Gastroesophageal reflux is defined as
the involuntary movement of stomach contents into the esophagus (tube
connecting mouth to stomach). Although ‘spitting up’ is normal in babies, there
are some that seem to ‘spit up’ with every meal. Although gastroesophageal
reflux can occur anytime during the life cycle, it is a very common problem in babies occuring in up to three percent of all newborns. The
majority of gastroesophageal reflux is resolved during the first two years of
life.
Gastroesophageal reflux occurs as a result of a dysfunctional lower esophageal
sphincter. Physiologic gastroesophageal reflux can be described as reflux in
neonates and infants, occurring without pathologic sequelae due to an
immaturity of the lower esophageal sphincter. Gastroesophageal reflux is
considered pathologic when it interferes with the child’s growth and
development or causes complications.
Clinical Presentation
There are a number of classic symptoms of
gastroesophageal reflux. Most of the presenting symptoms of gastroesophageal
reflux are actually a complication of the disease.
·
The most
common symptom of gastroesophageal reflux is vomiting; however, not all
children with reflux will vomit. The emesis volume may be as small as in
spitting or contain entire feedings.
·
Failure to
thrive including failure to gain weight or weight loss may occur if
insufficient calories are retained.
·
Pain and
irritability are very common presenting symptoms. These complaints are probably
due to a number of factors including esophagitis, heartburn, hunger
and breathing difficulties in the light of pulmonary compromise.
There is growing
evidence that some of the signs of GER are believed to manifest themselves as
disease of the ears, nose and throat in children. Among these diseases include
rhinitis (chronic runny nose), sinusitis, hoarseness, laryngitis, stridor,
laryngomalacia, subglottic stenosis, vocal cord granuloma, recurrent croup, ear
pain and middle ear infection or disease.
Gastroesophageal reflux may be serious in some children leading to
complications such as difficulty breathing, laryngomalacia, aspiration and
pneumonia, esophagitis, esophageal stricture, apnea and SIDS.
Diagnosis
A careful and detailed clinical evaluation and history is essential to revealing
a diagnosis of gastroesophageal reflux. There are a number of diagnostic tests
that may be useful in making the diagnosis.
Medical Treatment
The treatment of gastroesophageal reflux depends on the severity of the
disease, the presence of complications and the age of the child. There is a 60
to 95% spontaneous resolution from physiologic childhood gastroesophageal
reflux from which most children are symptom free by eight to ten months of age.
The majority of children with gastroesophageal reflux have the physiologic
type. Very often a child’s GER can be managed with conservative strategies
including thickening of feeds, refining the feeding schedule and volume and
positioning considerations.
·
Thickening of
formula- usually accomplished with rice cereal (1-4 teaspoons/4ounce feeding).
·
Smaller more
frequent feedings.
·
Therapeutic
positioning- positioning the child in a 30 degree upright position or being
held vertically by a caregiver for a minimum of thirty minutes following the
feeding. Placing the child in a seated position following feeds may increase
The expectation is
that these conservative interventions will decrease the incidence of GER and
its complications until the baby outgrows the
Pharmacologic Interventions
Children with more significant symptoms may benefit from medications. The goals
of the pharmacologic intervention include reduction of gastric acid production
and an increase in gastric motility.
·
Histamine
receptor blockers (e.g. Ranitidine, Cimetidine) are often effective by turning
off the stomach’s production of acid.
·
Prokinetic
agents (e.g. Reglan) stimulate the esophagus, gastric and intestinal motility.
It therefore assists with esophageal and gastric.
·
Proton pump
inhibitors ( Prilosec, Prevacid) are effective by
turning off the acid pumps that stimulate the production of acid from the
stomach. Occasionally, motility drugs such as Reglan l are used to strengthen
the lower esophageal sphincter (LES) and speed the emptying of the stomach to
reduce symptoms of GERD.
·
Antacids (e.g.
Maalox, Mylanta) are used to neutralize the gastric acid, thereby offering pain
relief. These drugs are often very effective but may need to be given
frequently. Magnesium based antacids may cause diarrhea in some children,
whereas aluminum and calcium based antacids may lead to constipation.
Surgical Treatment
Surgical treatment may be indicated for some children when medical management
fails and complications of gastroesophageal reflux persist.