Gastroesophageal Reflux Disease
With Dr. Rachel Rosen & Dr. Witt Holcomb · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 40:54 · stops at 41:39 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.
The peak age of reflux is between 4 and 6 months of age.
In children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk).
Normal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty.
Studies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children.
In kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough.
When you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids.
You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis.
In about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy.
Macrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs.
There are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult.
Reflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants.
An upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.
In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.
The majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN.
In Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy.
In kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.
Kids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this.
Rome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux).
The new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly.
If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.
In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.
The primary reason for redo fundoplication is transmigration of the wrap into the chest.
Kids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva.
Blenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia.
Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.
Cyproheptadine (Periactin) helps with gastric accommodation and can control retching in children.
Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.
The key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.
A study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.
Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.
Gastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility.
Botox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism.
Post-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning.
Patients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal.
On esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus.
If you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place.