Purpose of review: Although heartburn and regurgitation are common manifestations of gastroesophageal reflux disease (GERD), otolaryngologic or respiratory symptoms may be the only indication of GERD. This review focuses on the recent developments in the pathophysiology, diagnosis, and treatment of GERD and their implications in pediatrics.
Recent findings: Newer diagnostic modalities include intraesophageal impedance and Bravo wireless pH monitoring. Impedance technology measures both acid and non-acid reflux, whereas the Bravo capsule allows prolonged pH monitoring under more physiologic conditions. In managing children with GERD, there is increasing evidence that they need higher dosages of acid suppressive therapy to achieve clinical response. Alternative therapeutic options are also currently being explored, including pharmacotherapy that targets the primary mechanism for GERD. Endoluminal therapy for GERD in adults as an alternative to surgery has been an exciting development. At present, two of these procedures, Stretta (using radiofrequency energy) and Endocinch (gastroplication), have been approved by the Food and Drug Administration for use in adults.
Summary: Impedance technology has increased our understanding of acid and nonacid reflux; however, normal values for children are not yet established. There are also limitations to the applicability of the new endoluminal therapies in children. Further research is needed before these developments can be recommended for use in pediatric practice.
Abbreviations:GER gastroesophageal reflux, GERD gastroesophageal reflux disease, LES lower esophageal sphincter, PPI proton pump inhibitor, TLESR transient lower esophageal sphincter relaxation
Gastroesophageal reflux (GER) refers to the movement of gastric contents into the esophagus or oropharynx, whereas gastroesophageal reflux disease (GERD) can be defined as the clinical manifestations of GER. The symptoms of GERD are quite diverse and may vary according to the age of the child. In infants, regurgitation, vomiting, and irritability are common manifestations of GERD, whereas in older children heartburn, epigastric/substernal pain, and dysphagia are typical symptoms. Additionally, both infants and children with GERD may have an atypical presentation, such as recurrent respiratory symptoms (pneumonia, asthma, cough), otolaryngologic symptoms (hoarseness, globus, sore throat), or dental erosions. Tasker et al. detailed the finding of gastric juice in middle ear effusions at concentrations substantially higher than that found in serum . This supports GERD as a possible contributor to chronic otitis media with effusion.
Reflux is a physiologic event occurring daily in one half of infants 0 to 3 months of age and two thirds of infants 4 months of age . Generally, infants outgrow this “physiologic” reflux, and by 1 year of age, only approximately 5% of infants have persistent symptoms [2,3]. In both children and adolescents, symptoms suggestive of reflux, such as heartburn and abdominal pain, are frequent complaints ; however, the overall prevalence of GERD appears to be lower in children than in adults [4,5].