Evaluation and Management of Gastro-oesophageal Reflux in infants and children
Gastro-oesophageal reflux (GOR) is defined as the passage of gastric contents into the oesophagus due to spontaneous relaxation of the lower oesophageal sphincter, whereas gastro-oesophageal reflux disease (GORD) describes the symptoms consequent upon the associated oesophagitis. Both are very common events in infants and children.
The important features in management of these conditions are:
- Differentiating GOR from GORD.
- Excluding other potential causes of symptoms
- Using appropriate investigations and management options.
Vomiting and GOR/GORD:
GOR may be seen as a physiological event in most (if not all) healthy infants, and improves spontaneously in the majority of instances. Defining when this becomes "pathological" is vital. In addition, it is important to remember that "all that vomits is not reflux". A differential to be considered should include conditions such as infections (e.g. UTI), overfeeding, and structural abnormalities.
Diagnostic approaches:
In most cases history and physical examination provide the diagnosis of GOR and management can be initiated.
Diagnostic approaches include imaging studies, oesophageal pH monitoring, oesophagoscopy and biopsy, nuclear medicine scans, and empiric medical therapy.
Treatment options:
A number of management options including diet changes, positioning and lifestyle changes are relatively simple. These options may be all that is required in physiological GOR, and can be considered first.
Acid-suppression therapy with histamine receptor antagonists (HRA's) or proton pump inhibitors (PPI's) forms the cornerstone to management of GORD because of prompt symptom relief and mucosal healing. Initial therapy can entail ranitidine at appropriate doses. PPI's provide enhanced acid suppression, superior symptom control and healing. Antacids may be used for short-term symptom relief, but should not be considered as long-term therapy because the other agents provide more convenient and safer options.
Prokinetic agents have limited roles in children with GOR/GORD. Of the agents available there is most evidence favouring cisapride. Unfortunately, there has been increasing concern regarding for cardiac arrhythmias in elderly patients with heart disease. For these reasons cisapride should only now be administered for severe GOR. Full discussion of the potential risks and benefits should be undertaken, and clear guidelines given to avoid co-administration of cisapride with contraindicated medications.
There is no clear evidence to support the use of other prokinetic agents with GOR- and, other prokinetics such as metoclopramide may have additional side effects.
Surgical treatment is required for some infants and children with GOR/GORD. Case series illustrate generally favourable outcomes. The potential risks, benefits and costs of successful prolonged medical therapy versus fundoplication have not been well studied in infants or children.
Evaluation and management
The infant with recurrent vomiting:
A thorough history and exam is usually sufficient, when there are no alarm symptoms present, to establish whether or not this is physiological reflux. In most of these infants, who are otherwise thriving, reassurance and guidance are all that is required. Thickening of formulae or a brief trial of hypoallergenic formulae may be indicated. A barium study is not always required, but should be undertaken with any suggestion of obstruction, or if symptoms become severe or prolonged. Other diagnostic tests should only be considered if there are complications (such as severe irritability or failure to gain weight).
The infant with vomiting and poor weight gain:
These children should be investigated to determine the cause of the vomiting. Tests should include a barium study and urine culture. Management should
begin with food thickening and increasing caloric intake. Acid suppression, prokinetics and assisted feeding may all be required.
The vomiting infant with irritability:
Differentials should include food intolerance, UTI and neurological conditions. These children are often difficult to manage.
The child with recurrent vomiting and regurgitation:
In otherwise normal children, who present with this symptom after 2 years of age, management options include upper endoscopy and acid suppression therapy.
Heartburn in the child or adolescent:
May be due to simple acid reflux, as in adults. Lifestyle changes and possibly a trial of an H2RA are recommended. If symptoms persist, patients should be referred for endoscopy.
Dysphagia/Odynophagia:
Endoscopy may be the best initial diagnostic test as the symptoms indicate oesophagitis.
When oesophagitis is demonstrated initial options include
lifestyle changes although acid suppression may be required.
Respiratory associations with GOR:
Some children with recurrent respiratory conditions (e.g. recurrent pneumonia, difficult to control asthma) may have underlying GOR contributing to respiratory disease. An oesophageal pH study may demonstrate increased acid exposure and patients may then respond to prolonged acid suppression. Hoarseness and sore throat may be related to GOR in some individuals.
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