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Gastroesophageal Reflux Disease in Infants

From The Child's Doctor, Spring 2007

Disclosure: Dr. Morgenstein has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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Educational objectives

At the conclusion of this activity, participants will be able to:

  • Recognize symptoms and conditions that may signal infant reflux
  • Discuss evaluation approaches
  • Select appropriate treatment

CME credit

Credit statement


Summary

Gastroesophageal reflux disease (GERD) is a common problem among infants, although frequently the symptoms are not recognized as associated with reflux. Most often infant GERD causes minimal issues, such as emesis or irritability. However in some situations, it can be quite disruptive, contributing to reactive airway, sinusitis, and failure to thrive. This article will review the symptoms of infant GERD, approaches to evaluation, and treatment options.

GERD is defined as a backward flow of stomach contents up the esophagus and sometimes into the mouth. The stomach contains hydrochloric acid, but is protected from acid injury by a mucosal lining. The esophagus, throat, nose, and lungs have no such protection. As result, with GERD, damage to the above structures can occur. It will worsen with repeated exposures. The refluxate can cause tissue edema, ulcerations, granulation, glottic scarring, especially of the posterior larynx, and ultimately airway compromise.

The refluxate can be a result of micro- or macro-aspiration, both causing chemical injury, including chemical pneumonitis. The infant laryngeal epithelium is thin and is particularly susceptible to caustic chemical injury.

Contributing to infant GERD is a short intra-abdominal esophagus and immature lower esophageal sphincter (LES), which acts as a valve at the lower end of the stomach. LES opens with swallowing, allows passage of stomach contents into the small intestine and then closes. In the normal, healthy infant, the LES pressure increases when sleeping. Also, there is a decreased frequency of swallowing. In neurologically impaired infants this physiology often is disturbed, making them predisposed to GERD. Premature infants also are at higher risk for developing GERD.

The incidence of GERD is significant. Fifty percent of newborns have reflux as a result of an immature LES. The majority of these infants have no complications, with GERD resolving spontaneously by 1 year of age. However in approximately 3% of infants with GERD, the problem can persist. It can adversely affect development, quality of life, and overall health of the infant.

Symptoms and associated conditions

The symptoms of GERD are myriad and they can be atypical. They can include spitting up, vomiting, constant or sudden crying, colic, irritability, pain, frequent hiccups, excessive drooling, chronic cough, hoarseness, and halitosis. The infant may have poor sleep habits and frequent waking. Arching of neck and back during or after eating (Sandifer syndrome) is associated with GERD, but may sometimes be confused with seizures. Other less common symptoms include refusing food or accepting only a few bites.

Anemia, recurrent ear infections, and sinusitis also may signal GERD. Other conditions associated with GERD include sleep apnea, chronic bronchitis and pneumonia, asthma, subglottic stenosis, and laryngomalacia. GERD can be aggravated by laryngomalacia as a result of increased negative intrathoracic pressure during inspiration in severe laryngomalacia patients. Also, the presence of GERD can aggravate the laryngomalacia.

In addition to airway compromise, erosion of dental enamel may occur as a complication of GERD. Reflux also may be a significant cause of failure to thrive, and may contribute to the sudden infant death syndrome (SIDS).

In some situations, during evaluation for other conditions, such as failure to thrive, esophagoscopy with biopsy may reveal the presence of “silent” GERD. In these cases, reflux is occurring, but without symptoms. The infant appears comfortable and there is no emesis, but the refluxate is getting swallowed. Potentially, silent GERD can be more damaging, since burns occur while acid goes up and comes down.

It is important to be aware of another entity known as eosinophilic esophagitis (EE), which can mimic GERD. It is found in approximately 10% to 15% of children undergoing endoscopy for GERD symptoms. EE is an eosinophilic inflammatory infiltration of the esophagus and does not respond to acid suppression treatment. Treatment includes elimination diets or amino acid-based formula. Occasionally steroids are required.

Evaluation

Obtaining a thorough, detailed history is critical. Although numerous tests can be performed to evaluate and diagnose GERD, they can be uncomfortable, expensive, and cumbersome. Often when GERD is suspected, pediatricians opt to start with empiric therapy and follow closely the patient’s response to treatment. Testing for a definitive diagnosis usually is performed in more severe cases that require hospitalization.

A pH probe over 24 hours will determine the degree and frequency of reflux. This study is considered to be the gold standard for GERD evaluation. Reflux medications must be discontinued for 48 hours before the test to obtain the most reliable results. This test is often required prior to consideration for a possible surgical treatment option.

Unfortunately, there is very little correlation between the clinical symptoms and the presence of esophagitis. A barium swallow will show anatomical abnormalities, but there is high incidence of false positives and negatives. Direct endoscopy and biopsy can occasionally be helpful. There is poor correlation between biopsy and endoscopic findings, however. Biopsies can be positive despite a normal appearance of the esophageal mucosa. Esophageal biopsy may be used to rule out silent GERD in patients with associated conditions, as in some cases with persistent middle ear effusion requiring tube insertion.

One useful method to measure the severity of reflux present is with the Reflux Findings Score (see Table 1), which is based on clinical and exam findings at laryngosocopy (see examples in Fig. 1, 2) and bronchoscopy. The score quantifies evidence of subglottic edema, ventricular obliteration, arytenoidal erythema/hyperemia, vocal fold edema, diffuse laryngeal edema, posterior commissure hypertrophy, granuloma/granulation tissue, and thick endolaryngeal mucus. A score of 11 or above is considered as evidence of reflux. The highest score of 26 indicates severe GERD.

FIGURE 1: Laryngoscopy finding showing severe hemorrhagic and edematous mucosal changes of the supraglottic and glottic area with airway compromise as an effect of reflux.

FIGURE 2: Laryngoscopy finding showing erythema on both vocal cords with small granuloma on left anterior cord as an effect of reflux.

Nuclear medicine GER/gastric emptying is often helpful as well. Tc-99 sulfur colloid mixed in 5 ounces of formula is administered. Sequential 1-minute images are obtained over 1 hour. This study measures frequency of reflux episodes over 1 hour and percentage of gastric emptying.

Treatment

There are numerous treatments for GERD. Simple lifestyle changes include keeping the infant upright and motionless for half hour after feeding. If the infant is still breast-feeding, the mother should avoid dairy, soy, wheat, nuts, spicy or acidic foods, chocolate, carbonated beverages, and peppermint. Thickening formulas with rice helps to keep the food down and reduce emesis. Small and more frequent meals also are helpful. The infant should sleep propped up and not be fed before sleeping. The full stomach will increase stomach pressure on the LES. Pacifier use also may be considered, since it can result in increased saliva production. Saliva is alkaline and may help neutralize refluxed acid.

Medications include histamine H2 receptor antagonists (acid blockers), such as ranitidine or cimetidine. Histamine binds to H2 receptors located in the parietal cells of the stomach lining, which results in acid production. H2 receptor antagonists can block the acid production.

The next family of drugs is the proton pump inhibitors, such as lansoprazole, omeprazole, iansoprazole. These drugs affect the K+/H+ATPase system in parietal cells that produce acid. They can decrease acid production by as much as 90%. This medication must be given half hour before meals.

Improvement is seen in approximately 2 weeks after the start of treatment with either medication type. Acid blockers usually are selected as first-line treatment due to cost considerations. Proton pump inhibitors can be tried if acid blockers are ineffective.

Finally, the last group includes the prokinetic/ motility agents, such as metoclopramide. They increase the speed of stomach contents emptying. They stimulate and coordinate esophageal, gastric, pyloric valve and small intestine peristalsis. They also increase LES tone and gastric contractions. Unfortunately, they can have significant adverse effects, including involuntary muscle spasms (tardive dyskinesia). These agents usually are reserved for more critically ill children who are hospitalized. The best treatment is likely a combination of proton pump inhibitors and prokinetic agents.

Surgical options are considered only for GERD that has proven resistant to aggressive, maximal medical treatment. The most commonly performed procedure is the Nissen fundoplication. The upper portion of the stomach (fundus) is wrapped around the lower portion of the esophagus. The procedure creates a more closed LES to prevent reflux, but still allows passage of food. It can be performed through open surgery, through endoscopy, and most recently robotically. The length of stay is about equal.

Nissen fundoplication is considered to be the most effective treatment for GERD, but it is not a cure and it carries the highest risk. It should be combined with G-tube placement when aspiration is a concern. The success rate is about 57% to 92%. The incidence of complications is approximately 2.3% to 45%, including complications associated with the general anesthesia, bleeding from spleen and gastric vessels, esophageal tears with resultant leakage, pneumonia, and mediastinitis. Slippage of wrap can occur resulting in failure, pain, or dysphagia. Small bowel obstruction also has been reported.

Support for the family

Although the majority of infants with GERD grow out of it without complications, the condition can cause overwhelming stress and exhaustion for the family. The infants are constantly upset, usually with piercing screams, and often are inconsolable. The family tends to experience feelings of guilt, sorrow, or disappointment. Parents may develop a sense of isolation, since these babies are frequently disruptive to people around them. The treatment of GERD is expensive, resulting in financial pressures. There are also extensive time demands with office visits, diagnostic testing and administration of medications. Sometimes anger is expressed towards the treating physician. These families require much support, understanding, and compassion from their health care providers.

FOR FURTHER READING

[1.] Sears W, Sears M. Breastfeeding the baby with gastroesophageal reflux. In: The Baby Book: Everything You Need to Know About Your Baby – from Birth to Age Two. Boston: Little, Brown; 1993.

[2.] Davenport M, Davenport T. Making Life Better for a Child with Acid Reflux. Church Hill, MD: SportWork, Inc; 2006.

[3.] Burns D, Shah N. 100 Questions & Answers About Gastroesophageal Reflux Disease (GERD): A Lahey Clinic Guide. Boston: Jones and Bartlett; 2007.

[4.] MacLean R, McNeil J. Life on the Reflux Roller Coaster: Gastroesophageal Reflux Disease in Infants and Children. Baltimore: PublishAmerica; 2003.

[5.] Silva AB. Airway manifestations of pediatric gastroesophageal reflux disease. In: Wetmore R, Muntz H, McGill T, et al. eds. Pediatric Otolaryngology: Principles and Practice Pathways. New York: Thieme; 2000:619-634.


Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this live activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.