Gastroesophageal reflux

Gastroesophageal reflux in children: an updated review

Background

Gastroesophageal reflux is a common disorder in pediatrics. Clinicians should be familiar with the proper evaluation and management of this condition.

Objective

To provide an update on the current understanding, evaluation, and management of gastroesophageal reflux in children.

Methods

A PubMed search was performed with Clinical Queries using the key term ‘gastroesophageal reflux’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to the English literature and the pediatric age group.

Results

Regurgitation is the most frequent symptom of gastroesophageal reflux and is present in nearly all cases. Gastroesophageal reflux occurs normally in infants, is often physiological, peaks at 4 months of age, and tends to resolve with time. Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce troublesome symptom(s) and/or complication(s). A thorough clinical history and a thorough physical examination are usually adequate for diagnosis. When the diagnosis is ambiguous, diagnostic studies may be warranted. A combined esophageal pH monitoring and multichannel intraluminal esophageal electrical impedance device is the gold standard for the diagnosis of gastroesophageal reflux disease if the diagnosis is in doubt. In the majority of cases, no treatment is necessary for gastroesophageal reflux apart from reassurance of the benign nature of the condition. Treatment options for gastroesophageal reflux disease are discussed.

Conclusion

In most cases, no treatment is necessary for gastroesophageal reflux apart from reassurance because the condition is benign and self-limiting. Thickened feedings, postural therapy, and lifestyle changes should be considered if the regurgitation is frequent and problematic. Pharmacotherapy should be considered in the treatment of more severe gastroesophageal reflux disease for patients who do not respond to conservative measures. Proton pump inhibitors are favored over H₂-receptor antagonists because of their superior efficacy. Antireflux surgery is indicated for patients with significant gastroesophageal reflux disease who are resistant to medical therapy.

Effects of Anesthesia on Pediatric pH Impedance

OBJECTIVES

Anesthesia can alter gastric and small intestinal motility, but its effect on gastroesophageal reflux (GER) is unclear. We set out to evaluate the effect of anesthesia on pH-multichannel intraluminal impedance (pH impedance) evaluation of GER.

METHODS

Retrospective single-center analysis of 95 pH impedance probe studies performed in patients both with anesthesia exposure and esophagogastroduodenoscopy (n = 50) and without (n = 45).

RESULTS

Increased acid reflux per hour, nonacid reflux per hour, and total reflux per hour were observed in the first 4 hours, both overall and in children 1 year or older and in both sedation groups. This difference remained for the older children without sedation by multiple regression analysis for nonacid reflux per hour and total reflux per hour. Patients using proton pump inhibitors had more nonacid reflux events per hour and total reflux events per hour regardless of sedation.

CONCLUSIONS

Based on the results of the present study, there is no need to eliminate the data collected immediately after placement of the probe in children younger than 1 year of age, but in those who are 1 year or older without sedation, there may be a greater number of reflux events in the first 4 hours. The first 4 hours, therefore, should be carefully evaluated in patients older than 1 year of age. Further study is needed to provide normative data for the first 4 hours versus the later time period, both for those undergoing sedation and for unsedated patients, to validate the findings from the present study and to better understand the mechanism of GER.

Gastroesophageal reflux in the 21st century

PURPOSE OF REVIEW

Gastroesophageal reflux (GER) remains a common, challenging problem for clinicians, with differentiation of normal development from disease a particular issue. This review updates clinicians on advances in diagnosis of GER, relationship to other problems, and current practice in management.

RECENT FINDINGS

Development and understanding of multichannel intraluminal impedance-pH monitoring has given insights into the relationship of GER to symptoms. Medical treatment has changed little. Avoidance of overmedicalizing normal development is the major issue for clinicians. Laparoscopic fundoplication is established as equivalent to open fundoplication. Newer endoscopic techniques have only limited use in children to date.

SUMMARY

Major changes in pediatric GER relate to understanding of physiology and relationship of GER to symptoms. The major challenge for clinicians involve differentiation of normal from abnormal GER, and applying the most relevant management.

Chronic cough in children

The management of chronic cough, a common complaint in children, is challenging for most health care professionals. Millions of dollars are spent every year on unnecessary testing and treatment. A rational approach based on a detailed interview and a thorough physical examination guides further intervention and management. Inexpensive and simple homemade syrups based on dark honey have proved to be an effective measure when dealing with cough in children.