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, markedly increased 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 therapy.

Treatment Option

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 improve.

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 6 inches.

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 International, 1999

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 usually recommended:

"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 metoclopropamide 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 than H₂-RAs.

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%).