Gastrointestinal System - Pediatric/Paediatric Gastroesophageal/Gastro-oesophageal Reflux (GER/GOR) Disease (GERD/GORD)

Background


Gastrointestinal System - Pediatric/Paediatric Gastroesophageal/Gastro-oesophageal Reflux Disease (GERD/GORD) Background 

 

Contributors

Disease Etiology
Gastroesophageal reflux (GER) is defined as “a passage of gastric contents into the esophagus with or without regurgitation and/or vomiting” (1). The progression to gastroesophageal reflux disease (GERD) occurs when reflux results in symptoms and/or complications (2).

GERD is a multivariate disorder. The pathogenic variables that can impact one’s risk of GERD can be classified as motor abnormalities (i.e. delayed gastric emptying), anatomical factors (i.e. hiatal hernia) as well as genetic components and environmental factors (3). Other pediatric populations that are at an increased risk of GERD include individuals who have neurologic impairment, obesity, esophageal atresia, chronic lung diseases and a history of premature birth (2).
 
Screening/Diagnosis
Before diagnosing a child with GERD, it is important to rule out possible ‘red flags’, which are defined as any alternative underlying conditions that may be responsible for the patient’s symptoms (1). Table 2 in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition includes ‘red flag’ symptoms and signs suggesting a disorder other than GERD. 

Screening for GERD may be required when there is recurrent vomiting with poor weight gain, excessive crying or irritability, disturbed sleep, feeding problems or respiratory problems (2). To warrant a GERD diagnosis, a thorough history and physical examination must be obtained (2,4,5).
 
See Additional Content: 
 
When there is frequent regurgitation and/or vomiting, there are two possible diagnostic approaches to take, contingent on the child’s age (1). For infants 0-12 months, a diagnostic approach is outlined in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (Algorithm 1), which notes that acid suppression is not needed if symptoms do not alter the infant’s feeding, growth or developmental milestones. For 12 months to 18 years old, it is recommended to follow a separate diagnostic approach (Algorithm 2). 
 
It is not recommended to use salivary pepsin, extraesophageal biomarkers, manometry, scintigraphy, jejunal feeding trials, ultrasonography or barium contrast studies for the diagnosis of GERD in either infants or children (1). However, the latter two may be used to rule out possible anatomical abnormalities. For more detail, see a list of diagnostic interventions for GERD (p. 546) in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
 
Prevalence
GER is common and affects at least 40% of infants and begins around eight weeks of age (4). Approximately 5% of infants can have six or more episodes of GER per day and it usually resolves in 90% of infants before one year of age (4).
 
More than 25% of infants 0-18 months are found to present GERD symptoms daily (6). The frequency of symptoms steadily declines as the infant ages, with nearly no symptoms at 12 months of age. 
 
It should be noted that the exact global burden of GERD remains unreported and variations may occur between countries due to differences in parental tolerance of symptoms, access to health care services and heterogeneity of co-morbidities (7).  
 
There is an increased frequency and severity of GERD among children with neurologic impairment and development delay, including children with cerebral palsy, and certain genetic syndromes such as Cornelia de Lange and Down syndrome (2).  
 
Other pediatric patient populations that have increased prevalence of GERD are those with esophageal anatomic disorders and achalasia (i.e. esophageal achalasia), those with chronic respiratory disorders (including cystic fibrosis, bronchopulmonary dysplasia and idiopathic interstitial fibrosis) and premature infants (2).  
 
Symptoms
GERD symptoms are typically non-specific and vary extensively with age (1). It is difficult to make a definitive diagnosis of GERD in an infant as the symptoms of excessive crying, back-arching, regurgitation and irritability, can also be seen in infants without GERD. For older children, their symptoms usually align with those seen in adults, such as regurgitation and heartburn. 
 
Symptoms of GERD can be sorted into three categories: general, gastrointestinal and airway (1). General symptoms include refusal to feed, faltering growth and irritability. Gastrointestinal symptoms include hematemesis, regurgitation with/without vomiting and dysphagia/odynophagia. Airway symptoms include wheezing, stridor, coughing and hoarseness.

To see a full chart of symptoms and signs that may be associated with GERD, see Table 1 in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Medical Treatment 
Most infants with GER can be managed conservatively with parental education and reassurance regarding the natural course of GER in infants (2).
 
There are non-pharmacological, pharmacological, and surgical treatment options for GERD (2). The 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition includes a therapeutic algorithm that outlines the decision-making process of treatment options (1). See Algorithm 1 (for infants) and Algorithm 2 (for older children) to follow the steps of diagnosis through to treatment options. 
 
Non-Pharmacological/Nutritional Treatment 
In infants with visible regurgitation and/or vomiting and suspicion of GERD, the suggested approach is to avoid overfeeding infants by modifying the volume and frequency of feeding based on the infant’s age and weight and to thicken feeds (1). If there is no improvement and GERD continues, a change to an extensively hydrolyzed protein or amino acid-based formula is suggested for a two to four week trial. See Additional Content: What changes in formula have been shown to be effective in treating infants with gastroesophageal reflux/gastroesophageal reflux disease?
 
See additional details on the trials and recommendations for non-pharmacological treatments under Question 4 in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
 
See a Complete Summary List of non-pharmacological treatment recommendations in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
 
 
Pharmacological Treatment 
Antacids are not recommended for chronic treatment of pediatric GERD (1). In infants with typical symptoms of GERD, acid suppressants (H2RA or PPI) are suggested for a four to eight week treatment period. After this period, the efficacy of the treatment is to be evaluated. If the treatment fails, possible alternative causes (red flags) of the symptoms should be investigated (1). See Table 2 in the Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
 
Administration of H2RA or PPI is not recommended for infants with symptoms of crying, regurgitation or extraesophageal issues who are otherwise healthy (1).
 
If pharmacological treatments fail, the use of the prokinetic baclofen, exclusively as the first-line treatment, is suggested to be considered before resorting to surgery (1).
 
In consideration of effective and safe pharmacological treatment to reduce GERD symptoms, most were deemed “uncertain” (1). These include PPIs, alginates, H2RAs, Omeprazole, lansoprazole, esomeprazole, cimetidine, baclofen, domperidone, metoclopramide, bethanechol and erythromycin (1). For details on the meta-analysis and studies of these treatments, see Question 5 in the 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
 
 
Surgical Treatment
Anti-reflux surgery may be considered if the infant or child has both GERD and either: a life-threatening complication, chronic condition or need for chronic pharmacotherapy and persistent symptoms following medical management (1).
 
Esophagogastric disconnection is not recommended as a first-line surgical treatment unless it is used as a rescue procedure (1). Radiofrequency ablation or endoscopic full-thickness plication is not recommended for children with GERD symptoms unresponsive to optimal treatment.
 

Complications of GERD
There are a variety of complications that may occur because of GERD. If GERD is treated early and appropriately, these complications can be minimized or avoided (1). Complications include but are not limited to Barrett esophagus, strictures, esophageal stenosis and esophagitis.  
 
Resources for Professionals
Education materials for clients, practice guidelines and other professional tools and resources can be found under the Pediatric/Paediatric Gastroesophageal/Gastro-oesophageal Reflux (GER/GOR) (GERD/GORD) Related Tools and Resources tab. Use the Audience, Country and Language sort buttons to narrow your search.
 
References
  1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018 March;66(3):516-54. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/29470322
  2. Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2009 Oct;49(4):498-547. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/19745761
  3. Argyrou A, Legaki E, Koutserimpas C, Gazouli M, Papaconstantinou I, Gkiokas G, et al. Risk factors for gastroesophageal reflux disease and analysis of genetic contributors. World J Clin Cases. 2018 Aug;6(8):176-82. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/30148145/
  4. National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. NICE Guideline. 2015 (Last updated: 2019 Oct 19). Available from: https://www.nice.org.uk/guidance/ng1
  5. Baird DC, Harker DJ, Karmes AS. Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children. Am Fam Physician. 2015;92(8):705-14. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/26554410/
  6. Singendonk M, Goudswaard E, Langendam M, Wijk MV, Etten-Jamaludin FV, Benninga M, et al. Prevalence of Gastroesophageal Reflux Disease Symptoms in Infants and Children. J Pediatr Gastroenterol Nutr. 2019 Jun;68(6):811-7. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/31124988
  7. Badran EF, Jadcherla S. The enigma of gastroesophageal reflux disease among convalescing infants in the NICU: It is time to rethink. Int J Pediatr Adolesc Med. 2020 Mar;7(1):26-30. doi: 10.1016/j.ijpam.2020.03.001. Epub 2020 Mar 5. Erratum in: Int J Pediatr Adolesc Med. 2020 Dec;7(4):212. PMID: 32373699; PMCID: PMC7193076.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193076/

Target Group: Infant(0-2 yr.)
Knowledge Pathways: Gastrointestinal System - Pediatric/Paediatric Gastroesophageal/Gastro-oesophageal Reflux (GER/GOR) Disease (GERD/GORD)
 Last Updated: 2021-11-04


Current Contributors

 

Hannah Brown - Author

Evelyn Volders - Reviewer

Kiranjit Atwal - Reviewer

Past Contributors

 

Dawna Royall - Author

Christine Mehling - Reviewer

Joanna Drake - Reviewer

Shefali Raja - Reviewer

Susan Firus - Reviewer