Clinical Management of Infants and Children with Gastroesophageal Reflux Disease

Abstract

Gastroesophageal reflux refers to the passage of gastric contents including food, acid, and digestive enzymes up into the esophagus. Reflux is most commonly recognized in infants when it is associated with regurgitation, known as “spitting up,” and it is usually a self-limited, benign process that has little or no effect on normal weight gain or development. Adults and adolescents may also have reflux, which is usually either asymptomatic or recognized as dyspepsia or “heartburn.” Gastroesophageal reflux disease (GERD) is defined as symptoms or complications that result from reflux. Most evidence suggests the mechanism of reflux is due to transient relaxations of the lower esophageal sphincter at inappropriate times. The diagnosis of suspected GERD in infants and children depends on the age and the presenting symptoms. A thorough history, physical examination, and growth charts are sufficient for the evaluation and diagnosis of GERD in most infants with recurrent vomiting or children with regurgitation and heartburn. Additional evaluation may include an upper gastrointestinal series, esophageal pH monitoring, or endoscopy. The goals of GERD management are eliminating symptoms, healing esophagitis, preventing complications, promoting normal weight gain and growth, and maintaining remission. Therapeutic options include lifestyle changes, pharmacologic therapy, and anti-reflux surgery. Currently available pharmacologic agents for the treatment of GERD include antacids, mucosal protectants, prokinetic agents, and acid suppressants.

Evaluation of Complications and Weight Outcomes in Pediatric Cerebral Palsy Patients With Gastrostomy Tubes

“…[32][33][34] Even among 3-month old typical children, GERD can be present 50% of the time, with the percentage of children affected gradually decreasing over time. 35 If the complication of functional bowel issues is removed, 68.3% of patients still had a complication, as the majority of patients had more than one complication. Of note, historically concomitant Nissen fundoplication was performed in many children with CP because of the high rates of GERD.…”

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children

“…Recent research efforts have called into question whether even a positive IS or UGI study should dictate surgical decision making within this clinical scenario 3–5 . For example, in the case of GERD, the first‐line treatment remains lifestyle modifications (eg, a change in formula type or consistency or body positioning during/after feeds and the avoidance of triggering foods) and pharmacological therapy 7,8 . Proceeding with a concomitant fundoplication without a trial of nonoperative management first unnecessarily exposes patients to increased surgical risks and associated morbidity 6 .…”

“…[3][4][5] For example, in the case of GERD, the first-line treatment remains lifestyle modifications (eg, a change in formula type or consistency or body positioning during/after feeds and the avoidance of triggering foods) and pharmacological therapy. 7,8 Proceeding with a concomitant fundoplication without a trial of nonoperative management first unnecessarily exposes patients to increased surgical risks and associated morbidity. 6 However, although it was not possible to determine within the scope of this study, it is possible that IS results were used to guide patient care beyond operative management alone.…”

“…[3][4][5] Surgical intervention with fundoplication may not be warranted after positive IS until a trial of lifestyle modification or pharmacotherapy is attempted. [6][7][8] Similarly, universal testing for malrotation, a rare condition, results in negative studies in most cases. [9][10][11] Routine testing not only increases exposure to ionizing radiation but it also increases healthcare costs for the individual patient who otherwise may have no symptomatology indicative of reflux or malrotation.…”

“…Recent research efforts have called into question whether even a positive IS or UGI study should dictate surgical decision making within this clinical scenario 3–5 . Surgical intervention with fundoplication may not be warranted after positive IS until a trial of lifestyle modification or pharmacotherapy is attempted 6–8 . Similarly, universal testing for malrotation, a rare condition, results in negative studies in most cases 9–11 .…”