Gastroesophageal Reflux Disease in Children

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Gastroesophageal Reflux Disease in Children

Pediatric Otolaryngology
Author Credentials 

Ericka King, MD
Assistant Professor
Department of Otolaryngology-Head and Neck Surgery
Oregon Health and Science University
Portland, OR
Kinger@ohsu.edu

Module Summary

Gastroesophageal reflux (GERD) is extremely common in the pediatric patients, with a wide range of clinical manifestations.  Particularly in infants, it is so prevalent that it can be difficult to distinguish physiologic reflux from a pathologic process. Extraesophageal manifestations of reflux are commonly reported but poorly studied. Systematic clinical evaluation will help identify those patients with GERD which will most greatly benefit from treatment.

Module Learning Objectives 
  1. Describe the difference between physiologic and pathologic reflux in children. 
  2. Review the role of the esophageal sphincters, intrinsic mucosal protection, and elements of refluxate in the pathogenesis of GERD. 
  3. Identify signs and symptoms of GERD in children. 
  4. Appropriately order studies to assess reflux when needed. 
  5. Describe treatment options for GERD, including risks and benefits of each. 
  6. Recognize when to consider referral for surgical treatment of GERD. 

Embryology

Learning Objectives 

Understand the embryologic development of the esophagus and upper aerodigestive tract.

References 
  1. Kuo B, Urma D. Esophagus – anatomy and development. GI Motility. Published online May, 2006. Accessed on June 1, 2018. 

Anatomy

Learning Objectives 

Describe the anatomy of the upper and lower esophageal sphincters.

References 
  1. Kuo B, Urma D. Esophagus – anatomy and development. GI Motility. Published online May, 2006. Accessed on June 1, 2018. 

Pathogenesis

Learning Objectives 

Describe how transient lower esophageal sphincter relaxation (TLESRs), primary and secondary esophageal peristalsis, gastric emptying, and refluxate composition contribute to create pathologic GERD.

References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.
  2. De Giorgi F et al. Pathophysiology of gastro-oesophageal reflux disease. Acta Otorhinolaryngol Ital. 2006;26(5):241-6.

Basic Science

Learning Objectives 

Describe the mechanism by which pepsin may cause damage to the epithelial cells in the upper aerodigestive tract.

References 
  1. Johnston N, Wells CW, Samuels TL, Blumin JH. Rationale for targeting pepsin in the treatment of reflux. Ann Otol Rhinol Laryngol. 2010;119(8):547-58.

Incidence

Learning Objectives 
  1. Understand the incidence of physiologic reflux vs pathologic GERD in infants.
  2. Discuss otolaryngologic manifestations of GERD in children.
References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.
  2. Tolia V, Vandenplas Y. Systematic review: the estra-oesophageal symptoms of gastro-oesophageal reflux disease in children. Aliment Pharmacol Ther. 2009;29(3):258-72.
  3. Abu Jawdeh EG, Martin RJ. Neonatal apnea and gastroesophageal reflux (GER): is there a problem? Early Hum Dev. 2013;89 Suppl 1:S14-6.

Patient Evaluation

Learning Objectives 
  1. Recognize the common symptoms of reflux in infants, and when to be concerned regarding pathologic GERD.
  2. List the diagnostic modalities available to evaluate GERD in children, and the limitations of each.
  3. Assess the role of laryngoscopy and endoscopy in assessing GERD, and in ruling out alternative diagnoses.
References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.
  2. Fosen R et al. The edematous and erythematous airway does not denote pathologic gastroesophageal reflux. J Pediatr. 2017;183:127-31.
  3. Goldani HAS, Nunes DLA, Ferreira CT. Managing gastroesophageal reflux disease in children: the role of endoscopy. World J Gastrointest Endosc. 2012;4(8):339-46.
  4. Vela MF. Diagnostic work-up of GERD. Gastrointest Endosc Clin N Am. 2014;24(4):655-66.

Imaging

Learning Objectives 
  1. Discuss the role of sensitivity and specificity of esophagram for the diagnosis of GERD.
  2. Describe scintigraphy and its role in the diagnosis of aerodigestive manifestations of GERD.
References 
  1. Bar-Sever Z. Scintigraphic evaluation of gastroesophageal reflux and pulmonary aspiration in children. Sem Nuc Med. 2017;47(3):275-85.
  2. Saleh CMG, Smout AJPM, Bredenoord AJ. The diagnosis of gastro-esophageal reflux disease cannot be made with barium esophagograms. Neurogastroenterol Motil. 2015;27(2):195-200.

Pathology

Learning Objectives 
  1. Describe the grading of esphagogastroduodenoscopy findings in GERD, and understand the differences in histologic findings between children and adults.
  2. List the endoscopic features typical of esonophilic esophagitis, and contrast them with those associated with GERD.
References 
  1. Goldani HAS, Nunes DLA, Ferreira CT. Managing gastroesophageal reflux disease in children: the role of endoscopy. World J Gastrointest Endosc. 2012;4(8):339-46.

Treatment

Learning Objectives 

Describe lifestyle modifications that can be made to treat GERD in children, including changes in diet and positioning. 

References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.
  2. Vandenplas Y. Management of paediatric GERD. Nat Rev Gastroenterol Hepatol. 2014;11(3):147-57.
  3. Lightdale JR, Gremse DA. Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013;131(5):e1684-95.

Medical Therapies

Learning Objectives 
  1. List the pharmacologic options available to treat GERD in children. 
  2. Discuss the mechanism by which prokinetic agents may improve GERD, as well as their efficacy and adverse effects. 
  3. Contrast the mechanisms of action of H2 blockers and proton-pump inhibitors. 
  4. Compare the efficacy of proton pump inhibitors in infants vs older children. 
  5. Discuss the role of alginate preparations in controlling reflux symptoms in infants. 
References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.
  2. Orenstein SR et al. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr. 2009;154(4):514-20.
  3. Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Pharmacological treatment of children with gastro-oesophageal reflux. Cochrane Database Syst Rev. 2014;24(11):CD008550.

Pharmacology

Learning Objectives 

Describe how you would counsel a family about the risks of H2 blockers and proton pump inhibitors in infants.

References 
  1. Cohen S, de Mesquita MB, Mimouni FB. Adverse effects reported in the use of gastroesophageal reflux diseases treatments in children: a 10 years literature review. Br J Clin Pharmacol. 2015;80(2):200-8.
  2. Chung EY, Yardley J. Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013;3(1):16-23.

Surgical Therapies

Learning Objectives 
  1. Discuss when you would consider referring a child with GERD for anti-reflux surgery.
  2. Describe the surgical options available to treat GERD in children.
References 
  1. Sidwa F, Moore AL, Alligood E, Fisichella PM. Surgical treatment of extraesophageal manifestations of gastroesophageal reflux disease. World J Surg. 2017 Oct;41(10):2566-2571.
  2. Barnhart DC. Gastroesophageal reflux disease in children. Semin Pediatr Surg. 2016;25(4):212-8.
  3. Vandenplas Y. Management of paediatric GERD. Nat Rev Gastroenterol Hepatol. 2014;11(3):147-57.

Case Studies

  1. A 6-week-old girl presents to your office with 4 weeks of worsening stridor while lying supine, frequent spitting up with arching and fussiness, and concern for apneic spells with sleep. She is gaining weight well. Flexible laryngoscopy demonstrates an omega-shaped epiglottis, redundant arytenoid tissue prolapsing into the airway, shortened aryepiglottic folds, and severe edema of the interarytenoid and postcricoid mucosa. Is reflux playing a role in her presentation? Would you recommend a course of antireflux therapy, and if so, what would you recommend and how would you counsel the family?
  2. A 12-year-old male with a history of spitting up in infancy presents to the emergency department with difficulty swallowing solids for 1 week, and inability to take oral liquids for 1 day. Chest x ray is unremarkable. A swallow study demonstrates narrowing of the fluid column in the mid esophagus. What is your differential diagnosis? What is the next step in management?

Complications

Learning Objectives 

Identify the complications of untreated GERD in children.

References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.

Review

Review Questions 
  1. What are the extraesophageal manifestations of GERD in infants?
  2. What is the role of empiric proton pump inhibitor treatment for excessive fussiness in newborns?
  3. What is the best study to confirm a diagnosis of GERD in children?
  4. Why is cisapride no longer recommended in the treatment of GERD in children?
  5. When should you consider surgical treatment for GERD in children?
References 
  1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Pediatr Drugs. 2013;15:19-27.
  2. Orenstein SR et al. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr. 2009;154(4):514-20.
  3. Vandenplas Y. Management of paediatric GERD. Nat Rev Gastroenterol Hepatol. 2014;11(3):147-57.
Resources 

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