Gastroesophageal Reflux
The 5 Minute Pediatric Consult
Dror Wasserman
DEFINITION
Gastroesophageal reflux (GER) is defined as effortless regurgitation of gastric contents; it is extremely common in infants. GER occurs physiologically at all ages, and most episodes are brief and asymptomatic. It is important to identify the rare child with pathologic reflux, to perform the appropriate diagnostic studies, and to start effective therapy.
- GER is divided into a pathologic and a physiologic process. Physiologic reflux (the normal GER of infancy) is the more common form. Most infants will eventually outgrow the symptoms. Pathologic reflux is defined by quantity of reflux according to the age and the frequency of the reflux episodes. Complicated GER is pathologic reflux associated with irritability, pain, esophagitis, esophageal bleeding, failure to thrive, reactive airway disease, near-miss SIDS, or aspiration pneumonias.
- GER may be asymptomatic and still carry the risk of complications. GER is the most common cause of vomiting in infancy but may also indicate other disorders.
Other causes of vomiting in infancy include:
- Infection
- Gastroenteritis
- Urinary tract infection
- Sepsis
- Neurologic
- Meningitis/encephalitis
- Intracranial injury
- Brain tumor
- Hydrocephalus
- Subdural hematoma
- Metabolic
- Uremia
- Aminoacidopathies
- Adrenal hyperplasia
- Phenylketonuria
- Galactosemia
- Food intolerance
- Milk/soy protein allergy
- Celiac disease
- Anatomic malformation
- Gastric-outlet obstruction
- Pyloric stenosis
- Volvulus/malrotation
- Esophageal atresia
- Meconium ileus
- Enteral duplications
- Intussusception
- Trichobezoar
DRUGS THAT AFFECT LOWER ESOPHAGEAL SPHINCTER PRESSURE
- Nitrates
- Nicotine
- Narcotics
- Theophylline
- Anticholinergic
- Estrogen
- Somatostatin
- Prostaglandins
HISTORY
- Should identify episodes of near-miss SIDS, aspiration pneumonia, chronic cough, laryngitis, stridor, and reactive airways disease
- Should exclude bowel obstruction (bile in the emesis, polyhydramnios during pregnancy)
- If the vomiting begins after the first few weeks of life, it is important to rule out infection, metabolic disease, allergy, and neurologic disease.
Special Questions
- Presence of polyhydramnios
- Bile in emesis
- Family history of metabolic disease
- Family history of allergies
- Perinatal asphyxia (and other neurologic disorders)
- History of prematurity, skin rash (atopic dermatitis), and reactive airways disease
- May be normal
- Growth failure
- Blood in the stool
- Reactive airways disease and other manifestations of pulmonary complications
- Anemia
TESTS
Diagnosis of GER is made clinically. Testing is needed to identify potential causes or complications. Evaluation should include:
- Stool hemoccult
- Growth parameters
Radiographic Studies
- Barium swallow, tracheoesophageal fistulogram
- Chest radiography
- Nuclear medicine studies
- Milk scan
- Gastric emptying study
- Salivagram
pH Probe
- Simple (single-channel)
- Double-channel
- pH/Thermistor (apnea) study
Endoscopy
- Esophagogastroduodenoscopy (EGD)
- Laryngoscopy
- Bronchoscopy
Manometric Studies
- Esophageal manometry
- Antroduodenal manometry
Several modes of therapy are available, depending on the severity, duration of reflux, and complications. The treatment should be individualized and should consider cost efficacy. Traditional treatment includes:
- Small frequent feeds
- Thickening of the feeds (approximately 1 teaspoon of cereal per ounce of formula)
- Positioning: head elevation
- Consider use of a hypoallergenic formula for patients with associated food allergy.
PROKINETIC THERAPY
- Cisapride (Propulsid), 0.2 to 0.25 mg/kg/dose qid. Alert: cardiac toxicity, drug interaction
- Metaclopramide (Reglan), 0.1 mg/kg/dose qid
- Antacids
- Require multiple dosing, carry risk of diarrhea, and may also lead to malabsorption of other medications
- H2 Blockers
- Cimetidine (Tagamet), 10 to 12.5 mg/kg/dose qid
- Ranitidine (Zantac), 2 to 3 mg/kg/dose bid to tid
- Famotidine (Pepcid), 0.3 to 0.5 mg/kg/dose bid
- Proton pump inhibitors
- Omeprazole (Prilosec)
- Lansoprazole (Prevacid)
- Binding Agents
- Sucralfate (Carafate): maximally effective at pH 4 and on mucosal lesions
- Medication interactions
- Cisapride has adverse drug interactions with erythromycin; clarithromycin and ketoconazole may lead to ventricular fibrillation.
- Reglan may cause oculogyric crisis.
- Antacids may lead to diarrhea and constipation.
- H2 blockers may cause headache, rash, diarrhea.
SURGERY AND REFLUX
- The goal of surgery is to increase lower esophageal sphincter tone by wrapping a portion of the cardia around the lower esophagus. This is done to prevent reflux mechanically. Usually, this is associated with a gastric-emptying procedure (i.e., pyloroplasty) and gastric tube placement.
- The indications for surgery can be divided into patients with poor response to medications (i.e., failure to thrive, refractory and severe esophagitis, recurrent aspiration pneumonia, inability to wean from medications) and patients with no need for failure of medical trial (i.e., esophageal stricture, large and symptomatic diaphragmatic hernia, high-grade intestinal metaplastic changes, as in Barrett esophagus). Complications of fundoplication include retching, bowel obstruction, dumping syndrome, difficulty in feeding, paraesophageal hernia, sliding of the wrap, and recurrent GER.
| COMMON QUESTIONS AND ANSWERS |
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Q: How long will my baby suffer with GERD?
A: Most physiologic GERD resolves by 9 to 12 months of age. If GER persists after 1 year, it is highly likely that it is associated with a complication.
Q: Should I fear the use of Propulsid?
A: No; it is a safe drug, and with the proper precaution of an ECG prior to its use, the drug is highly effective and safe.
Q: How effective is the Nissen fundoplication in the resolution of GER?
A: The Nissen fundoplication has greater morbidity associated with it in the cohort of children with severe physical and mental disabilities. If performed by a surgeon with vast experience, the procedure is a last effort subsequent to GERD refractive to medical therapy.
ICD-9-CM 530.81
Jolley S, Halpem L, Tunnell W, et al. The risk of sudden infant death from gastroesophageal reflux. J Pediatr Surg 1991;26:691–696.
Orenstein SR. Gastroesophageal reflux. In: Wyllie R, Hyams J, eds. Pediatric gastrointestinal diseases. Philadelphia: WB Saunders, 1993:337–369.
Orenstein SR. Gastroesophageal reflux. Curr Probl Pediatr 1991;May/June:193–241.
Copyright © 2000 Lippincott Williams & Wilkins
M. William Schwartz, Louis M. Bell, Jr., Peter M. Bingham, Esther K. Chung, David F. Friedman and Andrew E. Mulberg, The 5 Minute Pediatric Consult