update on gastro-oesophageal reflux disease in children

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It is critical for the clinician who cares for children to distinguish between normal physiological gastro-oesophageal reflux (GER), and signs and symptoms that occur due to the persistent reflux, defined as gastro-oesophageal reflux disease (GERD).

The underlying natural history of physiological GER in the paediatric population up to about 12 years of age, is quite distinct from normal reflux in adults. Conversely, the underlying pathophysiology of GERD in both age groups is for the most part similar.

Regurgitation symptoms, which peak by 4-6 months of age, appear to resolve commonly by 12-18 months of life. However, there is a growing body of evidence that demonstrates that GERD may not be outgrown in a subset of children. In practice, many clinicians include an empiric therapeutic trial of an H2 receptor antagonist (H2RA) or proton pump inhibitor accompanied by symptom resolution for the diagnosis of GERD. GERD-associated symptoms in the paediatric population range from regurgitation, often accompanied by arching and irritability, to feeding refusal, and/or poor growth to respiratory symptoms such as nocturnal and/or chronic cough. Upper endoscopy with biopsy may be useful in documenting the presence and severity of macroscopic and microscopic mucosal abnormalities, as well as excluding other disorders such as eosinophilic oesophagitis.

Conservative management, particularly useful in mild GERD, consists of positioning during and after feeds, a 2- to 4-week trial of hydrolysate formula, addition of cereal to formula, and smaller, more frequent feeds. Among the current pharmacotherapeutic options available in the United States (US), the prokinetic agent metaclopramide and the acid-inhibitory agents (H2RAs, proton pump inhibitors) are the most widely prescribed. Numerous clinical investigations in both adults and children demonstrated that the proton pump inhibitors are more effective than the H2RAs in the relief of GERD symptoms and healing of erosive oesophagitis. The safety profile of the proton pump inhibitors in children is excellent with no significant adverse events observed either in the short- or long-term (>5.5 years continuous use). Finally, surgical procedures for GERD may also be indicated in certain circumstances.

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