Gastroesophageal reflux disease (GERD) occurs when GERleads to troublesome symptoms or complications such as poorgrowth, pain, or breathing difficulties. GERD occurs in a minorityof infants but is often implicated as the cause of fussiness. GERDis seen in fewer than 5% of older children. In older children, normal protective mechanisms against GER include antegradeesophageal motility, tonic contraction of the LES, and the geometry of the gastroesophageal junction. Abnormalities that causeGER in older children and adults include reduced tone of the LES, transient relaxations of the LES, esophagitis (which impairsesophageal motility), increased intra-abdominal pressure, cough,respiratory difficulty (asthma or cystic fibrosis), and hiatal hernia.
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Cough Hoarseness Wheezing Abdominal Pain Failure to Thrive
The presence of GER is easy to observe in an infant who spits up. In older children, the refluxate is usually kept down by reswallowing, but GER may be suspected by associated symptoms, such as heartburn, cough, epigastric abdominal pain, dysphagia, wheezing, aspiration pneumonia, hoarse voice, failure to thrive, and recurrent otitis media or sinusitis. In severe cases of esophagitis, there may be laboratory evidence of anemia and hypoalbuminemia secondary to esophageal bleeding and inflammation.
When esophagitis develops as a result of acid reflux, esophageal motility and LES function are impaired further, creating a cycle of reflux and esophageal injury.
A clinical diagnosis is often sufficient in children with classic effortless regurgitation and no complications. Diagnostic studies are indicated if there are persistent symptoms or complications or if other symptoms suggest the possibility of GER in the absence of regurgitation. A child with recurrent pneumonia, chronic cough, or apneic spells without overt emesis may have occult GER. A barium upper GI series helps to rule out gastric outlet obstruction, malrotation, or other anatomic contributors to GER. Because of the brief nature of the examination, a negative barium study does not rule out GER. Another study, 24-hour esophageal pH probe monitoring, uses a pH electrode placed transnasally into the distal esophagus, with continuous recording of esophageal pH. Data typically are gathered for 24 hours and analyzed for the number and temporal pattern of acid reflux events. Esophageal impedance monitoring records the migration of electrolyte-rich gastric fluid in the esophagus. Endoscopy is useful to evaluate for esophagitis, esophageal stricture, and anatomic abnormalities.
In otherwise healthy young infants, no treatment is necessary. For infants with complications of GER, an H2 blocker or pro-ton-pump inhibitor may be offered (Table 128-1), but these have shown little benefit in infants with uncomplicated GER and/or fussiness. Prokinetic drugs, such as metoclopramide, occasionally are helpful by enhancing gastric emptying and increasing LES tone, but they are seldom very effective and may lead to complications. When severe symptoms persist despite medication, or if life-threatening aspiration is present, surgical intervention may be required. Fundoplication procedures, such as the Nissen operation, are designed to enhance the antireflux anatomy of the LES. In children with a severe neurologic defect who cannot tolerate oral or gastric tube feedings, placement of a feeding jejunostomy may be considered as an alternative to fundoplication. In older children, lifestyle changes should be discussed, including cessation of smoking, weight loss, not eating before bed or exercise, and limiting intake of caffeine, carbonation, and high-fat foods. However, proton pump inhibitor therapy is more effective in reducing symptoms and healing.