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Pediatric RefluxAka: Pediatric GERD, Pediatric Gastroesophageal Reflux, Spitting Up

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  1. See Also
    1. Gastroesophageal Reflux Disease
  2. Epidemiology
    1. Peak age: 1 to 4 months old
    2. Resolution by age 6 to 12 months
    3. Incidence
      1. Age 0 to 3 months: 50% vomit >1 ounce daily
      2. Age 12 months: 1-5% reflux Incidence
  3. Mechanism
    1. Inappropriate LES relaxation
    2. Delayed gastric emptying
  4. Risk Factors
    1. Cerebral Palsy or developmental Disability
    2. Down Syndrome
    3. Esophageal atresia with repair
    4. Transesophageal fistula
    5. Respiratory disease
      1. Bronchopulmonary Dysplasia
      2. Asthma
      3. Chronic Cough
      4. Cystic Fibrosis
    6. Congenital Heart Disease
    7. Congenital Hiatal Hernia
    8. Medications
      1. Theophylline
      2. Caffeine
      3. Albuterol
  5. Symptoms and Signs
    1. Common
      1. Effortless spitting up 1-2 mouthfuls (under age 1)
      2. Irritability
    2. Uncommon
      1. Hematemesis
      2. Poor growth or poor weight gain
      3. Anemia
      4. Esophageal Stricture
      5. Respiratory disease
        1. Recurrent Pneumonia
        2. Chronic Cough
        3. Wheezing or Stridor
        4. Apnea or cyanosis
      6. Barrett's Esophagus
    3. Rare
      1. Protein loss
      2. Sandifer Syndrome
        1. Torticollis or neck tilting in infants
  6. Differential Diagnosis
    1. Pyloric stenosis
    2. Hiatal Hernia
    3. Malrotation
    4. Viral Gastroenteritis
    5. Cow's Milk Allergy
    6. Urinary Tract Infection
    7. Hydrocephalus or Meningitis
    8. Electrolyte disturbance
      1. Renal Tubular Acidosis
      2. Hypocalcemia
  7. Diagnosis
    1. Barium Swallow (Upper GI)
      1. Poor sensitivity and Specificity for GERD
      2. Very good for identifying underlying conditions
        1. Hiatal Hernia
        2. Pyloric stenosis
        3. Malrotation
    2. Milk study
      1. Good to assess gastric emptying
      2. Fair for identifying Reflux
    3. pH Probe (24 hour)
      1. Gold standard for Reflux diagnosis
      2. pH probe placed in distal esophagus
      3. pH below 4.0 suggests reflux
      4. Specific indications only
        1. Correlate reflux with respiratory symptoms
    4. Endoscopy
      1. Most sensitive test for Barrett's Esophagus
      2. Can also identify gastric outlet obstruction
    5. Manometry
      1. Can assess lower esophageal sphincter
  8. Management: Step 1 Conservative Management
    1. Indications
      1. Physiologic Reflux
      2. Normal weight gain
    2. Interventions
      1. Smaller, more frequent feedings
      2. Thickened Feedings
        1. Rice cereal up to 1 tablespoon per ounce formula
      3. Positioning
        1. Danny Sling
        2. Position completely upright or lying on right side
        3. Prone position helpful (risk of SIDS however)
        4. Minimize seated position
          1. May worsen reflux
          2. Increases intra-abdominal pressure
  9. Management: Step 2 Evaluate for Pathologic Reflux
    1. Indications
      1. Persistent regurgitation despite management in Step 1
      2. Poor weight gain
      3. Signs of esophagitis or respiratory symptoms
    2. Evaluation
      1. Consider differential diagnosis (see above)
      2. Consider Upper GI Study
    3. Interventions (trial for 2-3 weeks)
      1. Consider trial of formula change
        1. Identifies Cow's Milk Allergy
        2. Trial of casein hydrolysate formula for 2 weeks
      2. Antacid
        1. Ranitidine (Zantac) 5 mg/kg/day divided bid to tid
        2. Cimetidine (Tagamet) 10 mg/kg/dose qid
        3. Prevacid
          1. May be compounded for dosing in infants
          2. Dosing: 1 mg/kg/day (0.5 to 1.6 mg/kg)
            1. Weight <10 kg: 7.5 mg orally daily
            2. Weight 10-30 kg: 15 mg orally daily to bid
      3. Prokinetic
        1. Metoclopramide (Reglan) 0.1 mg/kg/dose tid to qid
          1. Risk of extrapyramidal effects, Dystonic Reaction
        2. Cisapride (Propulsid)
          1. Limited access in U.S. due to cardiac arrhythmias
    4. Follow-up: Evaluate efficacy after 2-3 weeks
      1. Interventions effective: Continue for 2-3 months
      2. Interventions not effective: See Step 3 below
  10. Management: Step 3 Refractory Reflux
    1. Indications
      1. Failed management in Step 2
    2. Evaluation
      1. Pediatric Gastroenterology Consultation
      2. Consider further studies
        1. pH probe for 24 hours
        2. Endoscopy
    3. Interventions for medically Intractable disease
      1. Fundoplication
  11. Complications
    1. Pulmonary aspiration
    2. Chronic Bronchitis
    3. Bronchiectasis
  12. References
    1. Boyle (1989) Gastroenterol Clin North Am 18:315
    2. Faubion (1998) Mayo Clin Proc 73:166
    3. Jung (2001) Am Fam Physician 64(11):1853
    4. Orenstein (1999) Pediatr Rev 20:24
    5. Tsou (1998) Otolaryngol Clin North Am 31:419

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