Overview
Definition:
Gastroesophageal reflux (GER) in infants is the passive regurgitation of gastric contents into the esophagus, occurring frequently and without distress in most healthy infants
Pathological gastroesophageal reflux disease (GERD) is defined as GER that leads to troublesome symptoms or complications.
Epidemiology:
GER is extremely common in infancy, affecting up to 50% of healthy infants in the first few months of life
The incidence peaks between 3-4 months and typically resolves by 12-18 months
GERD, requiring medical intervention, is much less common.
Clinical Significance:
While most GER is benign, it can cause significant morbidity if it progresses to GERD, leading to poor weight gain, esophagitis, respiratory symptoms, and feeding difficulties, impacting infant well-being and parental anxiety
Accurate diagnosis and management are crucial for optimal outcomes.
Clinical Presentation
Symptoms:
Regurgitation or spitting up after feeds
Excessive crying or irritability, especially after feeding or lying down
Arching of the back
Poor weight gain or failure to thrive
Feeding difficulties, including refusal to feed or gagging
Waterbrash (in older infants)
Disturbed sleep
Respiratory symptoms such as cough, wheezing, or apnea secondary to aspiration.
Signs:
Failure to thrive
Signs of dehydration
Esophagitis on endoscopy (rare in uncomplicated GER)
Signs of respiratory distress if aspiration occurs
Irritability and discomfort palpable during or after feeds.
Diagnostic Criteria:
No specific diagnostic criteria exist for uncomplicated GER
Diagnosis of GERD is typically made clinically based on troublesome symptoms or complications that are clearly attributable to reflux
The Montreal definition of GERD is used, focusing on troublesome symptoms or complications
The American Academy of Pediatrics (AAP) guidelines emphasize a clinical diagnosis for most infants, reserving further investigations for complicated cases.
Diagnostic Approach
History Taking:
Detailed history of feeding patterns, frequency and volume of regurgitation, timing of symptoms relative to feeds, infant's behavior (irritability, sleep disturbances), weight gain trajectory, associated symptoms (cough, wheezing), family history of GI issues, and any red flags like hematemesis or significant failure to thrive.
Physical Examination:
Assess growth parameters (weight, length, head circumference) on growth charts
Perform a thorough examination to rule out other causes of vomiting, abdominal distension, jaundice, or signs of systemic illness
Assess hydration status.
Investigations:
In most infants, investigations are not required
For persistent, severe symptoms or suspected GERD complications: pH probe study (24-hour esophageal pH monitoring) to assess acid reflux frequency and timing
Esophageal manometry to assess esophageal motility
Upper GI series to rule out anatomical abnormalities like malrotation or pyloric stenosis
Upper endoscopy with biopsies to assess for esophagitis, strictures, or Barrett's esophagus (rare in infants).
Differential Diagnosis:
Pyloric stenosis (projectile, non-bilious vomiting)
Intestinal obstruction (bilious vomiting, abdominal distension)
Allergic procolitis or milk protein intolerance (eczema, diarrhea, blood in stool)
Neurological disorders (poor feeding, developmental delay)
Metabolic disorders
Infectious gastroenteritis (diarrhea, fever)..
Management
Initial Management:
Conservative management is the cornerstone for uncomplicated GER
This includes thickening feeds with cereal or commercially available thickeners (controversial, assess for choking risk)
Smaller, more frequent feeds
Maintaining an upright position for 20-30 minutes after feeds
Avoiding passive smoke exposure.
Nonpharmacologic Management:
Conservative measures are preferred: Feed thickening (rice cereal, oatmeal, commercial thickeners
use with caution due to potential choking risk and altered nutrient absorption)
Prone positioning (controversial due to SIDS risk
supine positioning is standard)
Smaller, more frequent feeds
Avoiding overfeeding
Burping frequently during and after feeds
Maintaining upright posture after feeds
Lifestyle modifications for caregivers like avoiding tight diapers and tight clothing.
Pharmacologic Management:
Pharmacologic therapy is reserved for infants with established GERD, confirmed by troublesome symptoms or complications, after conservative measures fail
Medications aim to reduce gastric acidity or stimulate gastric emptying
Acid suppression: Histamine-2 receptor antagonists (H2RAs) like ranitidine (if available) or famotidine (1-2 mg/kg/day divided BID)
Proton pump inhibitors (PPIs) like omeprazole or lansoprazole (0.5-1 mg/kg/day divided QD-BID) are more potent
Use for the shortest duration necessary
Prokinetics are generally not recommended due to limited efficacy and potential side effects.
Supportive Care:
Nutritional support is vital, especially for infants with poor weight gain
consider high-calorie formulas if needed
Parental education and reassurance are crucial to reduce anxiety
Close monitoring of weight gain, feeding tolerance, and symptom resolution
Multidisciplinary approach involving pediatricians, gastroenterologists, and dietitians as needed.
Complications
Early Complications:
Esophagitis (inflammation of the esophagus, causing pain and difficulty feeding)
Failure to thrive or poor weight gain
Respiratory symptoms (cough, wheezing, recurrent pneumonia, apnea) due to aspiration.
Late Complications:
Strictures (narrowing of the esophagus) secondary to chronic inflammation
Barrett's esophagus (esophageal metaplasia, very rare in infants)..
Prevention Strategies:
Early recognition of GER symptoms and prompt initiation of conservative management
Avoiding prolonged or unnecessary pharmacologic therapy
Ensuring proper feeding techniques and positioning
Managing underlying comorbidities.
Prognosis
Factors Affecting Prognosis:
Severity of symptoms and complications
Presence of co-existing medical conditions
Adherence to management strategies
Resolution of reflux typically occurs by 12-18 months of age for most infants.
Outcomes:
Most infants with uncomplicated GER improve significantly with conservative management and have a good prognosis
Infants with GERD may require longer treatment durations, but outcomes are generally favorable with appropriate intervention
Persistent GERD can have long-term implications if not managed effectively.
Follow Up:
Regular follow-up to monitor growth, symptom resolution, and medication efficacy
Tapering and discontinuation of pharmacologic therapy should be attempted when symptoms improve or upon reaching age milestones (e.g., 12-18 months)
Long-term follow-up may be needed for infants with severe or complicated GERD.
Key Points
Exam Focus:
Differentiate GER from GERD
Recognize red flags requiring investigation
Understand the step-wise approach to management, prioritizing nonpharmacologic methods
Know indications and contraindications for pharmacologic therapy
Recall common drug classes (H2RAs, PPIs) and their role.
Clinical Pearls:
Always consider other causes of vomiting in infants before diagnosing GERD
Reassure parents that most GER is benign and self-limiting
Use pharmacologic agents judiciously and for the shortest effective duration
Monitor infants on PPIs for potential long-term effects if used for extended periods.
Common Mistakes:
Over-diagnosing GERD in infants with simple regurgitation
Initiating pharmacologic therapy without a thorough trial of conservative measures
Using prokinetic agents inappropriately
Failing to wean medications once symptoms resolve or the infant outgrows the condition.