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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 for most infants gastroesophageal reflux, spitting up, vomiting, infants.
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
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
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
Gastroesophageal reflux is a physiologic phenomenon up to a certain point, beyond which it becomes pathologic. Even healthy persons have reflux, but it
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. Infants with intractable vomiting should also be evaluated for immunologic, metabolic, renal, and infectious
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
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
Dietary Measures. The parents should avoid overfeeding the child, and smaller, more frequent meals will decrease intragastric distention. Thickening 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
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.
Pharmacologic therapy
Patients who do not respond to conservative measures can be treated with prokinetic agents and acid-suppressing therapy.
Histamine-2-receptor antagonists may be used in infants and children with esophagitis or with colic due to GER-related feeding refusal. Some commonly
Omeprazole ( Prilosec), a proton-pump inhibitor, is effective treatment for neurologically impaired children with severe esophagitis, and it can be used as a second-line acid suppressant in neurologically normal children. Omeprazole can be
Surgery
Patients who do not respond adequately to dietary modifications, postural changes, and pharmacologic management or
The procedure of choice is the Nissen fundoplication, in which the gastric fundus is wrapped around the lower 2-3 cm of the esophagus. This procedure is
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