eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Gastroesophageal Reflux: Follow-up

Author: Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Coauthor(s): Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: May 13, 2009

Follow-up

Complications

  • Gastroesophageal reflux (GER) strictures typically occur in the mid-to-distal esophagus. Patients present with dysphagia to solid meals and vomiting of nondigested foods. As a rule, the presence of any esophageal stricture is an indication that the patient needs surgical consultation and treatment (usually surgical fundoplication). When patients present with dysphagia, barium esophagraphy is indicated to evaluate for possible stricture formation. In these cases, especially when associated with food impaction, eosinophilic esophagitis must be ruled out prior to attempting any mechanical dilatation of the narrowed esophageal region. 
  • Barrett esophagus occurs when goblet cell metaplasia occurs. Risk of adenocarcinoma is increased 30-40 times. As with esophageal stricture, the presence of Barrett esophagus indicates the need for surgical consultation and treatment (usually surgical fundoplication).

Prognosis

  • Most cases of gastroesophageal reflux in infants and very young children are benign, and 80% resolve by age 18 months (55% resolve by age 10 mo). However, in refractory cases or when complications related to reflux disease are identified (eg, stricture, aspiration, airway disease, Barrett esophagus), surgical treatment (fundoplication) is typically necessary. The prognosis with surgery is considered excellent. The surgical morbidity and mortality is higher in patients who have complex medical problems in addition to gastroesophageal reflux.
  • During infancy, the prognosis for gastroesophageal reflux resolution is excellent (developmental disabilities represent an important diagnostic exception), with most patients responding to conservative nonpharmacologic treatment. Some patients require a "step-up" to acid-reducing medications. Surgery is required in only a very small minority of patients. In patients whose gastroesophageal reflux persists into later childhood, long-term therapy with antisecretory agents is often required. Because symptomatic gastroesophageal reflux after age 18 months likely represents a chronic condition, long-term risks are increased.
  • Methylxanthines exacerbate reflux secondary to decreased sphincter tone.
  • Children with neurodevelopmental disabilities, including cerebral palsy, Down syndrome and other heritable syndromes associated with developmental delay, have an increased prevalence of gastroesophageal reflux. When these disorders are associated with motor abnormalities (particularly spastic quadriplegia), medical gastroesophageal reflux management is often particularly difficult, and suck and/or swallow dysfunction is often present. Infants with neurological dysfunction who manifest swallowing problems at age 4-6 months may have a very high likelihood of developing a long-term feeding disorder.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recommend conservative diet and lifestyle changes before initiation of pharmacologic or surgical treatment
  • Failure to realize that most cases of gastroesophageal reflux (GER) during infancy are self-limited and respond to conservative management
  • Failure to understand the currently accepted clinical guidelines for gastroesophageal reflux management in children
  • Failure to inform parents that patience is important, because the therapeutic response may take several weeks; and, during infancy, that the goals of therapy are to ensure normal growth and development and to avoid gastroesophageal reflux–related complications
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jennifer DA Liburd, MD, to the development and writing of this article.



More on Gastroesophageal Reflux

Overview: Gastroesophageal Reflux
Differential Diagnoses & Workup: Gastroesophageal Reflux
Treatment & Medication: Gastroesophageal Reflux
Follow-up: Gastroesophageal Reflux
Multimedia: Gastroesophageal Reflux
References
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Further Reading

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Keywords

GER, gastroesophageal reflux disease, GERD, motility, heartburn, physiologic GER, lower esophageal sphincter, LES, esophagus, transient LES relaxation, tLESR, failure to thrive, erosive esophagitis, esophageal stricture formation, chronic respiratory disease, Barrett esophagus, esophageal mucosal dysplasia, asthma, gastric outlet obstruction, reactive airway disease, laryngeal inflammatory disease, otitis media, otalgia, chronic sinusitis, heartburn, apnea, bradycardia, pneumonitis, waterbrash, Sandifer syndrome, opisthotonus, torticollis, laryngitis, halitosis, pharyngitis, hiatal hernia, gastroparesis, pyloric stenosis, apparent life-threatening event, ALTE, treatment, diagnosis

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Contributor Information and Disclosures

Author

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Coauthor(s)

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jayant Deodhar, MD, Associate Professor in Pediatrics, BJ Medical College, India; Honorary Consultant, Departments of Pediatrics and Neonatology, King Edward Memorial Hospital, India
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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