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Review Article

Gastroesophageal reflux disease in children: A 2013 update

Mohammad I. El Mouzan Department of Pediatrics (Gastroenterology Division), King Khaled University Hospital and College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia Correspondence: Prof. Mohammad I. El Mouzan, Professor and Consultant Pediatrician (Gastroenterology), College of Medicine and King Khaled University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail: [email protected]

ABSTRACT Gastroesophageal reflux (GER) refers to the passage of gastric contents (acid, pepsin, etc) in the . It is a worldwide physiologic condition most common in infants. This physiologic condition (GER) should be differentiated from the pathologic reflux called gastroesophageal reflux disease (GERD). The distinction between GER and GERD is based on severity of the reflux episodes.[1,2] The most common mechanism of reflux is transient lower esophageal sphincter relaxation (TLESR) and less commonly low resting LES pressure.[3] GER presents with regurgitation and occasional vomiting only without effects on growth and development whereas GERD usually has additional presentations. The objective of this review is to provide update on recent developments in the diagnosis and management of this condition.

Key words: Children, GER, GERD

اإلرتجاع المعدي المريئي هو صعود محتويات المعدة إلى المرئ, وهذه ظاهرة فسيولوجية عالمية وشائعة بين األطفال. يجب التفريق بين اإلرتجاع الفسيولوجي والمرضي والذي يعتمد على حدة اإلرتجاع. يسبب هذه الظاهرة استرخاء العضلة العاصرة أسفل المرئ وبصورة أقل إنخفاض الضغط فيها. أعراض هذه الظاهرة اإلرتجاع والقئ دون تأثير على نمو وتطور الطفل وربما تكون هناك أعراض أخرى. يهدف هذا العرض إلى تزويد القارئ بآخر المستجدات في تشخيص وعالج هذه الحالة.

CLINICAL PRESENTATION Odynophagia (pain on swallowing) and dysphagia are features of and . Barrett’s The clinical features of GERD have been described in esophagus (BE) which is the replacement of the normal numerous publications.[4-6] The most common symptoms squamous by columnar epithelium, a premalignant lesion, include regurgitation and vomiting which may lead to is the most serious complication of GERD. High risks for failure to thrive or even weight loss. The presence of the development of GERD include neurologic impairment refluxed material in the esophagus which is frequently acid (NI) and esophageal atresia with tracheoesophageal atresia may cause pain in the form of irritability and refusal to feed after surgical repair. Because of functional and structural defects, chronic reflux persists may persist leading to BE in infants and heartburn and chest pain in older children. and carcinoma.[7] The Apparent Life-Threatening Events Esophagitis, called peptic or reflux esophagitis, is the (ALTE) and relationship with GERD is of particular result of prolonged presence of refluxate in the esophagus importance in infants. These are usually described by the causing occult blood loss (anemia) or . parents as cessation of breathing with or without cyanosis. However, from a medical point of view, in order to meet the Access this article online criteria for the diagnosis of ALTE, these episodes should Quick Response Code: Website: include: 1. Apnea for at least 15 seconds. 2. Presence of www.sjmms.net color changes (cyanosis, pallor or plethora). 3. Association with abnormal muscle tone (floppiness or stiffness).

DOI: There may be choking and gagging requiring intervention 10.4103/1658-631X.123644 by the observers. These episodes may be associated with respiratory infections, upper airway obstruction,

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neurologic, cardiac, metabolic disease, child abuse, and problems may lead to distorted quantitative analysis GERD. However, the low yield of investigations for reflux and assessment of the quality of the recording should suggests that GERD is a rare cause of ALTE.[8] be performed before interpretation of the results.[11] Quantitative parameters calculated over the study period Recurrent hoarsness, stridor, cough, wheezing, recurrent (usually 24 hours) include the total number of reflux pneumonia otitis media, sinusitis, and dental erosion have episodes, number of prolonged episodes, duration of the been associated with GERD. However, the causal relation longest reflux episode, and percentage of time pH was less with GERD is frequently difficult to establish. Similarly, than 4. The latter is called the reflux index. Advantages dystonic neck posturing (Sandifer syndrome) has been of the pH studies include the ability to quantify reflux associated with GERD. allowing the distinction between physiologic (GER) and pathologic reflux (GERD). In fact, this is the only test In the majority of infants gastroesophageal reflux resolves that quantifies reflux over a prolonged period of time. spontaneously by 18 months of age. However, reflux Another important advantage is to define the relation esophagitis and its complications may occur indicating between reflux episodes and symptoms occurring during the need for regular follow up. the recording by calculating the symptom index score (the number of symptoms occurring during or right after DIAGNOSTIC METHODS reflux episodes). A causal relationship is suggested when the symptom index score is more than 50%. However, the History and physical examination main drawback of this test is that esophageal pH studies This simple clinical assessment should be sufficient for do not detect non-acid reflux which commonly occurs in the preliminary diagnosis of uncomplicated physiologic the postprandial period and may be the cause of chronic reflux in otherwise normal infants and further respiratory disease. investigation is generally not needed. Multichannel intraluminal impedance Barium studies Impedance measures the conductance potential This should be barium meal rather than swallow. It is (electrical impedance) of refluxed material and identifies inexpensive, readily available, and allows identification its physical characteristics (liquid, gas, or mixed). This of structural anomalies such as hiatal and other recently described technique may be combined with pH causes of vomiting such as esophageal stricture, gastric monitoring in the same catheter to determine whether , malrotation, and . However, low these reflux episodes are acid or non-acid. Studies have sensitivity and specificity indicate that barium meal alone shown that combined impedance with pH identified more should not be used to diagnose or exclude reflux.[9] reflux episodes with better identification of weakly acid GERD not detectable by conventional pH probe alone Prolonged intraesophageal pH studies and yet responsible of symptoms of GERD. However, Also called pH probe or pH-Metry. The placement of the technique still has limitations. These include high a pH probe in the lower esophagus allows detection of cost, limited additional value regarding therapeutic refuxed acid. Although appears to be a simple test, it implications, and lack of evidence-based parameters for requires a strict technique to insure correct location of the assessment of and symptom association in children.[12] the probe which should be well above the LES to avoid the area of physiologic reflux. Clearly a probe placed too Endoscopy and biopsy low will produce false positive results and too high will Visualization of the esophageal mucosa detects signs yield false negative results. More recently, to minimize of inflammation which is confirmed by histopathology. discomfort, an alternative to the nasoesophageal route, Thus, this procedure is important for the detection of a wireless capsule (the Bravo capsule) is attached to the peptic esophagitis, a complication of GERD and not a esophagus.[10] Whether by probe or wireless capsule, the diagnostic test of GERD per se. The degree and extent of measurement of pH is transmitted to a recorder which esophageal lesions (erythema, erosions, and ulcerations) is disconnected from the patient after about 24 hours have been used in the grading of esophagitis. Endoscopy of recording. The data are downloaded into a computer and biopsy also detect strictures and BE. Endoscopy and program which produces a curve indicating the pH in the biopsy also help in the differential diagnosis of esophagitis lower esophagus from the start to the end of the recording which in addition to reflux esophagitis includes and quantitative analysis [Figure 1]. The interpretation , Crohn disease, infectious of the data requires expertise as artifacts and technical esophagitis, and webs. Because of poor correlation

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Figure 1: 24-hour esophageal pH monitoring results in a 5-year-old child with developmental delay, failure to thrive, and history of regurgitation. The most important pathologic findings are the percentage of recording time pH < 4 (reflux index) is 11.7% and the duration of longest reflux episode is 32 minutes which indicates defective esophageal clearance of refluxed acid and risk of reflux esophagitis

between endoscopic appearance and histology, biopsy those presenting with bloody vomiting or iron deficiency is commonly recommended whenever endoscopy is anemia as a result of occult blood loss secondary to reflux performed. esophagitis. In a study from our institution, esophageal pH was the most specific diagnostic study (91%), whereas Scintigraphy endoscopy was the most sensitive (92%) and had the best This technique is performed by oral ingestion or instillation (95%) positive predictive value.[13] of technetium-labeled formula (milk scan) or food into the stomach. The gastroesophageal region and lungs are scanned Other techniques by a gamma camera for evidence of reflux and aspiration Ultrasonography: Monitoring of the gastroesophageal for at least 30 minutes. Main advantages are the ability to region after a meal for reflux has been introduced as a demonstrate reflux of non-acidic gastric contents and study non-invasive technique for the identification of reflux. of gastric emptying, which may be delayed in children with However, the test requires dedication and expertise GERD. Disadvantages include lack of standardization, high which are not commonly available. Therefore, although cost in terms of equipments and expertise. attractive this test is not widely performed. Esophageal The accuracy of different diagnostic modalities varies with manometry is not a diagnostic test for reflux per se. It is the duration of investigation. In view of the intermittent frequently performed in adults to detect motility disorders nature of GER, the longer the duration of the study the associated with GERD, but rarely indicated in children. more reflux episodes will be detected. The duration of The bilitech 2000: A fiberoptic spectrophotometric probe symptoms and risk category of patients are other variables. detects bilirubin in the refluxate may be helpful in the For example, the yield of endoscopy will be greater diagnosis of nonacid reflux caused by duodenogastric children with reflux symptoms of long duration and reflux disease.

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THERAPEUTIC OPTIONS potato starch, decrease overt regurgitation and vomiting frequency and volume. When ingested in normal volumes, Medical measures include lifestyle changes, prokinetic AR formulae contain an energy density, osmolarity, drugs, and gastric acid-controlling agents. Surgery in protein, calcium, and fatty acid content appropriate to an the form of various types of fundoplication constitutes infant’s nutritional needs, whereas a formula with added the main therapeutic options and will be discussed below. thickener has a higher energy density. Endoscopic procedures in the form of gastroplication has been suggested as an alternative to surgery but still in Positioning therapy for infants evolution and will not be discussed further.[14] Several studies in infants have demonstrated significantly 1. Lifestyle changes include feeding and positioning decreased acid reflux in the flat prone position compared [22-26] in infants and other measures in older children. with flat supine position. The semisupine positioning [27] Parental education and support are usually sufficient as attained in an infant car seat exacerbates GER. Based to manage healthy, thriving infants caused by on these studies, the prone position was the recommended physiologic GER. positioning after feeds. However, reports on the association between prone positioning and sudden infant death syndrome Feeding infants (SIDS) led to modification of this recommendation that Breast-fed and formula-fed infants have a similar the prone position is no longer recommended routinely. frequency of physiologic GER. Some infants with However, in certain special situations prone positioning allergy to cow’s milk protein experience regurgitation may be considered, such as infants with certain upper and vomiting indistinguishable from that associated airway disorders in which the risk of death from GERD with physiologic GER. Elimination of cow’s milk protein may outweigh the risk of SIDS or children older than 1 year from the diet and replacement with hydrolyzed or amino of age with GER or GERD whose risk of SIDS is negligible. acid formula for about 2 weeks improve the vomiting and reintroduction causes recurrence of symptoms.[15,16] Lifestyle changes in children and adolescents Lifestyle changes often recommended for children Cow’s milk protein and other proteins pass into human and adolescents with GER and GERD include dietary breast milk in small quantities. Breast-fed infants with modification, weight loss in overweight patients, regurgitation and vomiting may therefore benefit from positioning changes, and avoidance of smoking. a trial of withdrawal of cow’s milk and eggs from the However, it is not known whether any lifestyle changes maternal diet.[17,18] However, discontinuation of breast have an additive benefit in children or adolescents feeding is generally not needed or recommended. receiving adequate pharmacological therapy. Although there are no data evaluating the role of soy-bean formula in the treatment of infants with Acid-controlling drugs regurgitation and cow’s milk protein allergy (CMPA), Antacids these formulae may be an alternative in countries where They directly buffer gastric contents, thereby reducing the hydrolyzed formulae are not available. Manipulation heartburn and healing esophagitis. On-demand use of volume and density of feeding: Large volume feedings of antacids may provide rapid symptom relief in some may promote regurgitation, probably by increasing the children and adolescents with GERD. However, frequency of TLESR and reduced feeding volume may prolonged treatment with aluminum-containing antacids [19] lead to decreased reflux frequency. Infants with failure significantly increases plasma aluminum in infants,[28,29] to thrive may benefit from increasing the caloric density and some studies report plasma aluminum concentrations of formula when volume or frequency of feedings is close to those that have been associated with osteopenia, decreased as a part of therapy. Thickening of feedings: rickets, microcytic anemia, and neurotoxicity.[30-31] Rice cereal — thickened formulae produce a decrease in Because safe and convenient alternatives are available, the volume of regurgitation but may increase coughing chronic antacid therapy is generally not recommended for during feedings.[20] Excessive energy intake however children with GERD. is a potential problem with long-term use of feedings thickened with rice cereal or cornstarch.[21] For example, Surface-protecting agents thickening a 20-kcal/oz infant formula with 1 tablespoon Most of these agents contain either alginate or sucralfate. of rice cereal per ounce increases the energy density to Efficacy of alginate is controversial. Sucralfate is a 34 kcal/oz (1.1 kcal/ml). Commercial anti-regurgitant compound of sucrose, sulfate, and aluminum, which, (AR) formulae containing processed rice, corn or in an acid environment, forms a gel that binds to the

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exposed mucosa of peptic erosions. In adults, sucralfate PPIs: Idiosyncratic reactions, drug–drug interactions, decreased symptoms and promoted healing of nonerosive drug-induced hypergastrinemia, and drug-induced esophagitis.[32] The available data are inadequate to hypochlorhydria. determine the safety or efficacy of sucralfate in the treatment of GERD in infants and children, particularly Idiosyncratic side effects occur in up to 14% of children the risk of aluminum toxicity with long-term use. None taking PPIs.[40,41] The most common are headache, of the surface agents is recommended as a sole treatment , , and nausea, each occurring in for severe symptoms or erosive esophagitis. 2% to 7%. These may resolve with decreased dose or change to a different PPI. Increasing evidence suggests Histamine-2 receptor antagonists (H2RAs) that hypochlorhydria, that is, acid suppression, associated These drugs decrease acid secretion by inhibiting with H2RAs or PPIs may increase rates of community- histamine-2 receptors on gastric parietal cells. These acquired pneumonia in adults and children, include cimetidine, famotidine, nizatidine, and in children, and candidemia and necrotizing in ranitidine. However, ranitidine is the most commonly preterm infants.[42-46] Lower respiratory tract infections were used in children. One dose of (5 mg/kg) has been the most frequent among these adverse effects, although the shown to increase gastric pH for 9 to 10 hours in difference in respiratory tract infection rate between treated infants.[33] Tachyphylaxis or diminution of the and placebo groups did not achieve statistical significance. response to intravenous ranitidine and escape from Other adverse effects have been reported in patients with its acid-inhibitory effect have been observed after 6 chronic PPI therapy, such as deficiency of vitamin B12 weeks.[34,35] and increased incidence of hip fractures.[47,48] In addition, PPI-induced acute interstitial nephritis causing acute renal Proton pump inhibitors (PPIs) failure have been reported, and may be unrecognized and + + They inhibit acid secretion by blocking Na –K -ATPase, classified as ‘‘unclassified acute renal failure’’.[49] PPIs are the final common pathway of parietal cell acid secretion considered to be one of the most common cause of acute (the proton pump). The superiority of PPIs is related interstitial nephritis in adults.[50,51] to their ability to maintain intragastric pH at or above 4 for longer periods and to inhibit meal-induced acid Prokinetic Therapy secretion, a characteristic not shared by H2RAs. In Cisapride is a mixed serotonergic agent that facilitates addition, the effect of PPIs does not diminish with the release of acetylcholine at synapses in the myenteric chronic use. The potent suppression of acid secretion plexus, thus increasing gastric emptying and improving by PPIs also results in decrease of 24-hour intragastric esophageal and intestinal peristalsis. After an initial volumes, thereby facilitating gastric emptying and widespread use in children with GERD, cisapride was decreasing gastric volume and reflux.[36] In children, as withdrawn from the market after it was implicated in in adults, PPIs are highly efficacious for the treatment prolongation of the QTc interval on electrocardiogram, a of symptoms due to GERD and the healing of erosive finding increasing the risk of sudden death.[52] disease. PPIs have greater efficacy than H2RAs and children below 10 years of age appear to require a higher Domperidone and metoclopramide are antidopaminergic dose per kilogram for some PPIs than adolescents and agents that facilitate gastric emptying. Metoclopramide adults. However, double-blind randomized placebo- has cholinomimetic and mixed serotonergic effects. controlled trials (RCTs) show that PPI therapy is not Metoclopramide and placebo equally reduced symptom beneficial for the treatment of infants with symptoms scores of infants with reflux. A meta-analysis of RCTs of that previously were purported but not proven to be metoclopramide in developmentally healthy children 1 due to GERD although in one study, esomeprazole month to 2 years of age with symptoms of GER found reduced esophageal acid exposure and the number of that the drug reduced symptoms and the RI but was acidic reflux events.[37-39] Poorly controlled asthma is an associated with significant side effects.[53] example of lack of benefit and even increased risk of PPIs. In a recent RCT, children with poorly controlled The reported adverse effects in infants and children asthma without symptoms of GER who were using include lethargy, irritability, gynecomastia, galactorrhea, inhaled corticosteroids, the addition of lansoprazole, and extrapyramidal reactions and has caused permanent compared with placebo, improved neither symptoms nor tardive dyskinesia.[54-57] A recent systematic review of lung function but was associated with increased adverse studies on domperidone[58] identified only 4 RCTs in events.[40] There are potential side effects related to children, none providing ‘‘robust evidence’’ for efficacy

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of domperidone in pediatric GERD. Domperidone 28% were unable to burp or vomit, and 25% choked on occasionally causes extrapyramidal central nervous system some solids.[70] Early and late operative failure may result side effects. Bethanechol, a direct cholinergic agonist from disruption of the wrap or slippage of the wrap into the studied in a few controlled trials, has uncertain efficacy and chest. In otherwise healthy children evaluated at a mean a high incidence of side effects in children with GERD.[55] of 10 months (1-35 months) following antireflux surgery, 67% had ‘‘no complaints,’’ but one third had objective Baclofen is a g-amino-butyric-acid receptor agonist that evidence of operative failure.[71] Operative complications reduces both acid and nonacid reflux in healthy adults include splenic or esophageal laceration, each of which and those with GERD.[59] In children, it was shown to occurs in about 0.2% of pediatric cases.[72] Laparoscopic accelerate gastric emptying for 2 hours after dosing, Nissen fundoplication has largely replaced open Nissen without any deleterious effect on LES resting pressure or fundoplication as the preferred antireflux surgery for esophageal peristalsis.[60] In a small group of children with adults and children, due to its decreased morbidity, shorter GERD and NI, it was reported to decrease the frequency of hospital stays, and fewer perioperative problems. emesis.[61] However, baclofen is known to cause dyspeptic symptoms, drowsiness, dizziness, and fatigue, and to lower Antireflux surgery may be of benefit in children with the threshold for seizures. Such side effects preclude its confirmed GERD who have failed optimal medical routine use.[62] However, a recent analysis suggested that therapy, or who are dependent on medical therapy baclofen may be used as supplement to other measures in over a long period of time, or who are significantly some children with refractory GERD.[63] non-adherent with medical therapy, or who have life- threatening complications of GERD. Surgical Therapy Fundoplication decreases reflux by increasing the Evaluation and therapeutic indications LES baseline pressure, decreasing the number of In view of the variety of presenting symptoms of reflux TLESRs, increasing the length of the esophagus that and that the diagnosis is usually made at different stages is intraabdominal, accentuating the angle of His, and of the disease, the evaluation and management should reducing hiatal hernia if present. When successful, be individualized. The following guidelines of the fundoplication usually eliminates reflux, including North American and European Societies for Pediatric physiologic reflux.[64] Compared to normal children, Gastroenterology Hepatology and Nutrition represent a those with NI have more than twice the complication rate, practical approach recommended for the evaluation and three times the morbidity, and four times the reoperation treatment of GERD.[2] rate.[65] One case series with a follow-up period of 1. Infants with uncomplicated recurrent regurgitation 3.5 years reported that more than 30% of children with and vomiting: This is the typical presentation NI had major complications or died within 30 days of of physiologic GER. The history and physical antireflux surgery.[66] Children with repaired EA also examination are usually sufficient for the diagnosis. have a high rate of operative failure [67,68] although not No other investigation is needed at this point. as high as those with NI. Recurrence of pathologic reflux Parental education, reassurance, and follow up are after antireflux surgery in children with NI or EA may recommended. In formula-fed infants, thickened not be obvious, and detection often requires a high index or AR formula reduce the frequency of overt of suspicion, repeated evaluation over time, and use of regurgitation and vomiting and may be prescribed. more than one test. Fundoplication in early infancy has a 2. Infants with recurrent vomiting and poor weight gain: higher failure rate than fundoplication performed later in These patients present with symptoms suggestive of childhood, and appears to be more frequent in children GERD rather than physiologic GER. Therefore, in with associated anomalies.[69] addition to complete history and physical examination, the initial evaluation should include nutritional history, Complications following antireflux surgery may be due to urinalysis, complete blood count, serum electrolytes, alterations in fundic capacity, altered gastric compliance, blood urea nitrogen, and serum creatinine. Other and sensory responses that may persist from months to investigations should be based on suggestive historical years. These include gas-bloat syndrome, early satiety, details or results of screening tests. Management may , and postoperative retching and include a discontinuation of cow’s milk and a 2-week gagging. In a postoperative study of children with no trial of extensively hydrolyzed formula or amino acid- underlying disorders, 36% had mild to moderate gas bloat based formula to exclude the possibility cow’s milk symptoms, 32% were ‘‘very slow’’ to finish most meals, allergy. Increased caloric density of formula and/or

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thickened formula, and education as to appropriate Recurrence of symptoms and/or esophagitis after daily formula volume may be required to achieve repeated trials of PPI withdrawal usually indicate normal growth. Careful follow-up of interval weight that chronic-relapsing GERD is present, if other change and caloric intake is essential. If management causes of esophagitis have been ruled out. At that fails to improve symptoms and weight gain, referral point, therapeutic options include long-term PPI to a pediatric gastroenterologist is recommended for therapy or antireflux surgery. further investigations. 7. Barrett’s esophagus (BE): Occurs in children with 3. Infants with unexplained crying and/or distressed less frequency than it does in adults. Multiple biopsies behavior: Reflux is not a common cause of unexplained documented in relation to endoscopically identified crying, irritability, or distressed behavior in otherwise esophagogastric landmarks are advised to confirm healthy infants. Other causes include cow’s milk or rule out the diagnosis of BE and dysplasia. In protein allergy, neurologic disorders, constipation, BE, aggressive acid suppression is advised by most and infection (especially of the urinary tract). experts. Symptoms are a poor guide to the severity Following exclusion of other causes, an empiric trial of acid reflux and esophagitis in BE, and pH studies of extensively hydrolyzed protein formula or amino are often indicated to guide treatment. BE per se is acid-based formula is reasonable in selected cases not an indication for surgery. Dysplasia is managed although evidence from the literature in support of according to adult guidelines. such a trial is limited. There is no evidence to support 8. Dysphagia, odynophagia, and food refusal: the empiric use of acid suppression for the treatment Dysphagia, or difficulty in swallowing, occurs in of irritable infants. If irritability persists with no association with oral and esophageal anatomic explanation other than suspected GERD, referral to abnormalities, neurologic and motor disorders, pediatric gastroenterologist for further investigation oral and esophageal inflammatory diseases, and is recommended. psychological stressors or disorders. Of the mucosal 4. The child older than 18 months of age with chronic disorders, eosinophilic esophagitis is increasingly regurgitation or vomiting: Although these symptoms recognized as a common cause of dysphagia or are not unique to GERD, evaluation to diagnose odynophagia. Odynophagia, or painful swallowing, possible GERD and to rule out alternative diagnoses must be distinguished from heartburn (substernal is recommended based on expert opinion. Testing pain caused by esophageal acid exposure) and may include upper gastrointestinal (GI) endoscopy dysphagia. Although odynophagia may be a symptom and/or esophageal pH/MII, and/or barium upper of peptic esophagitis, it is more often associated GI series. with other conditions such as oropharyngeal 5. Heartburn: Adolescents with typical symptoms of inflammation, esophageal ulcer, eosinophilic chronic heartburn should be treated with lifestyle esophagitis, infectious esophagitis, and esophageal changes if applicable (diet changes, weight loss, motor disorders. Although GERD is not a prevalent smoking avoidance, sleeping position, no late night cause of dysphagia or odynophagia, an evaluation eating) and a 2- to 4-week trial of PPI. If symptoms including barium upper GI series and possibly resolve, PPIs may be continued for up to 3 months. upper endoscopy should be considered if physical Heartburn that persists on PPI therapy or recurs examination and history of disease do not reveal after this therapy is stopped should be investigated a cause. Therapy with acid suppression without further by a pediatric gastroenterologist. evaluation is not recommended. In the infant with 6. Reflux esophagitis: In pediatric patients with feeding refusal, acid suppression without diagnostic endoscopically diagnosed reflux esophagitis or evaluation is not recommended. established non-erosive reflux disease, PPIs for 9. Infants with apnea or apparent life-threatening 3 months constitute initial therapy. Not all reflux events (ALTEs): In the majority of infants with apnea esophagitis are chronic or relapsing, and therefore or ALTEs, GER is not the cause. In the uncommon trials of tapering the dose and then withdrawal circumstance in which a relation between symptoms of PPI therapy should be performed at intervals. and GER is suspected or in those with recurrent In most cases of chronic-relapsing esophagitis, symptoms, MII/pH esophageal monitoring in symptom relief can be used as a measure of efficacy combination with polysomnographic recording and of therapy, but in some circumstances repeat precise synchronous symptom recording may aid in endoscopy or diagnostic studies may be indicated. establishing cause and effect.

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10. Reactive airways disease: In patients with asthma include juice drinking, bulimia, and racial and genetic who also have heartburn, reflux may be a contributing factors affecting the characteristics of enamel and saliva. factor to the asthma. Despite a high frequency of 14. Dystonic head posturing (Sandifer Syndrome): abnormal reflux studies in patients with asthma who Sandifer syndrome (spasmodic torsional do not have heartburn, there is no strong evidence to with arching of the back and opisthotonic posturing, support empiric PPI therapy in unselected pediatric mainly involving the neck and back) is an uncommon patients with wheezing or asthma. Three groups of but specific manifestation of GERD. It resolves with asthmatics may benefit from PPI or surgical therapy. antireflux treatment. These include patients with heartburn, those with nocturnal asthma symptoms, and those with steroid- REFERENCES dependent difficult-to-control asthma. Finding 1. El Mouzan MI. 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64. Berquist WE, Fonkalsrud EW, Ament ME. Effectiveness of Nissen Source of Support: Nil. Conflict of Interest: None declared. fundoplication for gastroesophageal reflux in children as measured

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