Gastroesophageal Reflux Disease (GERD)

Definition:

• Gastroesophageal Reflux (GER) is the retrograde passage of gastric contents into the esophagus
• Caused by intermittent relaxation of the LES
• Physiologic reflux occurs in:
• 50% of 0-3mo
• 67% of 4mo
• 5% of 12mo
• 1-8% between ages 3-17yo
  
• When pathologic complications arise from GER, GER --> GERD

Clinical Manifestations:

• GER - Asymtomatic "Happy-Spitters"
  
• GERD:
• Infants: bothersome reflux, signs of esophagitis, poor weight gain/FTT, crying with feeds/ irritability, arching back, opisthotonos, feeding refusal, sandifers, ALTE, recurrent PNAs
• Older Children: Abd pain, restrosternal CP, dysphagia, regurg, asthma/chronic cough, hoarseness, behavioral problems (esp if ASD), sleep disturbance

Dx:

• Typically made with H&P only unless complications or Dx in question
• Esophageal pH probe: (24Hr) Gold Standard. Reflux Index measures total time with pH<4
• Positive if:
• >12% (age <1yo)
• >6% (age >1yo)
• If used with esophageal impedence monitoring can improve sensitivity
  
• UGI Series/Barium Swallow not sensitive/specific but can identify anatomic abnormalities:
• Malro
• esophageal/antral web
• pyloric stenosis
• Schatzki rings
• hiatal hernia
• Endoscopy: visualize and Bx esophagus and duodenum for inflammation/ complications (normal appearance does not exclude GERD)
• Often Empiric trial of Tx can confirm Dx
• DDx includes
• Pyloric Stenosis (non-bilious emesis), colic, food allergy, gastroenteritis, TE-fistula, obstruction, overfeeding, sleep disturbance
  

Tx:

• Infants:
  
• evidence supports 2-3 week trial of extensively hydrolyzed protein formula
• Thickening feeds will decrease visible regurg but do not affect GER
• Continue to Sleep Supine (0-12mo) - SIDS risk outweighs potential GERD benefit
• Prone if monitored
• Avoid second hand smoke
  
• Acid suppresion therapy
• PPI > Histamine-2 receptor antagonists (H2RAs) both effective at promoting mucosal healing
• If long term PPI, check for H Pylori
• If using both, space dosing... H2RA may inhibit PPI
  
• Use smallest dose
• Ranitidine 4-10mg/kg/day div BID
• PPIs: (best taken in morning before any food)
  
• Lansoprazole
• <10kg: 7.5mg PO Daily
• 10-20kg: 15mg PO Daily
• >20kg: 30mg PO Daily
• Omeprazole
• 0.5 mg/kg/day
• consider study to confirm Dx if use >4-6wks
• Older children:
• Lifestyle
• avoid caffeine
• mint
• chocolate
• fatty foods
• large meals
• avoid smoke
• Lose weight, if indicated
• H2RAs
• PPIs
• Not sufficient evidence to support Prokinetic therapy (metoclopramide, erythromycin, bethanechol, domperidone) for GERD.
• cisapride may have some benefit?

Complications

• Respiratory
• Asthma, apnea, ALTA, cough
• ENT
• sinusitis, dental erosions, laryngitis
• Esophageal strictures
• Barrett
• adenocarcinoma
• UGI Bleed
  

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