Paediatrics and International Child Health

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Gastroesophageal reflux disease (GERD) in

children

Ujjal Poddar

To cite this article: Ujjal Poddar (2018): Gastroesophageal reflux disease (GERD) in children,
Paediatrics and International Child Health, DOI: 10.1080/20469047.2018.1489649

To link to this article: https://doi.org/10.1080/20469047.2018.1489649

Published online: 06 Aug 2018.

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PAEDIATRICS AND INTERNATIONAL CHILD HEALTH
https://doi.org/10.1080/20469047.2018.1489649

Gastroesophageal reflux disease (GERD) in children

Ujjal Poddar
Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

ABSTRACT ARTICLE HISTORY

Background: Gastro-oesophageal reflux (GER) and gastro-oesophageal reflux disease (GERD) Received 4 March 2018
are common in infants and children. Accepted 11 June 2018
Aims: To review the recent literature on GERD in children and to outline the approach to KEYWORDS
diagnosis and management. Regurgitation; pH study;
Methods: A literature search in PubMed was conducted with regard to the prevalence, impedance; endoscopy;
clinical features, diagnosis and management of GER and GERD in children with special proton-pump inhibitors
attention to low- and middle-income countries. Articles in English published during the last
25 years, the full text of which was available, were considered and the relevant information
extracted.
Results: Almost 50% of all healthy infants regurgitate at least once a day which peaks at
4 months of age and subsides by 12 months in 90% of cases. Conversely, the prevalence of
GERD increases with age and, by adolescence, is similar to that in adults (20%). While GER in
infancy does not require investigation or therapy, an empirical proton pump inhibitor (PPI) for
4-8 weeks is justified in older children with classical symptoms of GERD. There is no gold-
standard investigation for GERD. In extra-oesophageal manifestations, a pH/impedance is
useful and endoscopy in cases with oesophagitis. PPIs play a pivotal role in the management
of GERD but have not been found useful in infants with GER. Anti-reflux surgery plays a minor
role in GERD owing to the associated morbidity and high failure rate, especially in high-risk
groups who most need it.
Conclusions: Unless there are warning features such as failure to thrive, haematemesis,
abnormal posturing, choking/gagging or coughing while feeding, regurgitation in infancy
need not be investigated. In older children and adolescents with typical reflux symptoms,
empirical PPI therapy is justified. For extra-oesophageal manifestations, a pH/impedance
study and endoscopy to detect oesophagitis are the investigations of choice. PPI is the
mainstay of therapy in GERD, but not in GER.

Introduction followed a similar pattern: 20% at 0–3 months, 23% at

4–6 months and only 3% at 7–9 months and, by
Gastro-oesophageal reflux (GER) is a physiological pro-
12 months, only 2% of infants still had regular regurgita-
cess that occurs many times a day in healthy children as
tion. This natural history of GER in infancy has been
well as in adults. It is defined as the involuntary passage
substantiated by other studies in Australia and Italy
of gastric contents back into the oesophagus. Gastro-
[3,4]. The prevalence of GER in infants in LMIC is similar
oesophageal reflux disease (GERD) is symptoms or com-
to that in HIC. Studies of 602 patients in India [5] and 103
plications associated with pathological GER [1]. GER is
in Indonesia [6] reported a prevalence of GER in the first
one of the most common causes of upper gastro-intest-
6 months of life as high as 55–73% which had decreased
inal symptoms in children.
to 4–12% by 12 months of age. On the other hand, a
small proportion (5–9%) of all infants with regurgitation
Prevalence have GERD [2,6]. These studies [2–6] suggest that GER is
common in early infancy and has almost disappeared by
GER or regurgitation is a common phenomenon in
one year of age. The continuation or development of
infancy in both high-income countries (HIC) and low-
regurgitation after 18 months of age suggests a patholo-
and middle-income countries (LMIC). A study of 948
gical condition.
infants in the USA reported a 50% prevalence of at least
The prevalence of GERD is lower in younger chil-
one bout of regurgitation a day in infants aged 0–3
dren. In a study in the USA [7] of 566 children aged
months which increased to 67% at 4–6 months of age
3–9 years (parental interview) and 615 children aged
and then declined sharply to 21% at 7–9 months of age,
10–17 years (directly interviewed), pyrosis or heart-
and, by 10–12 months, only 5% of infants still had regur-
burn was reported in 1.8% of the 3–9-year-olds and
gitation [2]. A significant proportion of these infants
in 3.5% of the 10–17-year-olds. This figure was much
regurgitated more than four times a day and they too

CONTACT Ujjal Poddar ujjalpoddar@hotmail.com

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 U. PODDAR
less in comparison to the reported prevalence of
GERD in adults (20‒40%) [8,9]. During childhood, the
prevalence of GERD increases slowly with age and
becomes frequent in young adults. A cross-sectional
observational study of 10,394 French children (0–
17 years) estimated that 10% of all children have
GER and 6.2% have GERD [10].
Presenting symptoms
Presenting symptoms differ in infants and children
[11]. The vast majority of healthy infants present
with daily regurgitation or vomiting with no failure
to thrive and they are called ‘happy spitters’.
Nevertheless, it is important, and often difficult, to
differentiate between physiological GER and GERD
(Table 1). Features suggestive of GERD are associated
growth failure and/or features of oesophagitis such as
irritability, feeding difficulty, sleeping difficulties, cry-
ing episodes and anaemia. GERD in infants can pre-
sent with extra-oesophageal symptoms such as
coughing, choking, wheezing and, rarely, apnoea or
apparently life-threatening events. Important ele-
ments of the history which help to differentiate
GERD from other causes of vomiting are given in
Table 1. Older children and adolescents often present
with symptoms similar to those in adults such as
heartburn, epigastric pain, chest pain, dysphagia, noc-
turnal pain, regurgitation and sour burps. Extra-oeso-
phageal symptoms in older children include nocturnal
cough, wheezing, recurrent pneumonia, sore throat,
hoarseness, chronic sinusitis, laryngitis or dental ero-
sion [12]. Younger children (<12 years) often present
with nausea, vomiting, abdominal pain, anorexia and
food refusal [13]. A subset of children (Table 2) with
underlying disorders such as anatomic issues
(repaired trache-oesophageal fistula and oesophageal
atresia) or neurodevelopmental problems are at
greater risk of developing severe GERD [14].
Table 1. Features (alarm features) that
prompt further investigation [13].
Vomiting associated with:
● Presence of bile
●
Presence of blood
● Presence of forceful vomiting
● Onset of vomiting after 6 months of life
● Choking, gagging, coughing with feeds
● Failure to thrive
● Diarrhoea/constipation
● Abdominal tenderness or distension
● Fever
● Lethargy
● Hepatosplenomegaly
● Bulging fontanelle
● Microcephaly or macrocephaly
● Seizures
● Suspected genetic/metabolic syndrome
Table 2. Conditions predisposing to severe GERD in children [14].
● Obesity
● Neurological impairment, e.g. cerebral palsy
● Neuromuscular disease, e.g. congenital myopathy
● Genetic conditions, e.g. Down syndrome
● Repaired trache-oesophageal fistula
● Repaired oesophageal atresia
● Congenital diaphragmatic hernia
● Chronic lung disease, e.g. bronchopulmonary dysplasia, bronchiec-
tasis, asthma
● Cystic fibrosis
● Scleroderma
● Previous oesophageal caustic injury
● Significant prematurity
● Strong family history of GERD, Barrett oesophagus or oesophageal
adenocarcinoma
Diagnostic approach to GERD
In the absence of warning signs, a history and physical
examination are sufficient in most paediatric patients
to diagnose uncomplicated GER and initiate therapy.
Nevertheless, distinguishing between physiological
GER and pathological GERD often poses a serious
challenge, especially in infants. Accurate distinction
between GER and GERD is essential to guide further
investigation and treatment. When the presentation is
atypical, investigation is required to make the diag-
nosis and assess the severity, and outcome of GERD.
There is no single gold-standard test to diagnose
GERD. The choice of investigation depends on the
clinical situation for which the investigation is
requested. pH/MII (multichannel intraluminal impe-
dance) is required to document reflux in patients
with extra-oesophageal symptoms (e.g. bronchial
asthma, aspiration pneumonia, etc.) without any
symptoms of GER. When oesophagitis is suspected,
upper gastro-intestinal endoscopy and biopsy is
recommended. However, when there is a suggestion
of an anatomical abnormality such as dysphagia, a
barium series is indicated.
GERD in infants
The clinical approach to an infant with suspected GER
is illustrated in Figure 1. Reliable information about
symptoms is needed to make the clinical diagnosis of
GERD. In infants, information is often circumstantial
and by proxy (from parents); a number of GERD symp-
tom questionnaires have been validated and are useful
in differentiating GER from GERD. One of the most
commonly used is Orenstein’s infant GER questionnaire
(i-GERQ) [15] which has a symptom-based, 11-point
questionnaire (I-GERQ GERD) with a maximum score
of 25 (Table 3) to differentiate GER from GERD. A
score of >7 has 74% sensitivity and 94% specificity in
diagnosing GERD in infants. This questionnaire has
been validated in LMIC such as India [16] and has
been shown to be easily adaptable and reproducible
but with lower diagnostic accuracy (sensitivity of 43%

Figure 1. Suggested approach to gastro-oesophageal reflux in infants [18].
Table 3. GER vs. GERD in infants (modified Orenstein’s infant
GER questionnaire [15]).
Question
1 How often does the baby usually spit up?
● 1–3 times per day
● 3–5 times per day
● >5times/day
2 How much does the baby usually spit up?
● 1 teaspoonful to 1 tablespoonful
● 1 tablespoonful to 1 ounce
● >1 ounce
3 Does the spitting up seem to be uncomfortable for the
baby?
4 Does the baby refuse feeding even when hungry?
5 Does the baby have trouble gaining enough weight?
6 Does the baby cry a lot during or after feeding?
7 Do you think the baby cries or fusses more than normal?
8 How many hours does the baby cry or fuss each day?
● 1 to 3 h
● >3h
9 Do you think the baby hiccups more than most babies?
10 Does the baby have spells of arching the back?
11 Has the baby ever stopped breathing while awake and
struggled to breathe or turned blue or purple?
Total score
Score >7: sensitivity 74% and specificity 94% for diagnosing GERD.
and specificity of 79%) than the original study.
Nevertheless, the I-GERQ GERD questionnaire, because
of its simplicity (just 20 min to complete) and reprodu-
cibility, can be used to identify infants who need
further evaluation.
GERD in children and adolescents
The approach in older children and adolescents is
shown in Figure 2. In children >8 years who can
provide a proper history, the history and physical
examination are sufficient in most cases to diagnose
PAEDIATRICS AND INTERNATIONAL CHILD HEALTH 3
GERD. In adults, empirical therapy with a proton
pump inhibitor (PPI) for 2–4 weeks is an accepted
Points
method of diagnosing GERD with the classical symp-
1
2 toms of heartburn with or without regurgitation [17].
3 Although there is no empirical trial of PPI as a diag-
1 nostic test in children, an empirical PPI trial of
2 4–8 weeks is justified in older children and adoles-
3
cents with classical symptoms of GERD [18].
2 Diagnostic studies such as endoscopy and a pH/MII
study are useful when symptoms are not classical and
1
1 in cases of complicated GERD. To diagnose GERD,
3 barium upper gastro-intestinal series and nuclear scin-
1
1 tigraphy are not recommended because of their poor
2 sensitivity and specificity [18].
1
2
6 Management
25 Therapy for GERD is based on a combination of con-
servative measures (lifestyle and dietary modification)
and pharmacological and, rarely, surgical treatment.
When there is clinical suspicion of GERD and the
patient presents with alarm symptoms (Table 1), he/
she should not be treated but investigated. Patients
without alarm features should be treated
conservatively.
GER in infants (happy spitters)
The most important aspect of management is parental
education and support (counselling). The natural his-
tory of GER in infants should be explained to parents or
carers. Other measures are feeding advice, positioning
and feed-thickening. For formula-fed infants, reducing
4 U. PODDAR
Figure 2. Suggested approach to gastro-oesophageal reflux disease in older children and adolescents [18].
volumes in overfed infants or offering small frequent
feeds can decrease episodes of reflux. Although the
prone position is the best one to prevent reflux, in
view of the increased risk of sudden infant death syn-
drome, it is not recommended in infants. Nevertheless,
beyond infancy (>13 months), the left lateral position is
found to be the optimal for preventing reflux.
Thickening feeds by adding rice, corn or potato starch
(one table spoon per ounce) decreases the frequency
of regurgitation or amount of vomiting but it does not
decrease acid exposure in the oesophagus, shown by
pH monitoring [19]. In a subset of patients (1–10%),
regurgitation may be caused by cow’s milk protein
allergy [20]. In infants with persistence of symptoms
despite counselling and feed thickening, a 2–4-week
trial of a hypo-allergenic formula (extensively hydro-
lysed or amino acid-based formula in formula-fed or, in
breastfed infants, withdrawal of all dairy products,
including casein and whey, from the mother’s diet) is
recommended. If symptoms subside, a challenge and
continuation of a milk-free diet is recommended if
appropriate. However, if there is no response to a
hypo-allergenic formula over 2–4 weeks, there is no
advantage in continuing the above formula [18] and
the child should be referred to a paediatric gastro-
enterologist. If referral is not possible, consider
4–8 weeks of acid suppression and then, if symptoms
have improved, wean off the therapy [18].
PPIs are not recommended in this subset of
patients as only a few of them are likely to have
symptoms with an acid-related cause; the largest
randomised, placebo-controlled trial in infants
showed that, for symptoms presumed to be related
to reflux disease, a PPI was not better than pla-
cebo [21].
GERD in children
Besides medication, lifestyle modification in terms of
weight reduction in overweight/obese patients, the
avoidance of caffeine and chocolate and, in adolescents,
abstinence from alcohol and tobacco may help [18].
Adolescents, like adults, might benefit from the left lateral
decubitus sleeping position with elevation of the head.
Pharmacological therapy
Acid suppressants
Children with GERD require potent acid suppression
therapy for at least 12 weeks. It has been shown that
PPIs are more potent and more effective than a hista-
mine 2 receptor antagonist (H2RA). The healing rate
of erosive oesophagitis with H2RA such as ranitidine
(6–8 mg/kg/day, BID or TID) is 60–70% and with PPIs
such as omeprazole (0.7–3.5 mg/kg/day, OD) is
90–100% [22,23]. PPIs should be taken 30 min before
breakfast as they act best in activated parietal cells; a
once-daily dose is adequate and there is no difference
in efficacy between the various PPIs (omeprazole,
lansoprazole, esomeprazole, rabeprazole, pantopra-
zole). Antacids can be used for symptomatic relief

for a brief period but prolonged therapy is contra-
indicated in children owing to the side-effects.
Side-effects of PPIs
In general, PPIs are safe. Minor side effects such as head-
ache, constipation, nausea and diarrhoea are reported in
up to 14% of patients [24,25]. PPIs have been used safely
in children for more than a decade [26]. However, their
overuse or misuse, especially in infants, is a concern.
There is increasing evidence that PPIs may be a risk
factor for community-acquired pneumonia, gastro-
enteritis, systemic candidiasis and necrotising enteroco-
litis in preterm infants. Profound hypochlorhydria pro-
duced by PPI increases the risk of Clostridium difficile
infection which has been established in adults and has
also been reported in children [27,28]. Similarly, PPI-
induced hypochlorhydria causes calcium malabsorption
which may lead to low bone density and an increased
risk of fracture, especially in adults of 18‒29 years [29].
Surgery
Nissen fundoplication (open or laparoscopic) is indicated
for children in whom optimal medical therapy has failed,
who are dependent on medical therapy for a long period
or who have life-threatening complications of GERD.
Neurologically impaired children, a group who require
surgery the most often, are prone to develop surgery-
related complications and surgical failure. Surgery fails in
almost two thirds of neurologically impaired children and
one third of otherwise healthy children and they require
long-term medical treatment [1]. Early fundoplication in
infancy has a higher failure rate than in late child-
hood [1,18].
Conclusions
GER is common in infants but GERD is not so common in
early childhood. Most infants have physiological reflux
which subsides by 18 months of age. There is no gold
standard diagnostic test for GERD and investigations
should be tailored to the clinical concern. Empirical PPI
therapy for 4-8 weeks is justified in older children and
adolescents with classical symptoms, but not for infants.
pH-metry/MII for extra-oesophageal manifestations and
endoscopy for oesophagitis are the investigations of
choice. When indicated, acid suppressant therapy with
PPI is safe and very effective. Surgical therapy is not a
panacea as it carries significant morbidity and often fails
in those who need it most.
Disclosure statement
No potential conflict of interest was reported by the author.
PAEDIATRICS AND INTERNATIONAL CHILD HEALTH 5
Notes on contributor
Ujjal Poddar, is a Professor in the Department of Paediatric
Gastroenterology, SGPGIMS, Lucknow, India. Research inter-
ests include: Celiac disease, portal hypertension and
Hepatitis B.
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