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Chapter 16

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  • Definitions: Gastroesophageal reflux (GER) is normal passage of gastric contents into the esophagus; GERD consists of symptoms and complications of GER; rumination is voluntary habitual regurgitation of gastric contents into the mouth for self-stimulation.
    • Complications of GERD can be divided into three systems: Respiratory (asthma and /chronic cough, apnea and ALTE, recurrent aspiration pneumonia), ENT (hoarseness, laryngitis, sinusitis, dental erosions, recurrent OM), and GI (esophagitis, esophageal ulcers, esophageal strictures, Barrett's esophagus).
  • Prevalence of GER: 50% in infants age 0–3 mo; 67% in children age 4 mo; 5% of children age 10–12 mo; 1.4–8.2% in children age 3–17 yr (Arch Pediatr Adolesc Med. 1997;151:569). The prevalence of GERD is unknown.
  • Diagnosis
    • History and physical exam: A thorough H&P is sufficient for diagnosis. The clinical presentation is based on the age of the child:
      • Infants and young children present with recurrent vomiting, arching of the back during feeds (Sandifer syndrome), irritability, and poor weight gain (2° to vomiting or dysphagia). Some present with wheezing or chronic cough, recurrent pneumonia, upper airway symptoms (eg, recurrent stridor), apnea, or ALTE.
      • Older children and adolescents present with heartburn or retrosternal chest pain and regurgitation. Some present with dysphagia, hoarseness of the voice, weight loss, anemia, wheezing or chronic cough, recurrent pneumonia, food impaction, and Barrett's esophagus (rare).
      • History: Ask for details of meals (type, volume and frequency), recent change in appetite, reflux symptoms after feeding (regurgitation, pain, irritable, dyspepsia), presence of blood or bile, force of reflux, blood in the stool, trends in weight gain. Social history: Tobacco or alcohol use, psychological factors (eg, stressors, anxiety, depression). PMH: of eczema, neurologic issues (↑ or ↓ tone, hydrocephalus, presence of shunt), prematurity, surgery, ENT disease. Family history: Helicobacter pylori infection, reflux, atopic disease.
      • Signs suggesting non-GER cause of vomiting: Bilious or forceful vomiting, GI bleeding, diarrhea, constipation, abdominal pain or distension, fever, lethargy, HSM, seizures, micro- or macrocephaly, FTT, genetic d/o (trisomy 21), other chronic diseases (eg, HIV).
    • Laboratory studies/evaluation: None are required for the diagnosis of GERD. Consider H. pylori stool antigen testing for children and adolescents if the patient c/o abdominal pain ± dyspepsia or vomiting. In unclear cases, consider UGI to r/o anatomical abnormalities, esophageal pH monitoring or multichannel intraluminal impedance may be used to correlate reflux with symptoms; esophagoscopy may be used for complications (strictures, esophagitis) and to rule out anatomic abnormalities.
  • Treatment
    • Physiological GER: Reassurance
    • GERD in infants:
      • Step 1: Thicken formula or breast milk with rice cereal (add 1 Tbsp/oz of formula), reflux precautions (ie, sleeping supine at a 30- to 45-degree angle, small frequent feeds, frequent burping, maintain upright position for 30 min after feeding).
      • Step 2: If step 1 interventions fail, add pharmacologic therapy:
        • H2R antagonist (eg, ranitidine) or PPI (eg, lansoprazole; not currently FDA approved). PPIs are more effective at acid suppression and are most effective if given 30 min before morning feeds.
        • Surface agents (eg, sucralfate, sodium alginate) help protect ulcerated gastric mucosa. Consider use in infants with esophagitis or ulcers.
        • ...

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