Gastro-esophageal reflux in children:Symptoms, diagnosis and treatment
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Abstract
Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus and is a normal physiologic process occurring several times per day in healthy individuals. In infants and toddlers, no symptoms allow to diagnose GERD or to predict response to therapy. In older children and adolescents, history and physical examination may be sufficient to diagnose GERD.
Endoscopically visible breaks in the distal esophageal mucosa are the most reliable evidence of reflux esophagitis. Esophageal pH monitoring quantitatively measures esophageal acid exposure. The severity of pathologic acid reflux does not predict symptom severity or treatment outcome. Combined multiple intraluminal impedance and pH monitoring (MII-pH) measures both acid, weakly acid, non-acid and gas reflux episodes. MII-pH is superior to pH monitoring alone for evaluation of the temporal relationship between symptoms and GER. Barium contrast radiography is not useful for the diagnosis of GERD, but is useful to detect anatomic abnormalities. Tests on ear, lung and esophageal fluids for lactose, pepsin or lipid laden macrophages have all been proposed without convincing evidence. An empiric trial of acid suppression as a diagnostic test can be used in older children (> 10 years).
Parental education, guidance and support are always required and usually sufficient to manage healthy, thriving infants with symptoms likely due to physiologic GER. Use of a thickened feed, by preference commercially available anti-regurgitation formula, decrease visible regurgitation. Positional therapy brings additional benefit. Prone (beyond the age of sudden infant death syndrome) or left side sleeping position, and/or elevation of the head of the bed decrease GER.
Chronic use of buffering agents or sodium alginate is not recommended for GERD since some have absorbable components that may have adverse effects with long-term use. Potential adverse effects of currently available prokinetic agents outweigh the potential benefits of these medications for treatment of GERD. Proton pump inhibitors (PPIs) are superior to histamine-2 receptor antagonists (H2RAs). Administration of long-term acid suppression without a diagnosis is not recommended. No PPI has been approved for use in infants < 1 year of age. The potential adverse effects of acid suppression, including increased risk of community-acquired pneumonias and gastrointestinal infections, need to be balanced against the benefits of therapy. Anti-reflux surgery is of benefit in selected children with chronic, relapsing GERD. Indications include failure of optimized medical therapy; dependence on long-term medical therapy; significant non-adherence with medical therapy; or pulmonary aspiration of refluxate.
Endoscopically visible breaks in the distal esophageal mucosa are the most reliable evidence of reflux esophagitis. Esophageal pH monitoring quantitatively measures esophageal acid exposure. The severity of pathologic acid reflux does not predict symptom severity or treatment outcome. Combined multiple intraluminal impedance and pH monitoring (MII-pH) measures both acid, weakly acid, non-acid and gas reflux episodes. MII-pH is superior to pH monitoring alone for evaluation of the temporal relationship between symptoms and GER. Barium contrast radiography is not useful for the diagnosis of GERD, but is useful to detect anatomic abnormalities. Tests on ear, lung and esophageal fluids for lactose, pepsin or lipid laden macrophages have all been proposed without convincing evidence. An empiric trial of acid suppression as a diagnostic test can be used in older children (> 10 years).
Parental education, guidance and support are always required and usually sufficient to manage healthy, thriving infants with symptoms likely due to physiologic GER. Use of a thickened feed, by preference commercially available anti-regurgitation formula, decrease visible regurgitation. Positional therapy brings additional benefit. Prone (beyond the age of sudden infant death syndrome) or left side sleeping position, and/or elevation of the head of the bed decrease GER.
Chronic use of buffering agents or sodium alginate is not recommended for GERD since some have absorbable components that may have adverse effects with long-term use. Potential adverse effects of currently available prokinetic agents outweigh the potential benefits of these medications for treatment of GERD. Proton pump inhibitors (PPIs) are superior to histamine-2 receptor antagonists (H2RAs). Administration of long-term acid suppression without a diagnosis is not recommended. No PPI has been approved for use in infants < 1 year of age. The potential adverse effects of acid suppression, including increased risk of community-acquired pneumonias and gastrointestinal infections, need to be balanced against the benefits of therapy. Anti-reflux surgery is of benefit in selected children with chronic, relapsing GERD. Indications include failure of optimized medical therapy; dependence on long-term medical therapy; significant non-adherence with medical therapy; or pulmonary aspiration of refluxate.
Keywords
Gastroesophageal reflux, children
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