Pediatric Reflux

Aka: Pediatric Reflux, Pediatric GERD, Pediatric Gastroesophageal Reflux, Infantile Gastroesophageal Reflux, Infant Reflux, Spitting Up, Infant Spitting Up, Acid Reflux in Children

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II. Epidemiology

  1. Regurgitation is common for infants
    1. Peak age: 4 months old
      1. Regurgitation in 40% of infants with most feedings
    2. Resolution by age 10 to 14 months
      1. Persists in 5% of infants
  2. Pediatric Reflux persists in some children
    1. Ages 3-9 years old: 2-7% Prevalence
    2. Prevalence gradually declines until age 12 years, then peaks again after age 16 years old

III. Precautions

  1. Empiric prophylaxis of Preterm Infants may not be warranted
    1. Antireflux medications evaluated in very Low Birth Weight Infants
    2. Not associated with a difference in growth or neurodevelopment
    3. Malcolm (2008) Pediatrics 121(1): 22-7 [PubMed]
  2. Mild physiologic Gastroesophageal Reflux (spitting-up) is an expected condition
    1. Best treated conservatively (e.g. upright for feeds)
    2. No evidence for significant cardiopulmonary complications
      1. No increased risk of chronic lung disease, recurrent aspiration
  3. Gastroesophageal Reflux disease is more severe than physiologic spitting-up
    1. Associated with complications such as respiratory symptoms and growth restriction

IV. Mechanism

  1. Inappropriate LES relaxation
  2. Delayed Gastric Emptying

V. Risk Factors

  1. Cerebral Palsy or Developmental Disability
  2. Down Syndrome
  3. Esophageal atresia with repair
  4. Transesophageal fistula
  5. Respiratory disease
    1. Bronchopulmonary Dysplasia
    2. Asthma
    3. Chronic Cough
    4. Cystic Fibrosis
  6. Congenital Heart Disease
  7. Congenital Hiatal Hernia
  8. Seizure Disorder
  9. Prematurity
  10. Medications
    1. Theophylline
    2. Caffeine
    3. Albuterol

VI. Findings: Symptoms and Signs

  1. Precipitating factors
    1. Frequent, large volume feedings
    2. Supine position
  2. Common
    1. Effortless Spitting Up 1-2 mouthfuls (under age 1)
    2. Irritability
  3. Uncommon
    1. Hematemesis
    2. Poor growth or poor weight gain
    3. Anemia
    4. Esophageal Stricture
    5. Respiratory disease
      1. Recurrent Pneumonia
      2. Chronic Cough
      3. Wheezing or Stridor
      4. Apnea or Cyanosis
    6. Barrett's Esophagus
  4. Rare
    1. Protein loss
    2. Sandifer Syndrome
      1. Lateral Head Tilt with contralateral chin rotation
      2. Torticollis or neck tilting in infants
      3. Distinguish from Movement Disorders (refer for evaluation)

VII. Exam

  1. Growth measurements
    1. Plot height and weight on growth curve
    2. Evaluate for Failure to Thrive
  2. Head and Neck Exam
    1. Bulging Fontanelle
    2. Microcephaly
    3. Macrocephaly
  3. Lung Exam
    1. Wheezing
    2. Respiratory distress
  4. Abdominal exam
    1. Hepatosplenomegaly
    2. Abdominal Distention or tenderness
    3. Palpable abdominal mass
  5. Neurologic Exam
    1. Neurodevelopmental abnormalities

VIII. Differential Diagnosis: Common causes

  1. Viral Gastroenteritis
  2. Cow's Milk Allergy
  3. Hiatal Hernia
  4. Infantile Colic
  5. Nongastrointestinal Infection
    1. Urinary Tract Infection
    2. Meningitis
    3. Pneumonia
    4. Sepsis
  6. Rumination Syndrome
    1. Recently swallowed food is regurgitated, chewed and re-swallowed

IX. Differential Diagnosis: Less common causes

  1. Pyloric Stenosis
  2. Intestinal Malrotation
  3. Hydrocephalus
  4. Achalasia
  5. Crohn Disease
  6. Eosinophilic Esophagitis
  7. Cyclic Vomiting Syndrome
  8. Electrolyte disturbance
    1. Renal Tubular Acidosis
    2. Hypocalcemia

X. Precautions Red Flags suggestive of alternative diagnosis

  1. Fever
  2. Bilious Vomiting (e.g. Intestinal Obstruction)
  3. Forceful Vomiting (e.g. Pyloric Stenosis)
  4. Vomiting onset after 6 months
  5. Abdominal Pain, Abdominal Distention
  6. Hepatosplenomegaly
  7. Lethargy
  8. Bulging Fontanelle
  9. Seizures
  10. Developmental Delay
  11. Microcephaly or Macrocephaly

XI. Precautions: Red Flags suggestive of more significant GERD

  1. Poor weight gain, weight loss or Failure to Thrive
  2. Feeding refusal (or prolonged feedings)
  3. Infant with postprandial irritability
  4. Dysphagia
  5. Recurrent Vomiting
  6. Chest Pain or Epigastric Pain
  7. Regurgitation or Vomiting beyond18 months of age
  8. Recurrent respiratory disease (e.g. Pneumonia)
  9. Apparent life threatening Event (ALTE)

XII. Diagnostic Tests

  1. Indications
    1. Not generally indicated in most cases
    2. Obtain in severe and refactory cases that fail empiric management or demonstrate red flags
  2. Barium Swallow (Upper GI)
    1. Poor sensitivity and Specificity for GERD
    2. Very good for identifying underlying conditions
      1. Hiatal Hernia
      2. Pyloric Stenosis
      3. Malrotation
      4. Esophageal Webs and strictures
      5. Tracheoesophageal fistula
      6. Achalasia
  3. Milk study
    1. Good to assess gastric emptying
    2. Fair for identifying Reflux
  4. pH Probe (24 hour)
    1. Gold standard for Reflux diagnosis
    2. pH probe placed in distal Esophagus
    3. pH below 4.0 suggests reflux
      1. Abnormal if esophageal pH <4 for more than 7% of the time
    4. Specific indications only
      1. Correlate reflux with respiratory symptoms
  5. Endoscopy
    1. Most sensitive test for Barrett's Esophagus
    2. Can also identify gastric outlet obstruction
  6. Manometry
    1. Can assess lower esophageal sphincter and mechanisms of Swallowing
  7. Abdominal Ultrasound
    1. Evaluates Pyloric Stenosis
    2. May identify Hiatal Hernia

XIII. Management: Step 1 Conservative Management

  1. Indications
    1. Physiologic Reflux
    2. Normal weight gain
  2. Interventions in infants
    1. Smaller, more frequent feedings
    2. Thickened Feedings
      1. Rice cereal up to 1 tablespoon per ounce formula
      2. Avoid xantham gum (e.g. SimplyThick) due to risk of Necrotizing Enterocolitis
    3. Positioning
      1. Danny Sling
      2. Position completely upright or lying on right side
      3. Prone position helpful (risk of SIDS however)
      4. Minimize seated position
        1. May worsen reflux
        2. Increases intra-abdominal pressure
    4. Consider trial of formula change to extensively hydrolyzed formula
      1. Identifies Cow's Milk Allergy
      2. Trial of casein hydrolysate formula for 2 weeks
  3. Interventions in older children and adolescents
    1. See Gastroesophageal Reflux for lifestyle management

XIV. Management: Step 2 Evaluate for Pathologic Reflux

  1. Indications
    1. Persistent regurgitation despite management in Step 1 for 2-4 weeks
    2. Poor weight gain
    3. Signs of Esophagitis or respiratory symptoms
  2. Evaluation
    1. Consider differential diagnosis (see above)
    2. Consider Upper GI Study
  3. Trial of acid suppression
    1. Approach
      1. Start with initial trial for 4 weeks (and continue for 2-3 months if effective)
    2. Precautions
      1. Avoid acid suppression when reflux is effortless, painless and does not impact growth
      2. Acid suppression is overutilized in Pediatric GERD and has significant associated risks
        1. Risk of Necrotizing Enterocolitis in preterm and Low Birth Weight Infants
        2. Associated with increased risk of Pneumonia and gastrointestinal infections
        3. Microbiome alterations on acid suppression risk of allergy, Asthma and Obesity
        4. Increased risk of Pediatric Fractures
      3. References
        1. Wolf (2023) Am Fam Physician 108(6): 614-5 [PubMed]
    3. H2 Receptor Blockers (e.g. Ranitidine, Cimetidine)
      1. See H2 Blockers for dosing
    4. Proton Pump Inhibitors (e.g. Prevacid, Prilosec, Aciphex)
      1. See Proton Pump Inhibitors for dosing
  4. Other measures to consider (avoid in most cases)
    1. Prokinetics
      1. Metoclopramide (Reglan) 1 mg/ml oral solution
        1. Dose: 0.1 to 0.2 mg/kg/dose three to four times daily
        2. Risk of Extrapyramidal Effects, Dystonic Reaction, drowsiness
        3. Not recommended due to adverse effects in over one third of patients
      2. Erythromycin (EES) 200 mg/ml
        1. Dose 1.5 to 12.5 mg/kg every 6-8 hours
        2. Very expensive, no proven efficacy, no established doses in GERD
        3. Not recommended
    2. Other gastrointestinal agents
      1. Antacid solutions (Magnesium Hydroxide, aluminum hydroxide)
        1. Magnesium Hydroxide only has been FDA approved in infants
        2. Not recommended <12 years old
        3. Risk of Milk Alkali Syndrome
      2. Sucralfate (Carafate)
        1. Dose 40-80 mg/kg/day divided every 6 hours
        2. No established dosing or efficacy in Pediatric Reflux
  5. Follow-up: Evaluate efficacy after 2-3 weeks
    1. Interventions effective: Continue for 2-3 months
    2. Interventions not effective: See Step 3 below

XV. Management: Step 3 Refractory Reflux

  1. Indications
    1. Failed management in Step 2
  2. Evaluation
    1. Pediatric Gastroenterology Consultation
    2. Consider further studies
      1. pH probe for 24 hours
      2. Endoscopy
  3. Interventions for medically Intractable disease
    1. Nissen Fundoplication

XVI. Complications

  1. Pulmonary aspiration
  2. Chronic Bronchitis
  3. Bronchiectasis

XVII. References

  1. Baird (2015) Am Fam Physician 92(8): 705-14 [PubMed]
  2. Boyle (1989) Gastroenterol Clin North Am 18:315-337 [PubMed]
  3. Faubion (1998) Mayo Clin Proc 73:166-73 [PubMed]
  4. Gauer (2014) Am Fam Physician 90(4): 244-51 [PubMed]
  5. Jung (2001) Am Fam Physician 64(11):1853-60 [PubMed]
  6. Orenstein (1999) Pediatr Rev 20:24-8 [PubMed]
  7. Tsou (1998) Otolaryngol Clin North Am 31:419-34 [PubMed]

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