Watch for gastroesophageal reflux(GER), which can cause serious problems if untreated

Watch for gastroesophageal reflux(GER), which can cause serious problems if untreated: Excerpt from Avoiding Common Pediatric Errors

Author: Ellen Hamburger, MD

What to Do - Interpret the Data

The presentation of GER can be varied, subtle, and differ considerably dependinguponthechild'sage.GERiscausedbytransientloweresophageal sphincterrelaxation,whichallowspassiveflowofacidicandnonacidicgastric contents into the esophagus.

In infancy, reflux is likely to develop at approximately 1 month of age. Preterm infants may develop the condition even earlier. The incompetence of the lower esophageal sphincter allows the increasing volumes of breast milk or formula to wash up the esophagus, resulting in spitting up or frank vomiting. In addition to a motility disorder, there is now good evidence that food hypersensitivity is a cause of some cases of infant reflux. More severe symptoms occur in babies who reflux and swallow stomach contents, rather thanspit uporvomit. These infants develop esophagitis fromacidicstomach contents washing up and down the esophagus. Their clinical presentation is one primarily of arching and crying. In addition, they often have nasal congestion, frequent hiccups, and, less frequently, a cough. Parents often interpretthediscomfortas"gas."Inprimarycaresettings,cliniciansshouldask aboutrefluxsymptomsatthe1monthwell-childvisit,becauseparents rarely recognize the fussiness associated with esophagitis as a symptom of reflux.

If the reflux progresses, untreated, feedings can be disrupted. After beginning to feed, babies pop off the nipple (breast or bottle) to arch and cry. Ultimately, feeding aversion and failure to thrive can result. Parents often report that the only time the babies will feed is when they are almost asleep. The more relaxed state seems to have a protective effect on the amount of refluxing. There is no clear association between apnea or apparent life- threatening events (ALTE) and reflux.

In older children, reflux can present with more classic symptoms of "heartburn" with chest pain and discomfort. Pulmonary symptoms, including recurrent pneumonia, exacerbation of asthma, or chronic cough can also develop. The interplay between asthma and reflux can be confusing. Cases of refractory asthma may warrant diagnostic evaluation for reflux or a diagnostic trial of acid-suppressant therapy.

In infants, the diagnosis is made primarily by history. If weight gain is appropriate, further workup is often not necessary. For infants with accompanying symptoms of feeding difficulties or failure to thrive, diagnosis can often be achieved with a good history and a therapeutic trial as described below. When response to treatment is not adequate, further studies may be necessary to ensure correct diagnosis.

Thereisvariabilityintheuseofvariousdiagnosticstudiesandarechosen in part based on symptoms. A barium swallow is advisable for infants refractory to treatment who have pulmonary symptoms such as cough, wheeze, or stridor. A barium swallow may demonstrate anatomic malformations such as a tracheoesophageal fistula, intestinal malrotation, or a vascular ring whose symptoms mimic reflux. In older children, it can demonstrate hiatal hernia and esophageal stricture. Children with dysphagia or odynophagia (painful swallowing) should also have a barium esophagram.

Esophageal pH monitoring is another valid and reliable measure of acid reflux. It can help in establishing the temporal association of symptoms and acid reflux as well as the adequacy of acid-suppressant therapy. For infants andchildrenwhoserefluxisinlargepartnonacidic,itisnothelpful.Thismay be particularly true for many asthma patients whose course is complicated by reflux. Finally, endoscopy and biopsy are useful to assess the presence and severityofesophagitis,strictures,andBarrettesophagusandtoexcludeother disorders such as eosinophilic or infectious esophagitis. It may be warranted in refractory asthmatics as well.

The initial treatment for infants includes conservative measures designed to keep the milk in the stomach; thickening feeds and the use of gravity. Feeding should be thickened with baby cereal (rice or oatmeal) starting with 1 teaspoon per ounce and increasing to as high as 3 teaspoons per ounce. Alternatively, there are commercial formula options that thicken on contact with stomach acid. Given the association of GER with food hypersensitivity, a trial of elimination of milk and soy from a breastfeeding mother's diet or feeding amino acid-based formula is worthwhile. Positioning should be either vertical in the caretaker's arms or lying supine on a surface placed at almost a 45-degree incline.

For older children and adolescents, conservative measures and lifestyle changes can provide relief. Positioning during sleep with the head elevated and lying on the left side can be beneficial. Further, these patients should avoid foods that exacerbate symptoms including caffeine, chocolate, alcohol, and spicy foods. Obesity and exposure to tobacco also have adverse effects on reflux.

In infants, if there are clearly signs of esophagitis (arching, crying, with or without excessive hiccups, nasal congestion), acid-suppressant therapy should be started before a feeding aversion develops. Older children with heartburn should also receive acid-suppressants. For infants and older children,proton pump inhibitorsappear to be moreeffective inacid suppression and healing esophagitis than H2 blockers. Prokinetic agents have not proven useful. Surgical therapy for reflux is fundoplication. There are no good clinical trials comparing surgery to aggressive medical management comparing potential risks, benefits, and costs.

Suggested Readings

Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol. 2006;6(3):220–225.
Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997;151:569–572.
Rudolph CD, Mazur LJ, Liptak GS, et al. North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(Suppl 2):S1–S31.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

More About Gastroesophageal Reflux Disease

• Back to disease: Gastroesophageal Reflux Disease: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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