Gastroesophageal Reflux

Gastroesophageal reflux (GER) is very common in infants and children, and may be physiological in young infants. The incidence ranges from 18% in all infants up to 70% in children with underlying conditions such as tracheoesophageal fistula, neurological deficits and anatomic abnormalities of the esophagus (McGurnt 2003). GER decreases spontaneously from an incidence of 67% at 4-5 months, declining to 21% by 6-7 months and to less than 5% by 12 months (Nelson et al. 1997). In young infants, the short length of the intraabdominal esophagus and physiologic immaturity of the developing lower esophageal sphincter contribute to GER, which invariably improves with the introduction of solid food. GER resolves spontaneously when most

Fig. 2.19. Hiatal hernia. This infant with Marfan syndrome has intrathoracic gastric malposition

infants learn to sit up in the latter part of the first year of life, suggesting that gravity likely plays a role in aiding downward passage of esophageal contents. The presentation of GER is variable. In infants, GER manifests as regurgitation and "spitting up". Abdominal pain is a common symptom of GER in school-age children (Hassal 2005a).

There is a distinction between the common physiologic GER of childhood and pathological gastro-esophageal reflux disease (GERD). This more severe form of reflux can interfere with growth, and cause gastroesophageal and respiratory symptoms. GER has been linked to asthma, and pulmonary symptoms are significantly higher in children with GER than those without (Gold 2005). Children and adolescents with GER are more likely to present with cough and other respiratory symptoms than complaints of "heartburn". Asthma itself causes GER by a variety of mechanisms. Hyperinflation changes the pressure gradient across the lower esophageal sphincter, increases negative intrathoracic pressure and alters the relationship between the diaphragm and lower esophageal sphincter. This may be exacerbated by some asthma medications that decrease lower esophageal sphincter pressure.

While most children with "physiologic" GER will naturally outgrow the reflux, those children with underlying abnormalities will not (B0ix-Och0A and Canals 1976). The initial treatment for GER is most commonly thickening of the infant's formula, feeding smaller amounts per meal and maintaining the

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