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 Table of Contents  
REVIEW ARTICLE
Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 72-81

Gastroesophageal reflux disease in children: A 2013 update


Department of Pediatrics (Gastroenterology Division), King Khaled University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication25-Dec-2013

Correspondence Address:
Mohammad I El Mouzan
Professor and Consultant Pediatrician (Gastroenterology), College of Medicine and King Khaled University Hospital, King Saud University, Riyadh,
Saudi Arabia
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DOI: 10.4103/1658-631X.123644

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  Abstract 

Gastroesophageal reflux (GER) refers to the passage of gastric contents (acid, pepsin, etc) in the esophagus. It is a worldwide physiologic condition most common in infants. This physiologic condition (GER) should be differentiated from the pathologic reflux called gastroesophageal reflux disease (GERD). The distinction between GER and GERD is based on severity of the reflux episodes. [1],[2] The most common mechanism of reflux is transient lower esophageal sphincter relaxation (TLESR) and less commonly low resting LES pressure. [3]
GER presents with regurgitation and occasional vomiting only without effects on growth and development whereas GERD usually has additional presentations. The objective of this review is to provide update on recent developments in the diagnosis and management of this condition.

  Abstract in Arabic 

الإرتجاع المعدي المريئي هو صعود محتويات المعدة إلى المرئ, وهذه ظاهرة فسيولوجية عالمية وشائعة بين الأطفال. يجب التفريق بين الإرتجاع الفسيولوجي والمرضي والذي يعتمد على حدة الإرتجاع. يسبب هذه الظاهرة استرخاء العضلة العاصرة أسفل المرئ وبصورة أقل إنخفاض الضغط فيها. أعراض هذه الظاهرة الإرتجاع والقئ دون تأثير على نمو وتطور الطفل وربما تكون هناك أعراض أخرى. يهدف هذا العرض إلى تزويد القارئ بآخر المستجدات في تشخيص وعلاج هذه الحالة.


Keywords: Children, GER, GERD


How to cite this article:
El Mouzan MI. Gastroesophageal reflux disease in children: A 2013 update. Saudi J Med Med Sci 2013;1:72-81

How to cite this URL:
El Mouzan MI. Gastroesophageal reflux disease in children: A 2013 update. Saudi J Med Med Sci [serial online] 2013 [cited 2017 Apr 24];1:72-81. Available from: http://www.sjmms.net/text.asp?2013/1/2/72/123644


  Clinical Presentation Top


The clinical features of GERD have been described in numerous publications. [4],[5],[6] The most common symptoms include regurgitation and vomiting which may lead to failure to thrive or even weight loss. The presence of refluxed material in the esophagus which is frequently acid may cause pain in the form of irritability and refusal to feed in infants and heartburn and chest pain in older children. Esophagitis, called peptic or reflux esophagitis, is the result of prolonged presence of refluxate in the esophagus causing occult blood loss (anemia) or hematemesis. Odynophagia (pain on swallowing) and dysphagia are features of esophagitis and esophageal stricture. Barrett's esophagus (BE) which is the replacement of the normal squamous by columnar epithelium, a premalignant lesion, is the most serious complication of GERD. High risks for the development of GERD include neurologic impairment (NI) and esophageal atresia with tracheoesophageal atresia after surgical repair. Because of functional and structural defects, chronic reflux persists may persist leading to BE and carcinoma. [7] The Apparent Life-Threatening Events (ALTE) and relationship with GERD is of particular importance in infants. These are usually described by the parents as cessation of breathing with or without cyanosis. However, from a medical point of view, in order to meet the criteria for the diagnosis of ALTE, these episodes should include: 1. Apnea for at least 15 seconds. 2. Presence of color changes (cyanosis, pallor or plethora). 3. Association with abnormal muscle tone (floppiness or stiffness). There may be choking and gagging requiring intervention by the observers. These episodes may be associated with respiratory infections, upper airway obstruction, neurologic, cardiac, metabolic disease, child abuse, and GERD. However, the low yield of investigations for reflux suggests that GERD is a rare cause of ALTE. [8]

Recurrent hoarsness, stridor, cough, wheezing, recurrent pneumonia otitis media, sinusitis, and dental erosion have been associated with GERD. However, the causal relation with GERD is frequently difficult to establish. Similarly, dystonic neck posturing (Sandifer syndrome) has been associated with GERD.

In the majority of infants gastroesophageal reflux resolves spontaneously by 18 months of age. However, reflux esophagitis and its complications may occur indicating the need for regular follow up.


  Diagnostic Methods Top


History and physical examination

This simple clinical assessment should be sufficient for the preliminary diagnosis of uncomplicated physiologic reflux in otherwise normal infants and further investigation is generally not needed.

Barium studies

This should be barium meal rather than swallow. It is inexpensive, readily available, and allows identification of structural anomalies such as hiatal hernia and other causes of vomiting such as esophageal stricture, gastric volvulus, malrotation, and pyloric stenosis. However, low sensitivity and specificity indicate that barium meal alone should not be used to diagnose or exclude reflux. [9]

Prolonged intraesophageal pH studies

Also called pH probe or pH-Metry. The placement of a pH probe in the lower esophagus allows detection of refuxed acid. Although appears to be a simple test, it requires a strict technique to insure correct location of the probe which should be well above the LES to avoid the area of physiologic reflux. Clearly a probe placed too low will produce false positive results and too high will yield false negative results. More recently, to minimize discomfort, an alternative to the nasoesophageal route, a wireless capsule (the Bravo capsule) is attached to the esophagus. [10] Whether by probe or wireless capsule, the measurement of pH is transmitted to a recorder which is disconnected from the patient after about 24 hours of recording. The data are downloaded into a computer program which produces a curve indicating the pH in the lower esophagus from the start to the end of the recording and quantitative analysis [Figure 1]. The interpretation of the data requires expertise as artifacts and technical problems may lead to distorted quantitative analysis and assessment of the quality of the recording should be performed before interpretation of the results. [11] Quantitative parameters calculated over the study period (usually 24 hours) include the total number of reflux episodes, number of prolonged episodes, duration of the longest reflux episode, and percentage of time pH was less than 4. The latter is called the reflux index. Advantages of the pH studies include the ability to quantify reflux allowing the distinction between physiologic (GER) and pathologic reflux (GERD). In fact, this is the only test that quantifies reflux over a prolonged period of time. Another important advantage is to define the relation between reflux episodes and symptoms occurring during the recording by calculating the symptom index score (the number of symptoms occurring during or right after reflux episodes). A causal relationship is suggested when the symptom index score is more than 50%. However, the main drawback of this test is that esophageal pH studies do not detect non-acid reflux which commonly occurs in the postprandial period and may be the cause of chronic respiratory disease.
Figure 1: 24-hour esophageal pH monitoring results in a 5-year-old child with developmental delay, failure to thrive, and history of regurgitation. The most important pathologic findings are the percentage of recording time pH < 4 (reflux index) is 11.7% and the duration of longest reflux episode is 32 minutes which indicates defective esophageal clearance of refluxed acid and risk of reflux esophagitis

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Multichannel intraluminal impedance

Impedance measures the conductance potential (electrical impedance) of refluxed material and identifies its physical characteristics (liquid, gas, or mixed). This recently described technique may be combined with pH monitoring in the same catheter to determine whether these reflux episodes are acid or non-acid. Studies have shown that combined impedance with pH identified more reflux episodes with better identification of weakly acid GERD not detectable by conventional pH probe alone and yet responsible of symptoms of GERD. However, the technique still has limitations. These include high cost, limited additional value regarding therapeutic implications, and lack of evidence-based parameters for the assessment of and symptom association in children. [12]

Endoscopy and biopsy

Visualization of the esophageal mucosa detects signs of inflammation which is confirmed by histopathology. Thus, this procedure is important for the detection of peptic esophagitis, a complication of GERD and not a diagnostic test of GERD per se. The degree and extent of esophageal lesions (erythema, erosions, and ulcerations) have been used in the grading of esophagitis. Endoscopy and biopsy also detect strictures and BE. Endoscopy and biopsy also help in the differential diagnosis of esophagitis which in addition to reflux esophagitis includes eosinophilic esophagitis, Crohn disease, infectious esophagitis, and webs. Because of poor correlation between endoscopic appearance and histology, biopsy is commonly recommended whenever endoscopy is performed.

Scintigraphy

This technique is performed by oral ingestion or instillation of technetium-labeled formula (milk scan) or food into the stomach. The gastroesophageal region and lungs are scanned by a gamma camera for evidence of reflux and aspiration for at least 30 minutes. Main advantages are the ability to demonstrate reflux of non-acidic gastric contents and study of gastric emptying, which may be delayed in children with GERD. Disadvantages include lack of standardization, high cost in terms of equipments and expertise.

The accuracy of different diagnostic modalities varies with the duration of investigation. In view of the intermittent nature of GER, the longer the duration of the study the more reflux episodes will be detected. The duration of symptoms and risk category of patients are other variables. For example, the yield of endoscopy will be greater children with reflux symptoms of long duration and those presenting with bloody vomiting or iron deficiency anemia as a result of occult blood loss secondary to reflux esophagitis. In a study from our institution, esophageal pH was the most specific diagnostic study (91%), whereas endoscopy was the most sensitive (92%) and had the best (95%) positive predictive value. [13]

Other techniques

Ultrasonography: Monitoring of the gastroesophageal region after a meal for reflux has been introduced as a non-invasive technique for the identification of reflux. However, the test requires dedication and expertise which are not commonly available. Therefore, although attractive this test is not widely performed. Esophageal manometry is not a diagnostic test for reflux per se. It is frequently performed in adults to detect motility disorders associated with GERD, but rarely indicated in children. The bilitech 2000: A fiberoptic spectrophotometric probe detects bilirubin in the refluxate may be helpful in the diagnosis of nonacid reflux caused by duodenogastric reflux disease.


  Therapeutic Options Top


Medical measures include lifestyle changes, prokinetic drugs, and gastric acid-controlling agents. Surgery in the form of various types of fundoplication constitutes the main therapeutic options and will be discussed below. Endoscopic procedures in the form of gastroplication has been suggested as an alternative to surgery but still in evolution and will not be discussed further. [14]

  • Lifestyle changes include feeding and positioning in infants and other measures in older children. Parental education and support are usually sufficient to manage healthy, thriving infants caused by physiologic GER.


Feeding infants

Breast-fed and formula-fed infants have a similar frequency of physiologic GER. Some infants with allergy to cow's milk protein experience regurgitation and vomiting indistinguishable from that associated with physiologic GER. Elimination of cow's milk protein from the diet and replacement with hydrolyzed or amino acid formula for about 2 weeks improve the vomiting and reintroduction causes recurrence of symptoms. [15],[16] Cow's milk protein and other proteins pass into human breast milk in small quantities. Breast-fed infants with regurgitation and vomiting may therefore benefit from a trial of withdrawal of cow's milk and eggs from the maternal diet. [17],[18] However, discontinuation of breast feeding is generally not needed or recommended. Although there are no data evaluating the role of soy-bean formula in the treatment of infants with regurgitation and cow's milk protein allergy (CMPA), these formulae may be an alternative in countries where the hydrolyzed formulae are not available. Manipulation of volume and density of feeding: Large volume feedings may promote regurgitation, probably by increasing the frequency of TLESR and reduced feeding volume may lead to decreased reflux frequency. [19] Infants with failure to thrive may benefit from increasing the caloric density of formula when volume or frequency of feedings is decreased as a part of therapy. Thickening of feedings: Rice cereal - thickened formulae produce a decrease in the volume of regurgitation but may increase coughing during feedings. [20] Excessive energy intake however is a potential problem with long-term use of feedings thickened with rice cereal or cornstarch. [21] For example, thickening a 20-kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the energy density to 34 kcal/oz (1.1 kcal/ml). Commercial anti-regurgitant (AR) formulae containing processed rice, corn or potato starch, decrease overt regurgitation and vomiting frequency and volume. When ingested in normal volumes, AR formulae contain an energy density, osmolarity, protein, calcium, and fatty acid content appropriate to an infant's nutritional needs, whereas a formula with added thickener has a higher energy density.

Positioning therapy for infants

Several studies in infants have demonstrated significantly decreased acid reflux in the flat prone position compared with flat supine position. [22],[23],[24],[25],[26] The semisupine positioning as attained in an infant car seat exacerbates GER. [27] Based on these studies, the prone position was the recommended positioning after feeds. However, reports on the association between prone positioning and sudden infant death syndrome (SIDS) led to modification of this recommendation that the prone position is no longer recommended routinely. However, in certain special situations prone positioning may be considered, such as infants with certain upper airway disorders in which the risk of death from GERD may outweigh the risk of SIDS or children older than 1 year of age with GER or GERD whose risk of SIDS is negligible.

Lifestyle changes in children and adolescents

Lifestyle changes often recommended for children and adolescents with GER and GERD include dietary modification, weight loss in overweight patients, positioning changes, and avoidance of smoking. However, it is not known whether any lifestyle changes have an additive benefit in children or adolescents receiving adequate pharmacological therapy.

Acid-controlling drugs

Antacids

They directly buffer gastric contents, thereby reducing heartburn and healing esophagitis. On-demand use of antacids may provide rapid symptom relief in some children and adolescents with GERD. However, prolonged treatment with aluminum-containing antacids significantly increases plasma aluminum in infants, [28],[29] and some studies report plasma aluminum concentrations close to those that have been associated with osteopenia, rickets, microcytic anemia, and neurotoxicity. [30],[31] Because safe and convenient alternatives are available, chronic antacid therapy is generally not recommended for children with GERD.

Surface-protecting agents

Most of these agents contain either alginate or sucralfate. Efficacy of alginate is controversial. Sucralfate is a compound of sucrose, sulfate, and aluminum, which, in an acid environment, forms a gel that binds to the exposed mucosa of peptic erosions. In adults, sucralfate decreased symptoms and promoted healing of nonerosive esophagitis. [32] The available data are inadequate to determine the safety or efficacy of sucralfate in the treatment of GERD in infants and children, particularly the risk of aluminum toxicity with long-term use. None of the surface agents is recommended as a sole treatment for severe symptoms or erosive esophagitis.

Histamine-2 receptor antagonists (H2RAs)

These drugs decrease acid secretion by inhibiting histamine-2 receptors on gastric parietal cells. These include cimetidine, famotidine, nizatidine, and ranitidine. However, ranitidine is the most commonly used in children. One dose of (5 mg/kg) has been shown to increase gastric pH for 9 to 10 hours in infants. [33] Tachyphylaxis or diminution of the response to intravenous ranitidine and escape from its acid-inhibitory effect have been observed after 6 weeks. [34],[35]

Proton pump inhibitors (PPIs)

They inhibit acid secretion by blocking Na + -K + -ATPase, the final common pathway of parietal cell acid secretion (the proton pump). The superiority of PPIs is related to their ability to maintain intragastric pH at or above 4 for longer periods and to inhibit meal-induced acid secretion, a characteristic not shared by H2RAs. In addition, the effect of PPIs does not diminish with chronic use. The potent suppression of acid secretion by PPIs also results in decrease of 24-hour intragastric volumes, thereby facilitating gastric emptying and decreasing gastric volume and reflux. [36] In children, as in adults, PPIs are highly efficacious for the treatment of symptoms due to GERD and the healing of erosive disease. PPIs have greater efficacy than H2RAs and children below 10 years of age appear to require a higher dose per kilogram for some PPIs than adolescents and adults. However, double-blind randomized placebo-controlled trials (RCTs) show that PPI therapy is not beneficial for the treatment of infants with symptoms that previously were purported but not proven to be due to GERD although in one study, esomeprazole reduced esophageal acid exposure and the number of acidic reflux events. [37],[38],[39] Poorly controlled asthma is an example of lack of benefit and even increased risk of PPIs. In a recent RCT, children with poorly controlled asthma without symptoms of GER who were using inhaled corticosteroids, the addition of lansoprazole, compared with placebo, improved neither symptoms nor lung function but was associated with increased adverse events. [40] There are potential side effects related to PPIs: Idiosyncratic reactions, drug-drug interactions, drug-induced hypergastrinemia, and drug-induced hypochlorhydria.

Idiosyncratic side effects occur in up to 14% of children taking PPIs. [40],[41] The most common are headache, diarrhea, constipation, and nausea, each occurring in 2% to 7%. These may resolve with decreased dose or change to a different PPI. Increasing evidence suggests that hypochlorhydria, that is, acid suppression, associated with H2RAs or PPIs may increase rates of community-acquired pneumonia in adults and children, gastroenteritis in children, and candidemia and necrotizing enterocolitis in preterm infants. [42],[43],[44],[45],[46] Lower respiratory tract infections were the most frequent among these adverse effects, although the difference in respiratory tract infection rate between treated and placebo groups did not achieve statistical significance. Other adverse effects have been reported in patients with chronic PPI therapy, such as deficiency of vitamin B12 and increased incidence of hip fractures. [47],[48] In addition, PPI-induced acute interstitial nephritis causing acute renal failure have been reported, and may be unrecognized and classified as ''unclassified acute renal failure''. [49] PPIs are considered to be one of the most common cause of acute interstitial nephritis in adults. [50],[51]

Prokinetic Therapy

Cisapride is a mixed serotonergic agent that facilitates the release of acetylcholine at synapses in the myenteric plexus, thus increasing gastric emptying and improving esophageal and intestinal peristalsis. After an initial widespread use in children with GERD, cisapride was withdrawn from the market after it was implicated in prolongation of the QTc interval on electrocardiogram, a finding increasing the risk of sudden death. [52]

Domperidone and metoclopramide are antidopaminergic agents that facilitate gastric emptying. Metoclopramide has cholinomimetic and mixed serotonergic effects. Metoclopramide and placebo equally reduced symptom scores of infants with reflux. A meta-analysis of RCTs of metoclopramide in developmentally healthy children 1 month to 2 years of age with symptoms of GER found that the drug reduced symptoms and the RI but was associated with significant side effects. [53]

The reported adverse effects in infants and children include lethargy, irritability, gynecomastia, galactorrhea, and extrapyramidal reactions and has caused permanent tardive dyskinesia. [54],[55],[56],[57] A recent systematic review of studies on domperidone [58] identified only 4 RCTs in children, none providing ''robust evidence'' for efficacy of domperidone in pediatric GERD. Domperidone occasionally causes extrapyramidal central nervous system side effects. Bethanechol, a direct cholinergic agonist studied in a few controlled trials, has uncertain efficacy and a high incidence of side effects in children with GERD. [55]

Baclofen is a g-amino-butyric-acid receptor agonist that reduces both acid and nonacid reflux in healthy adults and those with GERD. [59] In children, it was shown to accelerate gastric emptying for 2 hours after dosing, without any deleterious effect on LES resting pressure or esophageal peristalsis. [60] In a small group of children with GERD and NI, it was reported to decrease the frequency of emesis. [61] However, baclofen is known to cause dyspeptic symptoms, drowsiness, dizziness, and fatigue, and to lower the threshold for seizures. Such side effects preclude its routine use. [62] However, a recent analysis suggested that baclofen may be used as supplement to other measures in some children with refractory GERD. [63]

Surgical Therapy

Fundoplication decreases reflux by increasing the LES baseline pressure, decreasing the number of TLESRs, increasing the length of the esophagus that is intraabdominal, accentuating the angle of His, and reducing hiatal hernia if present. When successful, fundoplication usually eliminates reflux, including physiologic reflux. [64] Compared to normal children, those with NI have more than twice the complication rate, three times the morbidity, and four times the reoperation rate. [65] One case series with a follow-up period of 3.5 years reported that more than 30% of children with NI had major complications or died within 30 days of antireflux surgery. [66] Children with repaired EA also have a high rate of operative failure [67],[68] although not as high as those with NI. Recurrence of pathologic reflux after antireflux surgery in children with NI or EA may not be obvious, and detection often requires a high index of suspicion, repeated evaluation over time, and use of more than one test. Fundoplication in early infancy has a higher failure rate than fundoplication performed later in childhood, and appears to be more frequent in children with associated anomalies. [69]

Complications following antireflux surgery may be due to alterations in fundic capacity, altered gastric compliance, and sensory responses that may persist from months to years. These include gas-bloat syndrome, early satiety, dumping syndrome, and postoperative retching and gagging. In a postoperative study of children with no underlying disorders, 36% had mild to moderate gas bloat symptoms, 32% were ''very slow'' to finish most meals, 28% were unable to burp or vomit, and 25% choked on some solids. [70] Early and late operative failure may result from disruption of the wrap or slippage of the wrap into the chest. In otherwise healthy children evaluated at a mean of 10 months (1-35 months) following antireflux surgery, 67% had ''no complaints,'' but one third had objective evidence of operative failure. [71] Operative complications include splenic or esophageal laceration, each of which occurs in about 0.2% of pediatric cases. [72] Laparoscopic Nissen fundoplication has largely replaced open Nissen fundoplication as the preferred antireflux surgery for adults and children, due to its decreased morbidity, shorter hospital stays, and fewer perioperative problems.

Antireflux surgery may be of benefit in children with confirmed GERD who have failed optimal medical therapy, or who are dependent on medical therapy over a long period of time, or who are significantly non-adherent with medical therapy, or who have life-threatening complications of GERD.

Evaluation and therapeutic indications

In view of the variety of presenting symptoms of reflux and that the diagnosis is usually made at different stages of the disease, the evaluation and management should be individualized. The following guidelines of the North American and European Societies for Pediatric Gastroenterology Hepatology and Nutrition represent a practical approach recommended for the evaluation and treatment of GERD. [2]

  1. Infants with uncomplicated recurrent regurgitation and vomiting: This is the typical presentation of physiologic GER. The history and physical examination are usually sufficient for the diagnosis. No other investigation is needed at this point. Parental education, reassurance, and follow up are recommended. In formula-fed infants, thickened or AR formula reduce the frequency of overt regurgitation and vomiting and may be prescribed.
  2. Infants with recurrent vomiting and poor weight gain: These patients present with symptoms suggestive of GERD rather than physiologic GER. Therefore, in addition to complete history and physical examination, the initial evaluation should include nutritional history, urinalysis, complete blood count, serum electrolytes, blood urea nitrogen, and serum creatinine. Other investigations should be based on suggestive historical details or results of screening tests. Management may include a discontinuation of cow's milk and a 2-week trial of extensively hydrolyzed formula or amino acid-based formula to exclude the possibility cow's milk allergy. Increased caloric density of formula and/or thickened formula, and education as to appropriate daily formula volume may be required to achieve normal growth. Careful follow-up of interval weight change and caloric intake is essential. If management fails to improve symptoms and weight gain, referral to a pediatric gastroenterologist is recommended for further investigations.
  3. Infants with unexplained crying and/or distressed behavior: Reflux is not a common cause of unexplained crying, irritability, or distressed behavior in otherwise healthy infants. Other causes include cow's milk protein allergy, neurologic disorders, constipation, and infection (especially of the urinary tract). Following exclusion of other causes, an empiric trial of extensively hydrolyzed protein formula or amino acid-based formula is reasonable in selected cases although evidence from the literature in support of such a trial is limited. There is no evidence to support the empiric use of acid suppression for the treatment of irritable infants. If irritability persists with no explanation other than suspected GERD, referral to pediatric gastroenterologist for further investigation is recommended.
  4. The child older than 18 months of age with chronic regurgitation or vomiting: Although these symptoms are not unique to GERD, evaluation to diagnose possible GERD and to rule out alternative diagnoses is recommended based on expert opinion. Testing may include upper gastrointestinal (GI) endoscopy and/or esophageal pH/MII, and/or barium upper GI series.
  5. Heartburn: Adolescents with typical symptoms of chronic heartburn should be treated with lifestyle changes if applicable (diet changes, weight loss, smoking avoidance, sleeping position, no late night eating) and a 2- to 4-week trial of PPI. If symptoms resolve, PPIs may be continued for up to 3 months. Heartburn that persists on PPI therapy or recurs after this therapy is stopped should be investigated further by a pediatric gastroenterologist.
  6. Reflux esophagitis: In pediatric patients with endoscopically diagnosed reflux esophagitis or established non-erosive reflux disease, PPIs for 3 months constitute initial therapy. Not all reflux esophagitis are chronic or relapsing, and therefore trials of tapering the dose and then withdrawal of PPI therapy should be performed at intervals. In most cases of chronic-relapsing esophagitis, symptom relief can be used as a measure of efficacy of therapy, but in some circumstances repeat endoscopy or diagnostic studies may be indicated. Recurrence of symptoms and/or esophagitis after repeated trials of PPI withdrawal usually indicate that chronic-relapsing GERD is present, if other causes of esophagitis have been ruled out. At that point, therapeutic options include long-term PPI therapy or antireflux surgery.
  7. Barrett's esophagus (BE): Occurs in children with less frequency than it does in adults. Multiple biopsies documented in relation to endoscopically identified esophagogastric landmarks are advised to confirm or rule out the diagnosis of BE and dysplasia. In BE, aggressive acid suppression is advised by most experts. Symptoms are a poor guide to the severity of acid reflux and esophagitis in BE, and pH studies are often indicated to guide treatment. BE per se is not an indication for surgery. Dysplasia is managed according to adult guidelines.
  8. Dysphagia, odynophagia, and food refusal: Dysphagia, or difficulty in swallowing, occurs in association with oral and esophageal anatomic abnormalities, neurologic and motor disorders, oral and esophageal inflammatory diseases, and psychological stressors or disorders. Of the mucosal disorders, eosinophilic esophagitis is increasingly recognized as a common cause of dysphagia or odynophagia. Odynophagia, or painful swallowing, must be distinguished from heartburn (substernal pain caused by esophageal acid exposure) and dysphagia. Although odynophagia may be a symptom of peptic esophagitis, it is more often associated with other conditions such as oropharyngeal inflammation, esophageal ulcer, eosinophilic esophagitis, infectious esophagitis, and esophageal motor disorders. Although GERD is not a prevalent cause of dysphagia or odynophagia, an evaluation including barium upper GI series and possibly upper endoscopy should be considered if physical examination and history of disease do not reveal a cause. Therapy with acid suppression without evaluation is not recommended. In the infant with feeding refusal, acid suppression without diagnostic evaluation is not recommended.
  9. Infants with apnea or apparent life-threatening events (ALTEs): In the majority of infants with apnea or ALTEs, GER is not the cause. In the uncommon circumstance in which a relation between symptoms and GER is suspected or in those with recurrent symptoms, MII/pH esophageal monitoring in combination with polysomnographic recording and precise synchronous symptom recording may aid in establishing cause and effect.
  10. Reactive airways disease: In patients with asthma who also have heartburn, reflux may be a contributing factor to the asthma. Despite a high frequency of abnormal reflux studies in patients with asthma who do not have heartburn, there is no strong evidence to support empiric PPI therapy in unselected pediatric patients with wheezing or asthma. Three groups of asthmatics may benefit from PPI or surgical therapy. These include patients with heartburn, those with nocturnal asthma symptoms, and those with steroid-dependent difficult-to-control asthma. Finding abnormal esophageal pH exposure by esophageal pH monitoring, with or without impedance, before considering a trial of long-term PPI therapy or surgery may be useful although the predictive value of these studies for this purpose has not been established.
  11. Recurrent pneumonia and interstitial lung disease: These conditions of GERD due to aspiration of gastric contents. No test can determine whether reflux is causing recurrent pneumonia. An abnormal esophageal pH test may increase the probability, but is not a proof, that it is the cause of recurrent pneumonia. Nuclear scintigraphy can detect aspirated gastric contents when images are obtained for 24 hours after enteral administration of a labeled meal. Aspiration during swallowing is more common than aspiration of refluxed material. A trial of nasogastric feeding may be used to exclude aspiration during swallowing as a potential cause of recurrent disease. A trial of nasojejunal therapy may help in determining whether surgical antireflux therapy is likely to be beneficial. In patients with severely-impaired lung function, antireflux surgery may be necessary to prevent further pulmonary damage, despite lack of definitive proof that GER is causative.
  12. Upper airway symptoms: The data linking reflux to chronic hoarseness, chronic cough, sinusitis, chronic otitis media, erythema, and cobblestone appearance of the larynx come mainly from case reports and case series. The association of reflux with these conditions and response to antisecretory therapy have not been proven by controlled studies. Patients with these symptoms or signs should not be assumed to have GERD without consideration of other potential etiologies.
  13. Dental erosions: An association between GERD and dental erosions has been established. The severity of dental erosions seems to be correlated with the presence of GERD symptoms and, in adults, with the severity of proximal esophageal or oral exposure to an acidic pH. Young children and children with neurologic impairment appear to be at the greatest risk. Factors other than reflux that cause similar dental erosions include juice drinking, bulimia, and racial and genetic factors affecting the characteristics of enamel and saliva.
  14. Dystonic head posturing (Sandifer Syndrome): Sandifer syndrome (spasmodic torsional dystonia with arching of the back and opisthotonic posturing, mainly involving the neck and back) is an uncommon but specific manifestation of GERD. It resolves with antireflux treatment.


 
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