen fundoplication is the most common procedure
Magnetic Sphincter Augmentation (LINX) is a newer option for select older children and adolescents.
Supportive Care:
Nutritional support is paramount, especially in infants with GERD leading to poor intake
Close monitoring of growth and hydration
Psycho-social support for the child and family, as GERD can significantly impact daily life and parental stress
Multidisciplinary approach involving pediatricians, gastroenterologists, dietitians, and surgeons.
Prognosis
Factors Affecting Prognosis:
Severity of GERD, presence of complications (esophagitis, strictures, aspiration), underlying comorbidities (neurological impairment, prematurity), adherence to medical therapy, and response to treatment
Most infants with GERD improve significantly by 1 year of age.
Outcomes:
With appropriate management, most children experience resolution or significant improvement of GERD symptoms
Long-term outcomes are generally good, though some may require ongoing medication or experience persistent symptoms
Complications like strictures can impact long-term swallowing function.
Follow Up:
Regular follow-up is essential to assess symptom control, growth, and adherence to therapy
The frequency of follow-up depends on the severity of GERD and response to treatment
Discontinuation of medication should be considered once symptoms resolve, particularly in infants
Older children with persistent symptoms may require long-term management and periodic reassessment.
Key Points
Exam Focus:
Differentiate physiological reflux from GERD
Recognize alarm symptoms in pediatric GERD
Understand indications and interpretation of pH-impedance monitoring
Know first-line medical management (PPIs) and their typical pediatric dosing
Identify candidates for surgical intervention.
Clinical Pearls:
Always consider GERD in infants with unexplained irritability or feeding difficulties
pH-impedance is most valuable when correlated with symptom diaries
Not all reflux is GERD
focus on troublesome symptoms and complications
Start PPIs at the lowest effective dose and titrate
Discuss potential for rebound hyperacidity upon PPI discontinuation.
Common Mistakes:
Diagnosing GERD solely on regurgitation without considering other symptoms or complications
Over-reliance on PPIs without addressing lifestyle and dietary factors
Inadequate investigation of refractory symptoms or alarm signs
Incorrect interpretation of pH-impedance studies without symptom correlation
Prescribing prokinetics without clear indication.