Pediatric Gastroesophageal Reflux Disease

by Thomas M Attard

One of the most common complaints referred to primary caregivers in infancy is reflux type emesis, less frequently posing as chest pain and discomfort upon swallowing. However reflux can also present in the older child and adolescent. Gastroesophageal reflux disease (GERD) can complicate the management of the child with neurodevelopmental disability wherein a more severe pattern of disease is exacerbated by delayed, sometimes atypical presentation.¹  Moreover, even in otherwise healthy children, there is increasing recognition of non-gastrointestinal presentations of gastroesophageal reflux disease that span the gamut from failure-to-thrive, dental erosion and complicated asthma.

In GERD the refluxate causes troublesome symptoms (Table 1). It is important, from the outset, to distinguish from physiologic reflux (GER) – the passage of gastric contents into the esophagus with or without regurgitation into the mouth, which is a normal process occurring several times a day in, amongst others, healthy infants. GERD is a clinical diagnosis; there is no gold standard investigation, indeed in most uncomplicated cases, clinical interview and examination are sufficient. This can however be supplemented with an empiric therapeutic trial obviating the need for any further investigations.²

There is mounting evidence to support a role of GERD in diverse disease processes including respiratory disease such as recurrent pneumonia and atypical asthma, dental erosion³ and, with less robust evidence; upper airway complaints such as hoarseness, chronic cough, recurrent sinusitis, otitis and the sensation of a lump in the throat (globus).^4,5  It is also important to bear in mind that GERD is more prevalent in obese children and is associated with greater severity of disease including the development of Barrett’s Esophagus and adenocarcinoma in adults.^6,7

In cases where a diagnostic workup is needed, for example in children with atypical presentations or who are refractory to standard, or first-line management, the choice for investigation falls between upper endoscopy with biopsy – which serves to rule out a gamut of alternative diagnoses based on gastrointestinal pathology (an example is illustrated in Table 2), and pH or impedance probe. Radiologic modalities such as upper gastrointestinal contrast study (barium meal) and nuclear scintigrapy scan (milk scan) are limited in scope but useful in select clinical scenarios including the need to rule out malrotation and duodenal stenosis (Barium meal – Figure 1)⁸, or reflux and aspiration or delayed gastric emptying (Milk scan).

The management of GERD depends on the consequences of the disease and associated conditions. Longstanding severe GERD can lead to scarring and difficulty in swallowing as well as transformation of the lower esophageal mucosa into premalignant, intestinal mucosa (Barrett’s Esophagus). This latter is rare in children, although the presence of neurodisability and hiatus hernia may be possible risk factors.⁹

Reassurance, education and conservative measures are all that are needed in most cases of infant GERD; lifestyle changes (Table 3) may include a switch to an antireflux formula (AR) although the presence of physiologic GER should not be construed as a justification to stop breastfeeding. First-line pharmacologic therapy include the use of ranitidine 2mg/kg/dose three times daily, although locally the liquid formulation (15mg/ml) is only available though the government pharmacy. Although well-established for use in infants and children, the emergence of tachyphylaxis as well as the limited acid suppression achievable with Histamine-2 Receptor Antagonists (H2RA) including ranitidine, resulted in now fairly routine use of proton-pump inhibitor agents (PPI) in this age group. Several are licensed for use in children, the usual dose is 1mg/kg/day and the most frequent, usually dose-dependent side-effects are headache, diarrhea, constipation and nausea. Although unlicensed for use in infants, PPI agents are increasingly used and are generally thought to be safe although, for obvious reasons, the choice is limited to soluble formulations.^10,11 The routine use of prokinetics in the long term management of GERD in children is not recommended based on the unfavourable risk-benefit relationship.¹²

Surgical options in the management of GERD are, in most clinical scenarios, limited to the last resort. A variety of different techniques for fundoplication purport to recreate or strengthen the physiologic lower esophageal sphincter. Decreased reflux is often achievable but at the risk of several potential long-term complications that tend to be more common in younger age at the time of operation, and with concomitant neurodisability.¹³ An alternative surgical option, especially in the latter subgroup of patients includes gastrostomy placement, which facilitates continuous (therefore low volume) feeds, and in rare cases jejunostomy feeds. Endoscopic fundoplication, which is established in adult medicine, is as yet unavailable in children.

Gastroesophageal reflux therefore emerges as a relatively common complaint in the peadeiatric population. In select scenarios the index of suspicion needs to be heightened, and despite tremendous progress in the diagnostic modalities, investigation and treatment needs to be individualized and preferably centered around conservative and safe measures.

Table 1. Symptoms and signs that may be associated with gastroesophageal reflux disease