This podcast will discuss the definition, pathophysiology, clinical manifestations, and management of gastroesophageal reflux. This podcast was developed by Viane Faily, a medical student at the University of Alberta, with guidance from Dr. Jackie Lee, a general pediatrician at the Stollery Children’s Hospital in Edmonton, Alberta, Canada.
Here are excerpts from the transcript:
Key Learning Points
Let’s go through some takeaway points from this podcast:
1. Gastroesophageal reflux is a physiologic process that involves the passive movement of stomach contents into the esophagus, resulting in regurgitation or emesis in infants. It can be managed with education, anticipatory guidance, and reassurance.
2. A diagnosis of GERD can be made when reflux is associated with failure to thrive or severe symptoms. In these cases, histamine-2 receptor antagonists or proton pump inhibitors to suppress acid production may be considered.
3. Both reflux and GERD are clinical diagnoses. Various studies can be used to help rule out other conditions on your differential diagnosis but are not necessary for the diagnosis of GERD.
4. Remember to evaluate for warning signs that may suggest alternative diagnoses, including bilious vomiting, hematemesis or hematochezia, progressively worsening forceful vomiting, failure to thrive, diarrhea or constipation, fever or bulging fontanelle, and abdominal tenderness or distension.
Gastroesophageal reflux occurs in more than two-thirds of
otherwise healthy infants and its incidence peaks at age four months, typically resolving by the age of one year in the majority of uncomplicated cases (1).
It is important to distinguish normal gastroesophageal reflux from gastroesophageal reflux disease, also known as GERD, which occurs when the reflux of gastric contents causes troublesome symptoms and/or complications. Symptoms due to reflux are considered troublesome when they have adverse effects on a patient’s wellbeing (2).
Signs and symptoms of reflux and GERD vary by age.
In infants between one and six months old, the most common presentation of normal physiologic gastroesophageal reflux is regurgitation, colloquially known as “spitting up,” which is
the passive movement of gastric contents into the mouth. Reflux can also present with vomiting, which is the forceful expulsion of gastric contents using a coordinated autonomic and voluntary
motor response (1).
Reflux can also present with apneas* or apparent life-threatening events**, wheezing, chronic cough, recurrent pneumonia, and abnormal posturing known as Sandifer
**Brief Resolved Unexplained Events (Apparent Life-Threatening Events)
Updated: Feb 28, 2019
Author: Patrick L Carolan, MD from emedicine.medscape.com
Less commonly, reflux can become GERD, with consequences such as failure to thrive, feeding refusal, and back-arching due to pain.
Children and adolescents often present similarly to adults, with symptoms such as heartburn or epigastric pain. In severe cases of GERD, children may develop erosive esophagitis, which can
manifest as dysphagia or hematemesis. Extra-esophageal signs and symptoms in children can include anemia, chronic cough, wheezing, recurrent pneumonia, and dental erosions (2)
When evaluating a child for suspected GERD, it is important to consider the broad differential diagnosis for regurgitation and/or vomiting. A detailed history focusing on feeding history,
pattern of regurgitation, bowel habits, growth, and a complete review of systems, along with a physical exam, are helpful in ruling out other causes of regurgitation and/or vomiting in children. These causes include cow’s milk protein allergy, food protein induced enterocolitis syndrome, pyloric stenosis, malrotation with volvulus, intussusception, eosinophilic esophagitis, peptic ulcer disease, post-tussive emesis, increased intracranial pressure, and migraines in older children.
Red flags that require further investigation include bilious vomiting, hematemesis or hematochezia, progressively worsening forceful vomiting, failure to thrive, diarrhea or
constipation, fever or bulging fontanelle, and abdominal tenderness or distension.
Diagnosis and Investigations
For the vast majority of infants and children, a detailed history and physical examination are sufficient and further diagnostic testing is not necessary to diagnose reflux. A diagnostic evaluation should be reserved for infants and children who have red flags on history or physical exam to evaluate for other causes of regurgitation or vomiting.
While an abdominal ultrasound would not help in the diagnosis of reflux or GERD, it is diagnostic in conditions including pyloric stenosis, intussusception, or malrotation, and it should be performed if there is a high index of suspicion of these conditions. In these situations, patients would likely present with red flag symptoms such as projectile vomiting, abdominal
tenderness, or abdominal distension.
Parental education and support are usually sufficient to manage healthy infants with symptoms of physiologic reflux that have no impact on feeding or growth. Lifestyle measures that are low
risk include: avoiding overfeeding, upright positioning after feeds, and potentially adding a thickening agent for those that are bottle fed (3). In older children, helpful lifestyle changes
include maintaining a healthy weight, not eating before sleeping or exercising, and potentially elevating the head of the bed.