Overview
Definition:
Gastroesophageal reflux disease (GERD) in infants is defined as the passage of gastric contents into the esophagus, leading to troublesome symptoms or complications
This is distinct from simple gastroesophageal reflux (GER), which is a common physiological event in healthy infants.
Epidemiology:
GER is extremely common in healthy term infants, affecting up to 60% in the first few months of life
GERD, the symptomatic form, is diagnosed in about 1-2% of infants, though exact figures vary
Premature infants have a higher incidence and severity.
Clinical Significance:
GERD can significantly impact an infant's well-being and development, leading to feeding difficulties, poor weight gain, respiratory issues, and parental anxiety
Accurate diagnosis and appropriate management are crucial for improving outcomes and avoiding unnecessary interventions.
Clinical Presentation
Symptoms:
Frequent regurgitation or vomiting
Irritability or fussiness, especially after feeding or when lying flat
Arching of the back (Sandifer's syndrome)
Poor feeding or refusal to feed
Poor weight gain or failure to thrive
Esophagitis symptoms: feeding refusal, painful feeding, hematemesis, melena
Respiratory symptoms: cough, wheezing, recurrent pneumonia, apnea.
Signs:
Weight faltering
Signs of dehydration
Oropharyngeal erythema or edema
Signs of aspiration
Palpable abdominal distension
Neurological deficits suggesting underlying conditions.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on troublesome symptoms and physical examination
No single test is definitive
The Rome IV criteria for infantile GERD suggest regurgitation occurring more than twice daily for 3 weeks in an infant <1 year old, without aforementioned alarm signs.
Diagnostic Approach
History Taking:
Detailed feeding history: frequency, volume, type of milk (breast milk, formula, thickened feeds)
Character of regurgitation/vomiting: volume, frequency, forceful nature
Infant's behavior: irritability, crying pattern, feeding comfort
Growth parameters: weight, length, head circumference trends
Associated symptoms: respiratory, neurological
Alarm symptoms: hematemesis, melena, poor weight gain, significant respiratory distress.
Physical Examination:
General assessment: alertness, hydration status, signs of distress
Growth assessment: plotting on growth charts
Abdominal examination: palpation for tenderness, masses, distension
Oral examination: looking for inflammation
Respiratory examination: assessing for breath sounds, wheezing
Neurological examination: assessing for tone, reflexes, signs of neurological compromise.
Investigations:
Often not required in typical cases of GER
Upper GI Endoscopy: for suspected esophagitis, strictures, or Barrett esophagus (rare)
pH monitoring (24-hour esophageal or impedance-pH): to quantify reflux events, assess correlation with symptoms, especially for refractory cases or when considering surgery
Barium swallow: to evaluate anatomy, rule out structural abnormalities, assess the degree of reflux, and identify aspiration
Upper GI series is less sensitive for diagnosing GERD compared to impedance-pH monitoring.
Differential Diagnosis:
Overfeeding
Cow's milk protein allergy or intolerance
Food allergy
Pyloric stenosis
Intestinal obstruction
Eosinophilic esophagitis
Neurological disorders affecting swallowing
Infections
Metabolic disorders
Sandifer syndrome (often associated with GERD but can be separate).
Management
Initial Management:
Conservative measures are the first line: small, frequent feeds
upright positioning for 20-30 minutes after feeds
avoiding overfeeding
burping frequently
For formula-fed infants, consider changing to a standard hydrolyzed protein formula if allergy is suspected.
Medical Management:
Thickened Feeds: Adding infant cereal (rice or oatmeal) or commercial thickeners to breast milk or formula can reduce regurgitation by increasing viscosity
Evidence supports its efficacy for reducing spit-ups, but not necessarily for improving GERD symptoms like irritability
Proton Pump Inhibitors (PPIs): Medications like omeprazole, lansoprazole, or pantoprazole are used to reduce gastric acid production
Indicated for infants with documented esophagitis or persistent troublesome symptoms despite lifestyle modifications
Dosing is typically weight-based (e.g., omeprazole 0.5-1 mg/kg/day divided BID)
Long-term use should be carefully monitored due to potential side effects (e.g., bone fracture risk, infections)
H2-receptor antagonists (e.g., ranitidine, famotidine) are generally less effective than PPIs for GERD with esophagitis but may be used for milder symptoms.
Surgical Management:
Rarely indicated for infants
Reserved for severe, refractory GERD with life-threatening complications (e.g., recurrent aspiration pneumonia, failure to thrive) unresponsive to medical therapy
Nissen fundoplication is the most common surgical procedure.
Supportive Care:
Nutritional support and monitoring of growth are paramount
Parental education and reassurance are critical to manage anxiety related to infant reflux
Multidisciplinary approach involving pediatricians, gastroenterologists, dietitians, and surgeons when needed.
Comparison Thickened Feeds Vs Ppi
Efficacy Thickened Feeds:
Primarily effective in reducing the volume and frequency of spit-ups
May offer some benefit for moderate GER symptoms
Evidence for reducing irritability or esophagitis is weaker compared to PPIs.
Efficacy Ppi:
Effective in reducing gastric acid production, which can alleviate symptoms of esophagitis and reduce pain associated with reflux
More effective for infants with confirmed esophagitis or significant irritability due to reflux.
Indications Thickened Feeds:
Simple reflux with bothersome spit-ups, without signs of esophagitis or significant failure to thrive
Can be a first-line approach for uncomplicated spitting up.
Indications Ppi:
Confirmed esophagitis by endoscopy, failure to thrive, significant irritability, or respiratory symptoms attributable to GERD, unresponsive to conservative measures and thickened feeds.
Risks Side Effects Thickened Feeds:
Potential for excessive calorie intake leading to obesity
Risk of choking or aspiration if not administered correctly
May contribute to constipation.
Risks Side Effects Ppi:
Long-term use associated with potential increased risk of fractures, Clostridium difficile infections, and altered gut microbiome
Acute side effects can include diarrhea, headache, and rash
Risk of rebound hyperacidity upon discontinuation.
Guideline Recommendations:
Guidelines generally recommend starting with conservative measures, including thickened feeds, before considering pharmacotherapy
PPIs are typically reserved for moderate to severe GERD with evidence of esophagitis or significant complications.
Prognosis
Factors Affecting Prognosis:
Severity of symptoms
Presence of complications like esophagitis or failure to thrive
Underlying contributing factors (e.g., prematurity, neurological impairment)
Response to treatment.
Outcomes:
Most infants with GER improve spontaneously by 6-12 months of age
With appropriate management, symptoms can be controlled, and complications avoided
Long-term outcomes are generally good for most infants who outgrow GERD.
Follow Up:
Regular monitoring of growth and symptoms
Tapering and discontinuation of medications as infant symptoms improve and feeding patterns normalize
Follow-up is essential to reassess the need for ongoing treatment and to detect any emerging complications.
Key Points
Exam Focus:
Distinguish between physiological GER and pathological GERD
Understand the stepwise approach to management: conservative measures, thickened feeds, lifestyle changes, then pharmacotherapy (PPIs)
Know the indications and limitations of thickened feeds versus PPIs
Recognize alarm symptoms requiring further investigation
DNB/NEET SS often tests clinical scenarios requiring rational decision-making between these management options.
Clinical Pearls:
Always consider nutritional status and feeding patterns
Empiric PPI trial should be for a defined period (e.g., 2-4 weeks) with clear reassessment criteria
Emphasize parental education and support, as this significantly impacts adherence and reduces anxiety
Remember that PPIs are not universally effective and should be reserved for confirmed indications.
Common Mistakes:
Over-reliance on PPIs for simple spitting up without evidence of GERD or esophagitis
Incorrect dosing or duration of PPI therapy
Not adequately exploring conservative measures and thickened feeds first
Misinterpreting Sandifer's syndrome as solely an epileptic phenomenon without considering GERD as a cause.