Definition (J Pediatr Gastroenterol Nutr 2009;49:498)
• Passage of gastric contents to esophagus, nml & w/o sx (GER), or pathologic (GERD)
Pathophysiology (Pediatr Rev 2007;3:101)
• Intermittent relaxation of LES, acid refluxing to esophagus w/ esophagitis, chronically causes change from columnar to squamous (Barrett)
Epidemiology
• Prevalence physiologic reflux ∼50% at 0–3 mo, 67% by 4 mo, 5% at 12 mo, and in children 3–17 yo, rates vary from 1.4–8.2%
Clinical Manifestation: Varies By Age
• Infants: Vomiting, FTT, irritability, congestion, ALTE, recurrent PNAs
• Children/adolescent: Abd pain, retrosternal CP, dysphagia, regurg, asthma/cough
Diagnostic Studies
• H&P only, unless complications present or dx in question; in infants H&P not diagnostic
• UGI: Not sensitive or specific for GERD but identifies malrotation, esophageal/antral webs, pyloric stenosis, Schatzki rings, hiatal hernia
• Esophageal pH probe: Checks freq and duration of acid exposure. Reflux index (RI) = % time pH <4 (most valid tool), upper nml 0–11 mo 11.7%, 1–9 yo 5.4%, adults 6%
• Endoscopy: Visualize and bx esophagus and duodenum for inflamm and complications
• Empiric Rx: For older children/adolescents widely used (up to 4 wk) but not validated
Treatment (J Pediatr Gastroenterol Nutr 2005;41:S41)
• Evidence for 2 wk trial of hypoallergenic hydrolyzed protein formula for formula-fed infants
• Thickening does not improve RI, does dec # of vomiting events (Pediatrics 2008; 122:e1268)
• Positioning (if >1 yr): Left-side positioning and elevation of head of bed in sleep
• Lifestyle Δ (adoles): No caffeine, chocolate, spicy food, tobacco, EtOH; not data-driven
• Acid suppression: PPIs > H2RAs; if long-term PPI, check for H. pylori (risk of atrophic gastritis w/ chronic >6 mo PPI use and untreated H. pylori) (Pediatr Rev 2003;24:12)
• Space dosing of PPIs and H2RAs as PPI require acidic environment for activation
• Majority of children develop tachyphylaxis to H2RAs w/i 2 wk
• There is evidence we are over prescribing (Pediatrics 2007;120:946)
• Prokinetic: Aside from cisapride (limited access 2/2 side effects) no prokinetics w/ benefit
• Surgical Rx: Case series show generally favorable outcomes
Prognosis: Most outgrow sx by 12 mo; poorer prognosis w/ neuro impairment, esophageal atresia, prematurity.
Complications
• Respiratory (asthma, apnea, ALTE, cough), ENT (sinusitis, dental erosions, laryngitis), esophageal strictures, Barrett, adenoCA, UGI bleeding, FTT, Sandifer syndrome
• ∼⅔ of children w/ asthma improve to some degree w/ rx for GERD
• Neurologically impaired at high risk of recurrent aspiration (PNA, pulm fibrosis)