Pediatric Gastroesophageal

Reflux Disease

Case Report

Loren M. Bellows

R1 – Pediatrics

Case Presentation: History• 7 mo white male cc frequent

regurgitation and wheezing x 2 months

• Wheezing prominent in AM• Regurgitation of bilious

mixture postprandially• Occ arches back while

feeding• Diet: 24oz Similac Soy q d,

rice cereal bid, 2 oz fruit or veg

Case Presentation: History• Mother Denies: fever,

diarrhea, rigors, lethargy• PMH: RAD at 4mo, C-section

3w pre-term, poor weight gain

• Meds: Albuterol syrup for RAD; mother denies improvement of sx

• FH: no Asthma, CF, allergies• SH: no smoke or resp.

irritants

Case Presentation: Physical Exam

• Irritable, slightly pale, app. Smaller and younger than age

• Pulm: Intermittent stridor, no retractions or grunting

• Spit-up twice while in exam room

• Remainder: unremarkable

Patient Dx and Rx• Dx: Gastroesophageal Reflux

Disease (GERD)– No Diagnostic Tests at this time

• Rx:– Nonpharmacologic

• Dec. volume of feeding, feeding more frequently, thickening formula with rice cereal, keeping infant upright q 30 min postprandially

– Pharmacologic• Ranitidine (Zantac) 5mg/kg/day orally

divided into 2 doses.• Continue Albuterol syrup, prn

• Follow-Up:– No official f/u; mother instructed to

call if sx not resolving or worsening.

Pediatric GERD Epidemiology

• Up to 4 of 10 infants under 6mo (Ferri et al, 2006)

• Becomes less common as GI system matures; 5% of infants spit up regularly after 12mo (Ferri et al, 2006)

• Most cases are benign, very few (3/1000) cases are significant w/ risk of complications (Ferri et al, 2006)

Pediatric GERD Etiology

• Sx or complications that may result from the passage of gastric materials from the stomach into the esophagus or oropharynx (Gold, 2004)

• Cause in children: unknown, but may be associated w/ genetic predisposition, premature birth, diet (Ferri et al, 2006)

Pediatric GERD Pathophysiology• Loss of esophogastric pressure gradient

due to:– Delay in neurologic maturation– Insufficient or abnormal LES tone– Spontaneous reductions in sphincter pressure– Changes in abdominal pressure from crying,

coughing, defecating (Ferri et al, 2006)

• Symptom Complex severity depends on:– Frequency and duration of reflux episodes– Cause of acid regurgitation– Susceptibility of esophagus to damage– Aspiration of refluxed gastric contents

(Orenstein et al, 2004)

Pediatric GERD: Diagnosis• Generally Hx and PE sufficient along w/ positive

response to Rx (Ferri et al, 2006)• Typical Presentation in infants:

– Recurrent vomiting– Inability to gain weight– Irritability associated w/ feeding (Gold, 2004)

• Typical Presentation in children & adolescents– AM nausea or abdominal discomfort– Heartburn, “spit-up” burps that burn, substernal pain– Recurrent vomiting (Gold, 2004)

• Tests occasionally used:– Upper GI series using Barium Contrast– Nuclear Scintiscan– Esophageal pH monitor

• Differential Dx– Excessive feeding, Viral Gastroenteritis, food

allergies/intolerances, enzyme deficiencies, anatomical abnormalities, colic, viral URI, asthma (Ferri et al, 2006)

Pediatric GERD Complications

• Common– Malnutrition– Failure to thrive– Anemia– Bronchospasm– Recurrent

pneumonia– Chronic coughing /

wheezing– Sleep apnea

• Rare– Erosive

Esophagitis– Barrett

esophagus– Severe Adult

GERD

Ferri et al, 2006 / Gold, 2004

Pediatric GERD Treatment• Goals of Rx

– Relieve Sx, promote normal growth, heal damage and inflammation, prevent complications

• Nonpharmacologic– Thickening feeds, decreased volume of feeds,

avoidance of carbonated / caffeinated beverages and smoke exposure, elevation of the head during feedings and 30 minutes postprandially

• Pharmacologic– Antacids: sporadic Sx or w/ diarrhea or constipation– H-2 receptor antagonists if esophagitis suspected– PPI’s suppress acid and aid healing– Metoclopramide

• Surgical– Fundoplication (RARE)

ReferencesOrenstein, S, Peters, J, Khan, S, Youssef, N, & Hussain, S. Chapter 204 - Gastroesophageal Reflux Disease (GERD). Behrman: Nelson Textbook of Pediatrics, 2004; http://www.mdconsult.com/das/book/body/72415925-6/591323078/1175/151.html?SEQNO=1 .

• Ferri, F, McIntire, S, Sheehan, D, & Ibia, E. Gastroesophageal reflux in children. 2006;http://www.firstconsult.com/fc_home/members/?urn=com.firstconsult/1/101/1016309@th_884957::ah_884957 .

• Gold, B. Gastroesophageal reflux disease: Could intervention in childhood reduce the risk of later complications? American Journal of Medicine Supplements, 2004; http://www.mdconsult.com/das/article/body/72415925-7/jorg=journal&source=MI&sp=15052092&sid=592056777/N/441810/1.html