GERD in Infants and Children

• Gastroesophageal reflux disease (GERD) is discussed, focusing on infants and children
• The presentation covers a GERD definition and objectives in children.

Objectives Overview

• Differentiate between gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) in infants and children
• Review the prevalence, age-based symptoms, and signs of GER in children
• Understand GERD's pathophysiology and potential complications
• Distinguish GERD from other conditions that mimic its symptoms
• Review GER and GERD diagnosis and management in children
• Briefly overview erosive esophagitis management in children

Case Studies

• Case 1: A 4-week-old infant spits up frequently after feeding but is otherwise well; the appropriate step is to educate and reassure parents
• Case 2: A 6-week-old infant vomits since birth, with suboptimal weight gain and irritability; consider partially hydrolyzed formula
• Case 3: A 14-year-old male with heartburn and intermittent vomiting, with a normal exam except for being overweight, consider lifestyle modifications and a PPI for 2-4 weeks
• Case 4: A 16-year-old male with dysphagia for one year, a history of allergies; investigate with barium study and manometry before a referral

GER/GERD Definition

• It's important to differentiate between GER and GERD
• GER is the retrograde passage of gastric contents into the esophagus or oropharynx, with or without regurgitation or vomiting, is often postprandial, and doesn't cause harm
• GERD is the retrograde passage of gastric contents into the esophagus, resulting in troublesome symptoms or complications like esophagitis or stricture

Refractory GERD, Regurgitation, and NERD

• Refractory GERD is GERD unresponsive to optimal therapy, like a PPI for 4-8 weeks
• Regurgitation is effortless, non-bilious gastric content passage into the pharynx or mouth
• 70-85% of infants regurgitate within the first 2 months of life, which is considered physiological
• Regurgitation typically resolves spontaneously in 95% of infants by age 1
• Non-erosive reflux disease (NERD) involves troublesome symptoms with a normal gastroscopy

Rumination, Regurgitation, and Vomiting

• Rumination involves effortless regurgitation of recently ingested food into the mouth, followed by re-chewing and re-swallowing
• Rumination is more common in children with neurological impairment and is increasingly recognized in older children and adolescents with eating disorders
• Food allergy in infants is often mistaken for GER, suggesting a protein hydrolysate formula or amino-acid based formula
• Bilious vomiting is not GERD, but suggests an obstruction such as pyloric stenosis or malrotation

Definitions

• GERD: Reflux of gastric contents causing troublesome symptoms with or without complications
• Troublesome symptoms: GER symptoms adversely affecting a patient's well-being
• Troublesome dysphagia: Older children and adolescents changing eating patterns or reporting food impaction
• Regurgitation: refluxed contents into the pharynx, mouth, or from the mouth
• Heartburn: A burning sensation in the retrosternal area in older children and adolescents
• Non-erosive reflux disease: Troublesome symptoms caused by reflux with no mucosal breaks during endoscopy
• Reflux esophagitis: Visible breaks of the distal esophageal mucosa during endoscopy
• Reflux stricture: Persistent luminal narrowing of the esophagus caused by GERD
• Endoscopically Suspected Esophageal Metaplasia (ESEM): Endoscopic findings suggestive of Barrett's esophagus

Prevalence of GER in Children

• An increase in the global prevalence of GER, along with medication use
• Prevalence varies globally
• GER prevalence in children is about 5-7%, compared to 25% in adults

Age-Based Symptoms of GER

• Symptoms of GER are diverse and age-dependent
• Infants: regurgitation and food refusal are common
• 1-6 years: regurgitation and abdominal pain (7.2%) are typical
• 6-17 years: regurgitation (8.2%), heartburn (5.2%), vomiting, and epigastric pain (5%) are observed
• Adults: heartburn and regurgitation

Natural History of GER

• Spitting up or regurgitation is physiologic in up to 60-70% of infants and resolves without intervention in 95% of infants by 12-14 months
• Peak prevalence of GER in infancy is 41% at 3-4 months
• 21% have symptoms at 7-9 months
• Symptoms resolve spontaneously in 60% of infants by 6 months and in 90% by 8-10 months

Symptoms and Signs of GERD in Infants and Children

• General symptoms may include discomfort/irritability, failure to thrive, feeding refusal, and dystonic neck posturing (Sandifer syndrome)
• Gastrointestinal symptoms include regurgitation with or without vomiting, heartburn/chest pain, epigastric pain, hematemesis, and dysphagia/odynophagia
• Airway symptoms include wheezing, stridor, cough, and hoarseness
• General signs includes dental erosion and anemia
• Gastrointestinal signs include esophagitis, esophageal stricture, and Barrett's esophagus
• Airway signs include apnea spells, asthma, recurrent pneumonia (associated with aspiration), and recurrent otitis media.

Gastroesophageal Reflux Symptoms

• Symptoms encompass esophageal and extra-esophageal manifestations
• Esophageal symptoms: heartburn, regurgitation, waterbrash, globus, vomiting, epigastric pain, dysphasia
• Extra-esophageal symptoms: cough, sore throat, laryngitis, otitis media, dental erosions, Sandifer syndrome, asthma, apnea, ALTE, chest pain
• Sandifer syndrome is a specific presentation of GER in infancy characterized by spasmodic torsional dystonia with back arching and opisthotonic posturing

Pathophysiology of GER

• Primary mechanisms include transient LES relaxation (TLESR) and impaired esophageal clearance
• Secondary mechanisms include increased intra-abdominal pressure, decreased gastric compliance, delayed gastric emptying, and reduced esophageal compliance

Complications of GERD

• Erosive esophagitis (mucosal breaks)
• Esophageal stricture (late presentation)
• Barrett's esophagus includes endoscopically suspected esophageal metaplasia and replacement of esophageal squamous epithelium
• Adenocarcinoma

Signs of Complicated GERD

• Poor weight gain, excessive crying or irritability, anemia, dysphagia, feeding problems, respiratory issues

Risk Factors for Severe GERD

• Neurologic impairment like cerebral palsy and genetic syndromes
• Neurologic impairment (cerebral palsy)
• Some genetic syndromes such as Cornelia de Lange syndrome
• Congenital esophageal abnormalities which may include esophageal atresia
• Hiatal hernia, obesity and family history of GERD

Masqueraders of GER

• Gastroesophageal reflux (GER)
• Food allergy
• Infections (viral gastroenteritis, UTI, meningitis)
• Eosinophilic esophagitis (EE): may cause vomiting and dysphagia
• Gl Obstruction
• Gl disorders
• Metabolic/Endocrine
• Toxic Ingestion

Red Flags for Diagnosis

• Warning signs suggesting a non-GER diagnosis
• The frequency and amount of emesis
• Failure to thrive with known genetic or metabolic syndromes
• Bilious emesis or hematemesis plus forceful/projectile vomiting
• Associated lethargy
• Associated fever
• Bulging fontanelle, micro or macrocephaly, hepatosplenomegaly; sleep history, presence of nocturnal symptoms, onset of symptoms at less than 1 week and after 6 months of age

Diagnosing GER in Children

• GER is usually diagnosed by clinical symptoms
• Most patients should be diagnosed at the primary care level, using history and physical examination to rule out red flags
• Validated symptom questionnaires for GERD in children have not been validated

Diet/Feeding, Medical, Family History

• Accurate formula preparation should be ensured, along with the amount and frequency of feeding to prevent overfeeding.
• Dietary history
• Positioning techniques during feeding
• Burping practices
• Observation of feeding behavior and intolerance of certain formulas and food
• Medical history should be recorded
• Family history and medication

Clinical History

• Regurgitation and vomiting, and if there are no warning signs
• Educate patients about unexplained crying
• Detailed feeding history for failure to thrive

GER in Children

• Challenges in diagnosis due to variable symptoms, low sensitivity/specificity, and unreliable symptoms in children under 8 years old
• Adolescents can be diagnosed with clinical symptoms

Diagnostic testing for GER

• Useful in diagnosing anatomical abnormalities, or motility disorders
• Not useful in detecting GER
• Esophageal manometry also can be effective in detecting motor disorders
• Multi-channel intraluminal impedance testing is helpful in detecting GER.

Intervention

• Primary prevention strategies for infants with GER is positioning and thickening the formula and formula changes
• To avoid the usage of tobacco, you must implement conservative methods.

Management of Erosive Esophagitis and GERD

• GERD can cause inflammation, so consider methods on how to manage inflammation of the esophagus.
• If symptom control is inadequate with PPI/Histamine combinations, increased the dosage.