Click here to view next page of this article

Gastroesophageal Reflux

Gastroesophageal reflux is defined as passive retrograde movement of gastric contents into the esophagus. GER often presents as frequent "spitting up" after meals, and it is a normal physiologic event.

Fifty to 65% of normal 2 month old infants regurgitate 3 or more times a day. By 3 months of age, only 4% are still regurgitating this amount. Two-thirds of these infants improve by 18 months of age, as the diet becomes more solid. By four years of age, symptoms resolve in most children with persistent GER. Severe GER can cause esophagitis, anemia, failure to thrive, and gastroesophageal reflux.

Physiology and Pathophysiology of GER

Two physiologic phenomena contribute to GER--transient lower esophageal sphincter (LES) relaxations and persistent or recurrent intraabdominal pressure increases. In infants with functional GER--which is what most babies have--transient LES relaxations are asynchronous with swallowing and last 5 seconds. Gastric distention due to delayed emptying, overfeeding, or gastric hypersecretion can provoke these inappropriate relaxations. Sustained increases in intraabdominal pressure can occur with excessive coughing, straining, or crying.

Gastroesophageal reflux is a physiologic phenomenon up to a certain point, beyond which it becomes pathologic. Even healthy persons have reflux, but it becomes a disease if the reflux causes symptoms and complications.

Physiologic reflux presents in infants as regurgitation in the first few months of life and resolves by 6-18 months of age.

Functional GER refers to reflux that is more frequent than physiologic GER, but which does not cause complications.

Pathologic GER consists of GER that is associated with complications. The most common pathologic presentation is failure to thrive.

Gastroesophageal reflux may cause vagal stimulation leading to bradycardia, with or without apnea and apparent life-threatening events.

Otalgia, recurrent abdominal pain, and Barrett's esophagus (glandular metaplasia of the distal esophagus) are complications of prolonged gastroesophageal reflux.

Diagnostic Approach to Gastroesophageal Reflux

Regurgitant GER must be differentiated from disorders such as gastric outlet obstruction (especially pyloric stenosis), acid-peptic disease, food allergies or intolerances, malrotation, cyclic vomiting, and CNS lesions.

The physical examination should include observation of the infant during and after feeding. Examination of the stool.

Vomiting in an infant younger than 2 months of age suggests possible anatomic abnormalities of the GI tract or metabolic disease. In an older infant, effortless regurgitation is a common manifestation of GER. No invasive evaluation is needed in an otherwise thriving infant.

Laboratory Evaluation

In a patient with significant vomiting, a complete blood cell count, electrolytes, blood urea nitrogen, urinalysis, and urine culture.

Conservative Treatment

Since the natural history of GER in pediatric patients is generally favorable, initial management should be conservative. Most infants and children with GER respond to conservative management.

Observing the parents feeding the infant, to be sure the infant is properly positioned and frequently burped, will eliminate the possibility of improperly held or propped bottles.

Dietary Measures. The parents should avoid overfeeding the child, and smaller, more frequent meals will decrease intragastric distention. Thicken ing agents (rice cereal) may deter some reflux; however, recent studies have discounted this effect in non-regurgitant occult reflux, possibly because of an adverse effect on gastric emptying.

Postural therapy for GER. Some evidence suggests that the prone position may reduce GER, but because of its association with sudden infant death syndrome, it is not routinely recommended. Keeping the baby upright after feeding may help.

Patients who do not respond to conservative measures can be treated with prokinetic agents and acid-suppressing therapy. Prokinetic agents are the ini tial drug therapy for GER in infants. If complications arise, acid-suppressing medication is added.