Basics
Description
- Effortless regurgitation of gastric contents. Occurs physiologically at all ages, and most episodes are brief and asymptomatic
- Divided into physiologic and pathologic processes:
- Some degree of physiologic gastroesophageal reflux (GER) is normal at all ages.
- Physiologic infant reflux (normal GER of infancy) is very common. Symptoms peak around 4 months of age and generally have resolved by 1 year of age.
- Pathologic reflux or gastroesophageal reflux disease (GERD) is defined by troublesome symptoms or complications of GER.
- Complications may include reflux esophagitis, bleeding, esophageal stricture, failure to thrive, chronic/recurrent respiratory tract disease, or vomiting.
Epidemiology
Prevalence
- Pathologic GERD: 10% of adults, 2-8% of children
Risk Factors
- Neurologic disorders (cerebral palsy/quadriplegia)
- Esophageal atresia
- Tracheoesophageal fistula
- Cystic fibrosis
- Asthma
- Gastroparesis
- Hiatal hernia
Pathophysiology
Transient relaxation of the lower esophageal sphincter during episodes of increased abdominal and gastric pressure. GERD is a multifactorial process involving number of reflux events, acidity, esophageal clearance, gastric emptying, mucosal barriers, visceral hypersensitivity, and airway responsiveness.
Diagnosis
History
- General symptoms of GERD:
- Vomiting
- Irritability
- Chest/abdominal pain
- Heartburn
- Hematemesis, melena
- Blood loss
- Dysphagia
- Food refusal
- Cough, wheezing
- Obstructive apnea
- Dysphonia
- Aspiration pneumonia
- Posturing (Sandifer syndrome)
- GERD may be asymptomatic and still carry risk of complications.
- Infant
- Many common conditions in infancy such as physiologic GER, infant colic, milk protein allergy, or multifactorial feeding difficulties/aversion can present with symptoms that can be difficult to distinguish from GERD and history should also assess for these conditions.
- Pay attention to feeding volume and frequency in addition to weight gain, failure to thrive, and irritability in association with regurgitation events.
- Identify episodes of pneumonia, obstructive apnea, chronic cough, stridor, wheezing.
- Identify additional signs/symptoms that suggest food protein allergy (hematochezia, rash, diarrhea, irritability, failure to thrive).
- Evaluate for evidence of bowel obstruction (forceful emesis, polyhydramnios during pregnancy).
- If vomiting is atypical or associated with other signs/symptoms, rule out infection, metabolic disease, anatomic abnormality, or neurologic disease.
- Special questions:
- Presence of polyhydramnios or bilious emesis?
- Family history of metabolic disease?
- Family history of allergies/atopy?
- Perinatal asphyxia (and other neurologic disorders)?
- History of prematurity?
- Older child
- Identify typical adult GERD complaints (chest pain, heartburn, regurgitation, dysphagia), but recognize that children describe discomfort poorly (often isolated abdominal pain).
- Identify episodes of pneumonia, choking, chronic cough, laryngitis, stridor, and wheezing (may need to assess swallowing function).
- Assess for solid food dysphagia (more common with eosinophilic esophagitis).
- Evaluate for presence of nocturnal GERD symptoms.
- Special questions:
- Family history of GERD?
- Family history of allergies/atopy?
- Family history of eosinophilic esophagitis or other chronic GI disease such as celiac disease or inflammatory bowel disease.
Physical Exam
- May be normal
- Growth failure
- Reactive airway disease and other manifestations of pulmonary complications
- Anemia or blood in stool (uncommon)
- Erosive dental disease (possibly linked to GERD, but common unrelated finding)
Diagnostic Tests & Interpretation
- Diagnosis of GERD is frequently made clinically.
- Testing is typically only needed to evaluate for other conditions, evaluate questionable cases, potential causes, complications, or symptom-reflux correlations. Evaluation may include the following:
- Common screening laboratories (CBC, routine chemistries, transaminases)
- Allergen testing (i.e., milk, soy, egg, etc.)
- Celiac serology
- Stool occult blood
- Stool Helicobacter pylori antigen
Imaging
- Upper GI contrast study: Evaluate anatomy.
- Chest x-ray: Evaluate for recurrent pneumonia (if warranted by respiratory symptoms).
- Modified barium swallow: Evaluate swallowing function and for aspiration.
- Gastric-emptying study (gastric scintigraphy): Evaluate gastric motility and/or pulmonary aspiration.
Diagnostic Procedures/Other
- Empiric trial of medication (recommended for 4 weeks)
- pH probe study
- To quantify and correlate esophageal acid exposure with symptoms over a 24-hour period (commonly performed off of acid blockade therapy)
- Combined pH/multichannel intraluminal impedance (MII):
- Allows detection of both acid and nonacid GER events. May detect more pathologic reflux than pH probe alone (can be performed on or off of acid blockade)
- Wireless pH monitoring (disposable probe placed endoscopically and clipped to esophageal mucosa)
- Esophagogastroduodenoscopy with biopsies
- Laryngoscopy
- Bronchoscopy
- Esophageal manometry
- Antroduodenal manometry
Pathologic Findings
Evidence of reflux esophagitis, allergic esophagitis, Barrett esophagus, adenocarcinoma, stricture
Differential Diagnosis
- Toxin
- Renal
- Obstructive uropathy
- Uremia
- Infection
- Gastroenteritis
- H. pylori
- Urinary tract infection
- Sepsis
- Pneumonia
- Hepatitis
- Otitis media
- Pancreatitis
- Cholecystitis
- Neurologic
- Meningitis/encephalitis: intracranial injury
- Brain tumor
- Hydrocephalus
- Subdural hematoma
- Metabolic
- Urea cycle defects
- Aminoacidopathies (phenylketonuria, maple syrup urine disease)
- Adrenal hyperplasia
- Galactosemia, fructosemia
- Allergy/food intolerance
- Milk/soy protein allergy
- Eosinophilic esophagitis
- Celiac disease
- Hereditary fructose intolerance
- Anatomic malformation
- Diaphragmatic hernia
- Gastric outlet obstruction
- Esophageal atresia
- Pyloric stenosis
- Antral/duodenal web
- Volvulus/malrotation
- Meconium ileus
- Enteral duplications
- Intussusception
- Trichobezoar
- Foreign body
- Incarcerated hernia
- Drugs that affect lower esophageal sphincter pressure:
- Nitrates
- Nicotine
- Narcotics
- Caffeine
- Theophylline
- Anticholinergic agents
- Estrogen
- Somatostatin
- Prostaglandins
- Other:
- Pregnancy
- Cyclic vomiting syndrome
Treatment
Treatment should be individualized, and cost effectiveness should be considered.
Medication
First Line
H2 blockers: Good for intermittent or PRN dosing. Can be used for maintenance of chronic GERD in some patients and/or promote mucosal healing.
- Ranitidine (PO)
- < 1 month: 6 mg/kg/24 h divided t.i.d.
- ≥ 1 month to 16 years of age: 5-10 mg/kg/24 h divided b.i.d.-t.i.d. (max 300 mg/24 h)
- Adults 150 mg b.i.d. or 300 mg nightly
- Famotidine (PO)
- <3 months: 0.5 mg/kg daily
- 3 months to 1 year: 0.5 mg/kg b.i.d.
- 1-12 years: 1 mg/kg/24 h divided b.i.d. (max 80 mg/24 h)
- 12 years-adults: 20 mg b.i.d.
Second Line
Proton pump inhibitors (PPI):
- Demonstrated to be more effective at blocking gastric acid as compared to H2 blockers. Can be used for symptoms as well as mucosal injury, refractory to H2 blockers. May be appropriate for short-term empiric trial of medication
- Omeprazole (PO)
- <1 year: 1-2 mg/kg/24 h (daily or divided b.i.d.); multiple studies demonstrate no improvement of clinical symptoms (crying, irritability).
- >1 year: 1-2 mg/kg/24 h (daily or divided b.i.d.) to adult dose range
- >20 kg: 20 mg once or twice daily
- Up to 3.5 mg/kg/24 h have been used.
- Lansoprazole (PO)
- <1 year: 0.4-1.8 mg/kg/24 h (daily or divided b.i.d.); multiple studies demonstrate no improvement of clinical symptoms (crying, irritability).
- 1-11 years: <10 kg 7.5 mg/24 h
- 10-30 kg: 15 mg/dose daily up to b.i.d.
- >30 kg: 30 mg/dose daily up to b.i.d.
- Several other PPIs are available.
- Side effects of PPIs may include headache, abdominal pain, and diarrhea.
- Recent reports of increased risk for acute gastroenteritis, Clostridium difficile infection, and pneumonia in children. Adult studies report increased risk of osteopenia and bone fracture associated with higher dose and long-term use. Benefits should outweigh risks, especially for long-term use.
- Prokinetics: as adjunctive therapy for more severe GERD complications and hypomotility
- No single drug has optimal prokinetic effect without significant side effects.
- Not recommended as routine therapy
- Erythromycin (PO)
- 3-4 mg/kg/dose b.i.d.-t.i.d. (used in lower dose than for antibiotic purposes for gastric prokinetic effect)
- Can prolong QT interval
- Can develop tachyphylaxis
- Short-term use can be considered for treatment of GERD symptoms seen in postinfectious gastroparesis which typically resolves spontaneously.
- Metoclopramide (Reglan)
- Dosage is significantly less for GERD indication as compared to the antiemetic indication.
- Side effects: may cause dystonia or oculogyric crisis, black box warning regarding risk of tardive dyskinesia
- Calcium and aluminum/magnesium-containing antacids
- Offers short-term symptom relief, requires multiple dosing
- Side effects: carry risk of diarrhea and aluminum toxicity
- Interactions: may lead to malabsorption of other medications
- Mucosal protective agents: sucralfate (Carafate) for erosive esophagitis; maximally effective at pH 4 and on mucosal lesions
Additional Treatment
General Measures
- Parental reassurance and education, especially in infants with physiologic GER
- Small, frequent infant feedings
- Encourage burping in infants.
- Reassure parents that infant GER/GERD is not associated with sudden infant death syndrome.
- Thickening of infant feedings (~2-3 teaspoons cereal/ounce of formula): may help with volume of regurgitation, does not stop GER
- Positioning: keeping infant upright after feeds, head elevation in bed of older children only; prone positioning not recommended
Surgery/Other Procedures
- Fundoplication (open or laparoscopic)
- To increase lower esophageal sphincter tone by wrapping portion of gastric fundus around lower esophagus
- Variations may include addition of a gastric emptying procedure (i.e., pyloroplasty).
- Indications: failure of aggressive medical management and/or persistent, life-threatening complications (i.e., esophageal stricture; intestinal metaplastic changes as in Barrett esophagus), presence of large hiatal hernia, poor airway protection leading to aspiration of gastric contents (i.e., severe neurodevelopmental delay)
- Fundoplication complications include the following:
- Gas bloating syndrome
- Intractable retching
- Bowel obstruction
- Dumping syndrome
- Dysphagia
- Paraesophageal hernia
- Wrap failure with recurrent GERD (up to 6% failure at 48 months)
- Limited long-term clinical effectiveness
- Greater morbidity may be associated with fundoplication in children with severe physical and mental disabilities.
Ongoing Care
Follow-up Recommendations
May be appropriate to recommend repeat endoscopy for evidence of pathologic changes of esophagus
Diet
- Dietary modifications in older child: Avoid large high-fat meals, especially before bedtime. Avoid caffeine, chocolate, acidic/spicy food, peppermint, but recent adult studies show this is on an individual basis only.
Additional Reading
- Colletti RB, Di Lorenzo C. Overview of pediatric gastroesophageal reflux disease and proton pump inhibitor therapy. J Pediatr Gastroenterol Nutr. 2003;37(Suppl 1):S7-S11. [View Abstract]
- Craig WR, Hanlon-Dearman A, Sinclair C, et al. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2004;(4):CD003502. [View Abstract]
- El-Serag HB, Gilger M, Carter J, et al. Childhood GERD is a risk factor for GERD in adolescents and young adults. Am J Gastroenterol. 2004;99(5):806-812. [View Abstract]
- Lightdale JR, Gremse DA. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013;131(5):e1684-e1695. [View Abstract]
- Lobe TE. The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children. Surg Endosc. 2007;27(2):167-174. [View Abstract]
- Thakkar K, Boatright RO, Gilger MA, et al. Gastroesophageal reflux and asthma in children: a systematic review. Pediatrics. 2010;125(4):e925-e930. [View Abstract]
- Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines. J Pediatr Gastroenterol Nutr. 2009;49(4):498-547. [View Abstract]
Codes
ICD09
ICD10
- K21.9 Gastro-esophageal reflux disease without esophagitis
- K21.0 Gastro-esophageal reflux disease with esophagitis
- P78.83 Newborn esophageal reflux
SNOMED
- 235595009 Gastroesophageal reflux disease (disorder)
- 266435005 Gastroesophageal reflux disease without esophagitis (disorder)
FAQ
- Q: How long will my baby suffer with GERD?
- A: Most infant reflux resolves by 9-12 months of age, but symptoms may persist up to 24 months. If GERD continues after 2-3 years, it is more likely to behave clinically like adult GERD and require chronic management.
- Q: Should all babies with reflux be treated with medication?
- A: No. Often infant reflux is physiologic and education is all that is needed. Conservative treatments such as thickened feedings, frequent small feedings, and postprandial upright positioning can be tried first, especially as data do not support acid blockade therapy in children younger than 12 months. It is often helpful to explain to parents that physiologic infant reflux tends to worsen from 1 to 3 months of age then typically starts to improve when children can sit upright at 6-7 months of age.