GERD in Infants & Children
Vomiting is the most common symptom of gastroesophageal reflux in infants.
During the first 3 months of life, recurrent vomiting occurs in 50% of infants.
The incidence of recurrent vomiting peaks at age 4 months. The presence of
associated symptoms such as anemia, irritability, feeding resistance, hematemesis
or failure to thrive indistinguishes GERD from physiologic reflux.
Less than 5% of infants with GERD carry this problem into their childhood.
Symptoms of GERD in pre-school children include intermittent vomiting, abdominal
pain, unexplained nighttime awakening, feeding resistance, or respiratory symptoms.
Older children and adolescents with GERD exhibit symptoms similar to those
experienced by adults such as heartburn, epigastric pain, chest pain, nocturnal
pain, dysphagia, odynophagia, or waterbrash. Erosive esophagitis can lead to
anemia, hypoalbuminemia, hematemesis, and melena. Barrett's esophagus may also
occur in children.
Diagnostic Evaluation of GERD in Pediatrics
The upper gastrointestinal series (UGI) is useful to detect anatomic abnormalities
in children with vomiting such as pyloric stenosis, malrotation, hiatal hernia,
antral web, or esophageal stricture.
Esophageal pH monitoring is valuable in evaluating the correlation between
acid reflux and atypical symptoms of GERD in infants and children such as chronic
cough, stridor, wheezing, apnea, and irritability.
Esophagoscopy with biopsy is an
accurate way to diagnose reflux esophagitis in infants and children. However,
numbers of eosinophils
in the esophageal epithelium (>15 eosinophils/hpf) suggest the diagnosis
of eosinophilic esophagitis. In infants, eosinophilic esophagitis is commonly
associated with milk protein allergy and may not respond well to acid suppressant
As in adults, treatment options for pediatric GERD include lifestyle changes,
pharmacological, and surgery.
Lifestyle changes in infants include alterations in formula composition and
infant feeding techniques, while in adolescent lifestyle changes are similar
to adult patients such as dietary modification, weight reduction, avoidance
of alcohol and smoking cessation.
The risk of life-threatening respiratory symptoms associated with GERD is
greater in infants than older children and may be an indication for surgery.
Feeding Changes in Infants
Elimination of cow's milk in the diet of infants with cow's protein milk allergy
reduces vomiting within 24 hours. So one to two weeks trial of a change in
formula from Enfamil or Similac to a casein hydrolysate formula such as Alimentum,
Nutramigen, or Pregestimil in formula fed infants with vomiting is suggested.
There are no studies to evaluate the effect of a soy protein formula such as
Isomil or Prosobe or a lactose- free formula for this condition.
In infants with protein intolerance to casein hydrolysate change to an amino
acid-based formula such as NeoCate or EleCare may be required before symptoms
Thickening the formula with one tablespoon of rice cereal to 2-4 ounces of
formula decreases vomiting without changing 24 hour pH monitoring results.
The hole in the nipple will need to be enlarged.
Holding the infant in a head-elevated position by placing the infant's head
on the shoulder for 20-30 minutes after feeding before putting infant in a
supine or semi-supine position may reduce GERD. In older children GERD is decreased
in the left lateral decubitus (left side down), and elevating head of the bed
The prognosis of infants with uncomplicated GERD is excellent as symptoms
resolve by age 12 months in these patients.
Benefits of Breastfeeding for Infants with Reflux
"Breastfed babies with reflux have been shown to have fewer and less
severe reflux episodes than their artificially fed counterparts. Some breastfed
babies with reflux have few symptoms. Human milk is more easily digested than
formula and is emptied from the stomach twice as quickly. This is important
since any delay in stomach emptying can aggravate reflux. The less time the
milk spends in the stomach, the fewer opportunities for it to back up into
the esophagus. Human milk may also be less irritating to the esophagus than
artificial formulas." Breastfeeding the Baby with Reflux, La Leche League
Sensitivity or allergy to cow's milk protein can contribute to reflux. In order
to determine if the breastfed baby is sensitive to cow's milk protein, the
mother avoids all forms of cow's milk protein for two weeks (including milk,
yogurt, ice cream, cheese, butter, casein and whey). If the baby seems to
be feeling better, it is best for the mother to continue to avoid all dairy
products. The mother may need suggestions for dietary sources of calcium
other than dairy. Some mothers find they can eat very small amounts of dairy
products without the baby becoming symptomatic, while in other cases any
amount of dairy in the mother's diet will trigger symptoms in the baby.
Also, with regard to thickening feed for breastfeeding babies, this is not
"Too early introduction of solid foods interferes with breastfeeding
by replacing human milk in the baby's diet and decreasing the mother's milk
supply. It may also endanger the baby by making it possible for solids to be
regurgitated, which are irritating to the body's tissues and can be aspirated
into the baby's lungs. Solids also have the potential to trigger allergies
in an already sensitive baby." The Breastfeeding Answer Book, Mohrbacher,
N. and Stock, J, 2003, La Leche League International
Pharmacological Therapy in Pediatric GERD
In infants and children who remain symptomatic in site of dietary and lifestyle
modifications trial of medications specially H2-RAs is recommended. Infants
with recurrent vomiting, irritability, failure to thrive PPIs or increasing
PPI dose may be required. If the diagnostic studies are normal and there is
no response to therapy, it is unlikely that GERD is the cause of symptoms.
Antacids in Pediatric GERD is generally not recommended for long term treatment.
Significant aluminum absorption from antacid use can occur in infants approaching
levels reported to cause osteopenia and neurotoxicity.
Prokinetic therapy, with the exception
of Cisapride there is insufficient evidence that other prokinetic agent like
is effective in
the treatment of GERD in infants and children. Metoclopramide may be tried
in children > 2 years old with recurrent non-bilious vomiting unresponsive
to acid-supresive therapy. Adverse effects are not uncommon with metoclopramide
therapy and include extrapyramidal side effects such as dystonic reactions,
tardive dyskinesia, parkinsonian reactions, tremor and irritability. Metoclopropamide
syrup 1mg/ml and tabs:5,10mg, Dose,1mg/kg/dose up to 10 mg a.c.&h.s.
Sucralfate (carafate) is an aluminum containing surface cytoprotective agent.
There is not enough data on its safety of use in children. Syrup: 1 gm/5ml,
Tabs:1gm, dose: 40-80mg/kg/day
Histamine-2 Receptor Antagonists in Pediatric with GERD (H2-RAs)
Cimetidine, Ranitidine, and Famotidine are safe and effective.
Ranitidine comes in 75mg/5ml syrup, dose 4-10mg/kg/day, divided BID-TID.
Cimetidine 300mg/5ml syrup, dose 20-40 mg/kg/day, divided BID-QID
Famotidine 40mg/5ml syrup, dose1-1.2mg/kg/day, divided BID-TID
Proton Pump Inhibitors
PPIs are used in infants with recurrent vomiting and failure to thrive, and
or irritability that have not responded to H2-RAs, child with frequent heartburn
or chest pain, the child with feeding resistance or dysphagia, the child with
asthma, the child with recurrent pneumonia and GERD and the infant with Apparent
Life-Threatening Events (ALTE).
PPIs decrease acid secretion by inhibition of the H+, K+, -ATPase in the gastric
parietal cell canaliculus and are more potent suppressor of acid secretion
Omeprazole, Caps: 10, 20, 40 mg, dose 0.7-3.3mg/kg/day
Lanzoprazole, Caps: 15, 30 mg, dose 0.8-4mg/kg/day
Surgical Treatment of Pediatric GERD
Surgery is often recommended for patients who failed medical therapy or who
are unable to withdraw from maintenance medical therapy. The presence of serious
symptoms such as life-thratening bronchospasm or recurrent aspiration pneumonia,
when caused by GERD, may argue in favor of surgery if the events can not be
controlled with medical therapy.
Success rate based on symptom relief in pediatric patients ranges from 57-92%.
Mortality ranges from 0-4.7% and complications ranges from 2.2-45%. The most
common complications are breakdown of fundoplication (0.9-13%), small bowel
obstruction (1.3-11%), gas-bloat syndrome (1.9-8%), infection (1.2-9%), atelectasis
or pneumonia (4.3-13%), perforation (2-4.3%), persistent esophageal stricture(1.4-9%),
and esophageal obstruction (1.4-9%).