eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Gastroesophageal Reflux

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

Introduction

Background

Gastroesophageal reflux (GER) represents the most common gastroenterological disorder that leads to referral to a pediatric gastroenterologist during infancy. It refers to immaturity of lower esophageal sphincter (LES) function, manifested by frequent transient lower esophageal relaxations (tLESRs) that results in retrograde flow of gastric contents into the esophagus.

Although minor degrees of gastroesophageal reflux are noted in both children and adults, the degree and severity of reflux episodes are increased during infancy. Thus, gastroesophageal reflux represents a common physiological phenomenon in the first year of life. As many as 60-70% of infants experience emesis during at least one feeding per 24-hour period by age 3-4 months. The distinction between this "physiologic" gastroesophageal reflux and "pathologic" gastroesophageal reflux in infancy and childhood is determined, not merely by the number and severity of reflux episodes (when assessed by intraesophageal pH monitoring), but is most importantly determined by the presence of reflux-related complications, including failure to thrive, erosive esophagitis, esophageal stricture formation, and chronic respiratory disease.

Other complications noted in adults with gastroesophageal reflux, including Barrett esophagus and esophageal mucosal dysplasia, are uncommon in childhood. 

Gastroesophageal reflux is classified as follows:

• Physiologic (or functional) gastroesophageal reflux: These patients have no underlying predisposing factors or conditions. Growth and development are normal, and pharmacologic treatment is typically not necessary.
• Pathologic gastroesophageal reflux or gastroesophageal reflux disease (GERD): Patients frequently experience complications noted above, requiring careful evaluation and treatment.¹
• Secondary gastroesophageal reflux: This refers to a case in which an underlying condition may predispose to gastroesophageal reflux. Examples include asthma (a condition which may also be, in part, caused by or exacerbated by reflux) and gastric outlet obstruction.

Pathophysiology

Similarities between adults and infants

• For many years, gastroesophageal reflux during infancy and childhood was thought to be a consequence of absent or diminished LES tone. However, studies have shown that baseline LES pressures are normal in pediatric patients, even in preterm infants.
• The major mechanism in infants and children has now been demonstrated to involve increases in tLESRs. Factors that may promote gastroesophageal reflux during tLESRs include increased intragastric liquid volume and supine and "slumped" seated positioning.
• Likely because of reduced viscosity and increased gastric volumes, the fluid diet of the infant facilitates the process of regurgitation compared with solid meals ingested by older children and adults.
• Esophageal clearance is similar in infants and adults, although evidence of reduced peristaltic activity in preterm infants has been reported.

Differences between adults and infants

• The volume ratio of meal-stomach-esophagus differs. Necessary amounts of infant caloric requirements easily overwhelm gastric capacity. Reflux occurs when esophageal capacity is exceeded by refluxate.
• Decreased gastric compliance is believed to lead to LES relaxation at lower intragastric volumes in infants. This aspect, in conjunction with abdominal wall muscle contraction (if it occurs during periods of LES relaxation) propels refluxate into the esophagus with subsequent regurgitation.
• An association between gastroesophageal reflux and delayed gastric emptying is recognized. This is more common in premature infants.

Gastroesophageal reflux and respiratory symptoms in infants and children

• Gastroesophageal reflux has been associated with significant respiratory symptoms in infants and children.
• The infant's proximal airway and esophagus are lined with receptors that are activated by water, acid, or distension. Activation of these receptors can increase airway resistance, leading to development of reactive airway disease.²  
• In 1892, Osler first postulated a relationship between asthma and gastroesophageal reflux, manifested by a bidirectional cause and effect presentation. Accordingly, although gastroesophageal reflux may be involved in both the etiology and progression of reactive airway disease, the asthmatic condition (in addition to antiasthmatic medications) may play a role in exacerbation of gastroesophageal reflux.
• One postulated mechanism for gastroesophageal reflux–mediated airway disease involves microaspiration of gastric contents that leads to inflammation and bronchospasm. However, experimental evidence also supports the involvement of esophageal acid–induced reflex bronchospasm, in the absence of frank aspiration. In such cases, gastroesophageal reflux therapy using either histamine 2 (H₂) blockers or proton pump inhibitors has been shown to benefit patients with steroid-dependent asthma, nocturnal cough and reflux symptoms.

Gastroesophageal reflux and other conditions in infants and children

• Two major areas of controversy surround the relationship between gastroesophageal reflux and both apnea and otolaryngologic disease. Although early studies appeared to demonstrate a link between gastroesophageal reflux and obstructive apnea (including an association with apparent life-threatening events [ALTE]), recent work suggests a weak relationship between these disorders.³  
• Laryngeal tissues are exquisitely sensitive to the noxious effect of acid, and recent studies support a significant relationship between laryngeal inflammatory disease (manifested by hoarseness, stridor, or both) and gastroesophageal reflux.
• Conversely, no conclusive clinical evidence supports a link between gastroesophageal reflux and other supraesophageal problems, including otalgia, recurrent otitis media, and chronic sinusitis.

Frequency

United States

• Symptoms of gastroesophageal reflux are most often directly related either to the consequences of emesis (eg, poor weight gain) or a result of exposure of the esophageal epithelium to gastric contents.
• Approximately 85% of infants vomit during the first week of life, and 60-70% manifest clinical gastroesophageal reflux at age 3-4 months.
• Symptoms abate without treatment in 60% of infants by age 6 months, when these infants begin to assume an upright position and eat solid foods. Resolution of symptoms occurs in approximately 90% of infants by age 8-10 months. 
• Symptoms that persist after age 18 months suggest a higher likelihood of chronic gastroesophageal reflux.⁴

Age

• Gastroesophageal reflux is most commonly seen in infancy, with a peak at age 1-4 months. However, it can be seen in children of all ages, even healthy teenagers.

Clinical

History

One must remember that the typical symptoms (eg, heartburn, vomiting, regurgitation) in adults cannot be readily assessed in infants and children. Pediatric patients with gastroesophageal reflux (GER) typically cry and report sleep disturbance and decreased appetite. The following are some of the common signs and symptoms of gastroesophageal reflux in the pediatric population:

• Signs and symptoms of gastroesophageal reflux in infants and young children
  • Typical or atypical crying and/or irritability
  • Apnea and/or bradycardia
  • Poor appetite
  • Apparent life-threatening event (ALTE)
  • Vomiting
  • Wheezing
  • Abdominal and/or chest pain
  • Stridor
  • Weight loss or poor growth (failure to thrive)
  • Recurrent pneumonitis
  • Sore throat
  • Chronic cough
  • Waterbrash
  • Sandifer syndrome (ie, posturing with opisthotonus or torticollis)
  • Hoarseness and/or laryngitis
• Signs and symptoms in older children - All of the above, plus heartburn and history of vomiting, regurgitation, unhealthy teeth, and halitosis

Physical

No classic physical signs of gastroesophageal reflux are recognized in the pediatric population (although an infant or toddler arriving in the office wearing a bib is often a sure tip off). One exception would be the relatively uncommon Sandifer syndrome, which is often misdiagnosed as spastic torticollis.

In toddlers and older children, excessive regurgitation may lead to significant dental problems caused by acid effects on tooth enamel. In the vast majority of cases, a diagnosis of gastroesophageal reflux is typically made once the primary care provider has obtained a clinical history that suggests this disorder.

• ALTEs that involve apnea associated with bradycardia, pallor, and/or cyanosis have been linked to gastroesophageal reflux, especially in premature infants. In these events, reflux into the hypopharynx is postulated to lead to laryngospasm and subsequent obstructive apnea. However, data suggest only a weak association between these phenomena. Any such relationship can only be objectively determined by esophageal pH monitoring performed in conjunction with pneumography and either nasal thermistor or pulse oximetry recording.
• Some patients have atypical symptoms (eg, nocturnal cough, wheezing, or hoarseness as the only major complaint). Gastroesophageal reflux is a complicating factor in asthma. The mechanism may include microaspiration, which leads to reflex bronchoconstriction. The association of gastroesophageal reflux and airway or respiratory tract disease is common. Cough, stridor, and pharyngitis have all been linked to gastroesophageal reflux. In addition, an association with rumination is commonly observed in patients with developmental delay.
• Regurgitation of food, one of the most common presenting symptoms in children, ranges from drooling to projectile vomiting. Most often, regurgitation is postprandial, although delays of 1-2 hours occur. One must also consider anatomic anomalies and protein allergy in a vomiting child, as well as inborn metabolic disorders (rare).
• Esophagitis may manifest as crying and irritability in the nonverbal infant. Failure to thrive can result from insufficient caloric intake secondary to repeated vomiting and nutrient losses in the emesis. Hiccups, sleep disturbances, and Sandifer syndrome (arching) have also been shown to be associated with gastroesophageal reflux and esophagitis.

Causes

Reflux after meals occurs in healthy persons; however, these episodes are generally transient and are accompanied by rapid esophageal clearance of refluxed acid. Some consider the small reservoir capacity of the infant's esophagus to be a predisposing factor to vomiting.

The causes and risk factors for gastroesophageal reflux in children are frequently multifactorial.

• Anatomic factors that predispose to gastroesophageal reflux include the following:
  • The angle of His (made by the esophagus and the axis of the stomach) is obtuse in newborns but decreases as infants develop. This ensures a more effective barrier against gastroesophageal reflux.
  • The presence of a hiatal hernia may displace the lower esophageal sphincter (LES) into the thoracic cavity, where the lower intrathoracic pressure may facilitate gastroesophageal reflux. The presence of a hiatal hernia by itself does not predict gastroesophageal reflux. Many patients who have a hiatal hernia do not have gastroesophageal reflux.
  • Resistance to gastric outflow raises intragastric pressure and leads to reflux and vomiting. Examples include gastroparesis, gastric outlet obstruction, and pyloric stenosis.
• Other factors that predispose individuals to gastroesophageal reflux include the following:
  • Medications (eg, diazepam, theophylline)
  • Smoking
  • Alcohol
  • Poor dietary habits (eg, overeating, eating late at night, assuming a supine position shortly after eating)
  • Food allergies
  • Certain foods (eg, greasy, highly acidic)
  • Motility disorders (postulated to potentially cause reflux): These include antral dysmotility and delayed gastric emptying. Such disorders are considered functional problems and frequently do not have an identifiable anatomical or organic cause. 
  • Transient lower esophageal sphincter relaxation (tLESR): This is currently believed to be the main mechanism of gastroesophageal reflux, accounting for 94% of reflux episodes in children and adults. Poor basal LES tone was previously thought to be a cause.
  • Obesity: Obesity has been cited as a major risk factor for gastroesophageal reflux. In studies conducted with adult patients, weight loss was demonstrated to be one of the lifestyle modifications that can decrease the severity and frequency of reflux.
  • Supine position
  • Decreased gastric emptying and reduced acid clearance from the esophagus: These can cause abnormal reflux.
• Physiologic factors: Reflux is facilitated when an increase in intraabdominal pressure occurs. In some cases, and particularly in children with neurodevelopmental disabilities, the presence of a chronically lax LES associated with decreased or even absent  sphincter tone results in severe gastroesophageal reflux.

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