Management of gastroesophageal reflux disease in pediatric patients: a literature review

A narrative review of gastroesophageal reflux in the pediatric patient

Gastroesophageal reflux (GER) is the retrograde passage of gastric contents into the esophagus. It is a physiologic condition that is common in neonates, typically resolves spontaneously, and does not result in clinically significant complications. When pathologic, gastroesophageal reflux disease (GERD) can cause numerous complications including persistent emesis, failure to thrive, aspiration, and respiratory symptoms. While a diagnosis can often be made from a thorough history and physical, some patients may require further testing. In general, many clinicians will reserve extensive investigation such as multiple intraluminal impedance and pH monitoring for patients with a confounding clinical picture or relative contraindications to medical or surgical management. Whereas most pediatric GER resolves spontaneously, medical management including lifestyle changes, changes to feeds, and the use of H₂-antagonists and/or proton pump inhibitors (PPIs) can be utilized to alleviate symptoms. Surgical treatment is reserved for patients who are refractory to medical management or have suffered significant complications as a consequence of GER. In this article we seek to provide a concise but detailed review of recent updates in the understanding, work up and management of GER in the pediatric patient. A summary of new technologies used in the diagnostic and therapeutic arms of this disease are included.

Management of gastroesophageal reflux disease in pediatric patients with cerebral palsy

Question As a family physician who provides care to a large pediatric population in the community, I see children with various neurologic impairments, many with cerebral palsy (CP), presenting with gastroesophageal reflux disease (GERD). What are the current recommendations to manage GERD in pediatric patients with CP?Answer A variety of lifestyle modifications can be used to manage GERD in pediatric patients with CP, including raising the head of the patient's bed, reducing patient weight, limiting exposure to smoke, and avoiding caffeine, spicy foods, fatty foods, and chocolate. The primary pharmacologic treatments currently recommended are histamine-2 receptor antagonists and proton pump inhibitors. Surgical treatments for GERD, like the Nissen fundoplication, might result in complications, so there is ongoing research looking at the benefits of using high-pectin diets, baclofen, and prokinetic agents like mosapride instead.

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Question En tant que médecin de famille qui dispense des soins à une vaste population pédiatrique de la communauté, je vois des enfants atteints de diverses déficiences neurologiques, dont beaucoup de cas de paralysie cérébrale (PC), qui présentent un reflux gastro-œsophagien (RGO). Quelles sont les recommandations actuelles de prise en charge du RGO chez les enfants atteints de PC?

Réponse Diverses modifications du mode de vie sont utiles pour prendre en charge le RGO chez les enfants atteints de PC, notamment soulever la tête du lit du patient, faire maigrir le patient, limiter l’exposition à la fumée, et éviter la caféine, les aliments épicés, les aliments gras et le chocolat. Les traitements pharmacologiques recommandés à l’heure actuelle sont les antagonistes des récepteurs de l’histamine H₂ et les inhibiteurs de la pompe à protons. Le traitement chirurgical du RGO, comme la fundoplicature de Nissen, pourrait entraîner des complications, alors la recherche se poursuit sur les bienfaits liés aux régimes riches en pectine, au baclofène et aux agents stimulant la motilité gastrique, comme le mosapride, à titre de solution de rechange.

[Profile of gastrointestinal diseases in a pediatric gastroenterology center in Colombia: 15 years of follow-up]

INTRODUCTION

The profile of gastrointestinal diseases is constantly changing globally and locally affecting suspected diagnosis and medical methods.

OBJECTIVE

To establish the main diagnoses in a gastroenterology, hepatology, and pediatric nutrition unit in Bogota between 2009 and 2013, and to compare with findings from the same unit during the two prior five-year periods (1997 to 2006).

MATERIALS AND METHODS

We conducted a retrospective descriptive study. Medical records were reviewed to extract diagnoses. Data from the two previous five-year periods were taken from institutional records. A univariate analysis was performed, along with calculation of absolute and relative frequencies for qualitative variables, and central tendency and dispersion measures for quantitative variables.

RESULTS

The study collected the diagnoses of 1,171 patients, 51.8% (607) of whom were male, and 64% (753/1171), under five years of age. The main diagnoses were: constipation (33.9%), food allergy (23.5%), eating disorders (5.5%), gastroesophageal reflux disease (4.1%), peptic ulcer disease (4.1%), persistent diarrhea (3.8%) and cystic fibrosis (3.4%). Upon comparing this period with the two previous ones, we observed that peptic ulcer disease decreased while constipation, which was in the second position, rose to the first place. Food allergy, not registered within the first ten diagnoses in previous periods, appeared during this last period.

CONCLUSIONS

During the last five years, constipation was the first gastrointestinal diagnosis followed by food allergy, in agreement with the global trend. It is essential, therefore, to apply diagnostic algorithms, timely treatment, and prevention.