This document summarizes a seminar on approaching gastroesophageal reflux disease (GERD) in children. It discusses the anatomy and physiology of the esophagus and lower esophageal sphincter. It also covers the prevalence, pathophysiology, symptoms, diagnostic approaches including pH monitoring and endoscopy, and management including lifestyle changes, acid suppressants, prokinetics, and surgery for GERD in infants and children. The conclusion is that GERD is common in infants but usually resolves by 18 months, medical therapy with proton pump inhibitors is effective for treatment, and surgery is not generally recommended.

1. Seminar
On
“APPROACH TO GERD IN CHILDREN”
Presented by
Vijay kr. Singh
DNB PGT (Pediatrics)
Under guidance of
Dr T K MAITY
MD(PEDIATRICS)
Consultant physician M R Bangur Hospital
Date 23rd march 2013
Venue
DNB Seminar hall M R Bangur hospital Kolkata-33

2. APPROACH TO
GERD IN
CHILDREN

3. ANATOMY AND PHYSIOLOGY
 Esophagus begins at lower border of cricoids
cartilage.
 It develops from foregut and is recognizable by
third week of gestation.
 Food or fluid delivered from the esophagus to the
stomach, swallowing must be accompanied by a
coordinated wave of peristaltic contractions

5. It is lined by four layers
Mucosa- stratified squamous non
keratinized epithelium
Sub mucosa- mucous glands and
lymphoid tissue
Muscularis externa
Adventitia

6. Lower esophageal sphincter
 It is not a true anatomical sphincter.
 The lower 3-4 cm smooth circular muscle
fibers form LES.
 Its remain tonic activity prevent reflux of
gastric contain into stomach.
 The tone of LES is under control of
parasympathetic neural control.
 The tone of LES is also under influenced of
gastric hormone

7. Mechanism which prevent gastro
esophageal reflux
 Tonic activity of LES
 Valve like mechanism of short portion of
esophagus that extend into the diaphragm
 Fibres of crural portion of diaphragm surround
esophagus at the lower end which prevent
reflux

9. Introduction
 Gasrtroesophageal reflux disease is the most common
esophageal disorder in children.
 Gastroesophageal reflux signified the retrograde
movement of gastric contents across the lower
esophageal sphincter .
 The regurgitation is normal in infant,
 The phenomenon becomes pathological GERD in children
who have more frequent and persistent.
 It produce esophageal symptoms or have respiratory
symptoms.

10. Prevalence
 Infant reflux becomes evident in the 1st few months
of life.
 Peaks at 4months, at 12 months it resolves upto
88% and nearly all up to 24 months.
 Prevalence of GERD in the infant range from 1 to
8%.
 85% of premature infant have GERD, with upto 10%
of them having extra intestinal manifestations like
bradicardia and apnea.

11. Path physiology of reflux
 A well- coordinated relaxation of the lower
esophageal sphincter is essential for the
transport of food into stomach.
 Basal LES pressure is maintained above
4mmHg to prevent reflux.
 Pressure theory is disproved by many pressure
studies.

12.  Reflux is primarily due to Transient LES relaxation.
 TLESR occur independent of swallowing, reduce LES
pressure to 0-2mm Hg and last for>10 seconds, and
they appears by 26 wks of gestation.
 A vaso vagal reflex, composed of afferent
mechanoreceptors in the proximal stomach, a brain
stem pattern generated, and efferent in the LES,
regulates TLESRs.
 Gastric distention the main stimulus for TLESRs.
 The pathogenesis of reflux in premature infant is not
well understood.

13. Symptoms and manifestation
In Infant
 Vomiting
 Poor weight gain
 Irritability
 Feeding refusal
 Recurrent pneumonia
 Asthma or any upper respiratory tracts symptoms
 Apnea

14. children
Heartburn and retrosternal chest pain.
Dysphasia.
Regurgitation.
Asthma and chronic cough.
Recurrent pneumonia.
Anemia and haemetemesis.
Sandifer’s syndrome.

15. Conditions predisposing to severe
GERD
Obesity
 Neurological impairment
Rep. aired trachea- esophageal fistula
Congenital diaphragmatic hernia
 Chronic lung disease
Significant prematurity

16. Diagnostic approach to GERD
 History and physical examination suffice the
diagnosis.
 Evaluation aims to identify the positive
support of the diagnosis.
 The history standardized by ORENSTIEN’S
questionnaireI-GERQ and its derivatives I-
GERQ-R

17. Esophageal pH monitoring
 Ph monitoring help to establish the presence
of acid reflux Ph <4.
 It assess the efficacy of treatment.
 It is non-invasive and done in any age group.
 It does not measure the non –acid and weakly
acidic reflux.

18. Multichannel intraluminal -
impedance measurement
It detect the change in the electrical
resistance that occur during the passage
of a bolus of gas or liquid .
This study detects both acid and non acid
reflux and direction of reflux.
The limitation of the procedure is – high
cost, limited availability

19. Endoscopy
Upper GI endoscopy is the best method
of detecting esophagitis.
 Normal endoscopy does not rule out
GERD.
This type of GERD is called non-erosive
reflux.

20. Advantages of endoscopy
 It gives direct information about the presence of
esophagitis.
 Detects complications like ulcer, stricture, Barrett’s
esophagitis.
 Endoscopic biopsy help to exclude other cause of
esophagitis.
 Histology is more sensitive than endoscopy in the
early stage. Erosive esophagitis is the most definite
evidence of GERD on endoscopy.

21. Barium UGI series
This test is useful to detect anatomical
abnormalities but it is not useful in
diagnosis of GERD.
The sensitivity and specificity is less
than 50%.

22. Nuclear scintigraphy
Nuclear scintigraphy has poor sensibility and
specificity.
Used in recurrent aspiration pneumonia.
 Retention of radioactivity in lung beyond 24
hours suggests GERD .
Nuclear scintigraphyis not recommended for
the routine evaluation.

23. MANAGEMENT

24. GER in infant (Happy splitters)
Counseling and natural history of GER in infant
to be explained to the parents or care givers.
It is advised to give small and frequent
feeding .
 Thickening of feed.

25. GERD in children
Acid suppressants- GERD need acid
suppression therapy for 12weeks.
Proton pump inhibiter is more potent than H2
blocker.
Neutralizing agent- Useful in symptomatic
relief of heartburn.
Not for long term due to risk of side effects.

26. Prokinetics
There is insufficient evidence to justify the
role of prokinetics in management of GERD.
 It is only indicated in GERD associated with
gastro paresis.

27. Duration of therapy
PPI therapy is recommended for at least
12weeks .
Taper over 2 to 3 months to prevent rebound
hyperacidity .
 If there is no improvement in 4 weeks then
the dose of PPI need to be increased.

28. Surgery
Nissen fundoplication may be of
beneficial in children with confirmed
GERD who have failed optimal medical
therapy.

29. Bronchial asthma and GERD
The clinical association of bronchial
asthma and GERD is very strong.
 Causal relationship between these two
entities has no yet established.

30. Persistent asthma with
symptomatic GERD
It can be treated with a clear explanation given
to the parents.
 Reflux symptoms will improve but chance of
improvement of asthma is remote.

31. GERD in neurologically impaired
children
Prevalence of GERD in neurological impaired
children is 50% higher than normal child .
The prevalence of erosive esophagitis about
30 to 70%.
This group of children needs prolonged
treatment and often surgery.

32. Conclusion
 GER is common in infant.
 Most infant have physiological reflux and need
minimal intervention.
 Symptoms resolve by 18 months of age.
 No gold standard test for GERD diagnosis
 Medical therapy with PPI is very effective and safe.
 Surgical therapy is not recommended because of its
morbidity and often fails in those who need it most.