Gastroesophageal reflux disease (pediatrics): Clinical sciences

Gastroesophageal reflux refers to the retrograde movement of gastric contents into the esophagus. When ongoing gastroesophageal reflux is severe enough to cause troublesome symptoms or complications like erosive esophagitis or Barrett esophagus, it’s called gastroesophageal reflux disease, or GERD. In the pediatric population, evaluation and treatment of GERD depends on the patient’s age and symptom severity.

Now, if a pediatric patient presents with a chief concern suggesting GERD, first obtain a focused history and physical exam, and then assess your patient’s age. Let’s start by discussing GERD in infants. Caregivers typically report that their infant spits up frequently, and some may become irritable, refuse to feed, or arch their back during feedings. In this age group, exam findings are typically normal. With this clinical presentation, you should suspect GERD.

Here’s a high-yield fact to keep in mind! Healthy infants commonly experience recurrent episodes of spitting up or regurgitation that peak around 6 months of age. These episodes of reflux are caused by relaxation of the lower esophageal sphincter, which allows gastric contents to enter the esophagus. When gastroesophageal reflux is not associated with troublesome symptoms or complications, it’s considered normal, and it usually resolves without intervention.

Now, once you suspect GERD, you should assess for the presence of any warning signs that suggest a condition other than GERD. Some examples include an age of onset less than 1 week or over 6 months; weight loss or suboptimal weight gain; fever; or lethargy. Also look for signs suggesting intracranial pathology, such as seizures, microcephaly, macrocephaly, or a bulging fontanelle.

Other red flags suggesting another disease include abdominal distention, hepatosplenomegaly, nocturnal or bilious emesis, hematemesis, chronic diarrhea, and rectal bleeding. If you identify one or more of these warning signs, consider an alternative diagnosis, such as intestinal obstruction, infection, or an intracranial mass.

On the other hand, if no warning signs are present, diagnose GERD. Alright, now that you’ve diagnosed GERD, it’s time to begin management. Start by having caregivers thicken their infant’s feedings with rice cereal or a commercial-based thickener. Additionally, you should recommend feeding modifications, such as reducing the volume of feedings and increasing their frequency. Another helpful consideration is to reduce or eliminate environmental exposure to tobacco. Now, assess your patient’s response to these changes. If their symptoms have improved, continue the current management.

On the flip side, if your patient’s symptoms persist, eliminate cow’s milk protein from their diet. Formula-fed infants can transition to protein hydrolysate or amino acid-based formulas. For infants that are breastfed, you can recommend removing cow’s milk from the breastfeeding parent’s diet. Next, assess the response to this dietary change. If the patient’s symptoms have improved, continue the current management.

However, if your patient’s symptoms persist despite dietary changes, refer them to a pediatric gastroenterologist for further evaluation. You can also consider treating your patient with a proton pump inhibitor, or PPI for short, if there is a delay in obtaining an appointment. However, PPIs can have long term deleterious adverse effects, including poor impact on bone health, so this should only be done in cases where there are severe symptoms, and for no longer than 4 to 8 weeks, especially if there is no symptomatic improvement.

Alright, let’s switch gears and discuss GERD in children and adolescents. At this age, patients often describe symptoms like heartburn, nausea, and epigastric or chest pain. Additionally, history may reveal anorexia, food refusal, specific food aversions, or recurrent vomiting, but the physical exam is typically normal. With these findings, suspect GERD.

Here’s a clinical pearl! Conditions that increase a patient’s risk of GERD include obesity, hiatal hernia, and gastrointestinal motility disorders, such as achalasia. Other patients at risk for GERD include those with neurologic conditions, like cerebral palsy; respiratory disorders, including bronchopulmonary dysplasia or cystic fibrosis; lung transplantation; and prematurity.