Gastroesophageal Reflux Disease in Neonates and Infants

Abstract

Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. It is a frequently experienced physiologic condition occurring several times a day, mostly postprandial and causes no symptoms. These infants are also called 'happy spitters'. GER disease (GERD) occurs when reflux of the gastric contents causes symptoms that affect the quality of life or pathologic complications, such as failure to thrive, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, apnea, and apparent life-threatening events. About 70-85 % of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95 % of infants by 1 year of age. The predominant mechanism causing GERD is transient lower esophageal sphincter (LES) relaxation, which is defined as an abrupt decrease in LES pressure to the level of intragastric pressure, unrelated to swallowing and of relatively longer duration than the relaxation triggered by a swallow. Regurgitation and vomiting are the most common symptoms of infant reflux. A thorough history and physical examination with attention to warning signals suggesting other causes is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER. Choking, gagging, coughing with feedings or significant irritability can be warning signs for GERD or other diagnoses. If there is forceful vomiting, laboratory and radiographic investigation (upper gastrointestinal series) are warranted to exclude other causes of vomiting. Irritability coupled with back arching in infants is thought to be a non-verbal equivalent of heartburn in older children. Other causes of irritability, including cow's milk protein allergy, neurologic disorders, constipation and infection, should be ruled out. The presentation of cow's milk protein allergy overlaps with GERD, and both conditions may co-exist in 42-58 % of infants. In these infants, symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein from the diet. For non-complicated reflux, no intervention is required for most infants. Effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux. Sandifer syndrome, apnea and apparent life-threatening events are the extraesophageal manifestations of GERD in infants. Pharmacotherapeutic agents used to treat GERD encompass antisecretory agents, antacids, surface barrier agents and prokinetics. Currently, North American Society for Pediatric Gasroenterology, Hepatology and Nutrition (NASPGHAN) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) practice guidelines concluded that there is insufficient evidence to justify the routine use of prokinetic agents. Esomeprazole (Nexium) is now approved in the US for short-term treatment of GERD with erosive esophagitis in infants aged from 1 to 12 months. Although Nissen fundoplication...

From Newborn to Teenage: Gastroesophageal Reflux

“…While its incidence peaks approximately at the 4 th month, it gradually decreases after 1 year of age and almost all children recover at 2 years of age. Regurgitation, which is highly seen in 70-85% of healthy infants, especially those younger than 3 months old, heals spontaneously at 12-14 months of age at a rate of 95% (1,4). GER in older children tends to become chronic and has a similar clinical picture to reflux in adults (5).…”

Gastroesophageal Reflux

“…Dietary treatment does not treat GERD. Parental reassurance and education regarding regurgitation and lifestyle changes such as the use of thickened formula are usually sufficient to manage infant noncomplicated reflux and regurgitation [1,2,119]. Recent, limited data seem to suggest that the protein source (hydrolysate) may also be effective in reducing regurgitation.…”

Comparison of Hypoallergenic Diet vs. Ranitidine in Treatment of Gastroesophageal Reflux Disease of Infants: A Randomized Clinical Trial

“…Decreased lower esophageal sphincter (LES) tone is the most important cause of GERD (4). The role of other factors such as food allergy and cow milk allergy (CMA) have also been suggested in this regard (5).…”

“…Though the symptoms of food allergy overlap with GERD and the conditions could co-exist in 42% -58% of infants and children, there are evidences showing that not only GER can be associated with CMA, but CMA itself can also induce GER (5,6). The findings of studies that have investigated the association of CMA and GERD are controversial (7)(8)(9).…”