Gastroesophageal reflux disease (pediatrics): Clinical sciences

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Introduction0:00–0:32

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.

H&P/Infant0:32–2:19

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 six 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 one week or over six 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 distension, hepatosplenomegaly, nocturnal or bilious emesis, hematosis, 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.

GERD2:19–3:55

On the other hand, if no warning signs are present, diagnose GERD. All right.
Now that you've diagnosed GERD, it's time to begin management. Start by having caregivers thicken their infants, 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 the 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 your 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, PPI S 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's no symptomatic improvement.

Children and Adolescents3:55–5:41

All right, 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 the 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.
Keep in mind that GERD can aggravate or trigger recurrent pneumonia or otitis media asthma and apnea spells. So, remember to ask about GERD symptoms if your patient has one of these conditions.
Now, once you suspect GERD, be sure to assess for warning signs that suggest a different condition. Some warning signs include symptom onset before 12 months of age or persistence beyond 12 months of age and weight loss or suboptimal weight gain.
Other warning signs to look for include fever, lethargy, seizures, abdominal distention and hepatosplenomegaly. As well as nocturnal or bilious emesis, hematosis, chronic diarrhea or rectal bleeding.
If you identify one or more of these warning signs, you should consider an alternative diagnosis such as intestinal obstruction infection or an intracranial mass.
On the other hand, if you don't identify any warning signs, diagnose GERD time for a clinical pearl. Occasionally patients with GERD report atypical symptoms such as hoarseness, dysphasia, which means difficulty swallowing and ade aphasia which is painful, swallowing.

GERD5:41–7:04

Other atypical GERD symptoms include coughing, choking, wheezing, upper respiratory symptoms or dental erosions. However, if these symptoms occur in the absence of classic symptoms like heartburn, you should evaluate for other underlying causes.
For example, you might consider an upper gi series to evaluate for structural abnormality such as gastric outlet obstruction or intestinal malrotation.
Let's follow that up with a high yield fact. Eosinophilic esophagitis or E oe is an immune mediated disease that can present with symptoms that mimic GERD Children with E oe commonly report dysphasia and food impaction and these patients can even develop esophageal strictures.
Moreover, even though esophageal biopsies in both EO E and GERD can demonstrate eosinophils. GERD biopsies usually contain fewer than seven eosinophils per high power field.
Whereas eoe biopsies contain at least 15 along with eosinophilic microabscesses. Now that you've diagnosed GERD, it's time to move on to management.

Lifestyle Changes7:04–8:37

Start by recommending lifestyle changes such as weight reduction and alcohol or smoking cessation if indicated and advise your patient to avoid caffeinated beverages and acidic foods.
Additionally, you should recommend that your patients sleep in a left lateral decubitus position and have them elevate the head of their bed during sleep, then assess your patients response to these modifications if their symptoms improve, continue the current management.
However, if your patient's symptoms persist, despite these interventions begin a trial of a PPI such as omeprazole after 4 to 8 weeks, wean the medication and assess their response to the treatment.
If your patient's symptoms improve. After weaning the PP continue to monitor for recurrent symptoms on the flip side.
If the patient's symptoms persist despite the maximum PPI dose or while weaning the PPI refer them to a pediatric gastroenterologist for further evaluation and treatment.
You might also consider ordering an esophagogastroduodenoscopy or EG D or a 24 hour esophageal ph probe with impedance monitoring.
Here's one more clinical pearl. There are non pharmacological remedies that may reduce GERD symptoms.
Some examples include consumption of ginger, ginger ale, licorice or baking soda as well as chewing sugarless gum after meals.
All right. As a quick recap.

Review8:37–9:11

Infants with classic symptoms and no warning signs can be diagnosed with GERD. Initial management is focused on feeding if symptoms persist, eliminate cow's milk protein from the infants diet and if symptoms still don't improve refer to a specialist for older Children or adolescents with classic symptoms and no warning signs diagnose GERD and recommend appropriate lifestyle changes if symptoms persist, begin a PPI trial, if this doesn't help, refer to a specialist for further evaluation and management.