Pediatric Gastroesophageal Reflux Disease

The vast majority of kids who have vomiting, respiratory symptoms, and wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux.

Proton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid.

In infants fed every 2 to 3 hours, milk remains in the stomach for up to 2–3 hours; acid production only begins after 3 hours, so infants reflux non-acidic gastric content.

Studies have shown that both H2 blockers and PPIs increase the risk of sepsis, UTIs, necrotizing enterocolitis, pneumonia, pharyngitis, upper respiratory infections, GI bugs, and C. diff in infants.

In children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive.

Eosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms.

In older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia.

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.

About 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy.

Macrolides (erythromycin) are motilin agonists that make the antrum of the stomach contract and can help with vomiting; they also have an anti-inflammatory effect on the airway and lungs.

We use a lot of erythromycin in babies who have respiratory symptoms; macrolides are motilin agonists and also have an anti-inflammatory effect for the airway and lungs.

There are no great normal values for the number of reflux episodes in pediatric patients, so the best use of a probe is to correlate symptoms with reflux episodes.

An upper GI is really not a good study for reflux; it doesn't 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 study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.

The majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.

In kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy.

When we looked at our own data at Boston Children's, once a gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures.

The kids who are the most miserable post-Nissen are the kids that were retching pre-op, because they retch a lot post-op too.

There are three Rome IV diagnostic categories for older children with chest pain or heartburn: non-erosive reflux disease (NERD, abnormal acid burden with normal scope), reflux hypersensitivity (normal acid burden but symptom correlation with reflux), and functional heartburn (normal scope, normal acid, no symptom correlation).

New GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months, then attempting to wean; if unable to wean, restart the drug, but the goal should be to try to wean ideally 2 times a year.

If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.

In Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.

When you look at kids that tend to do the worst after Nissen, it's the kid who had a Nissen for pulmonary reasons; if they're aspirating during swallowing, their saliva pools in the esophagus over the Nissen and they continue to aspirate, so they gag, retch, and cough all the time.

Being able to use blenderized food instead of formula has really changed our rates of needing to think about fundoplication, because everything we're putting through the gastrostomy tube is so heavy 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 kids.

By doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.

The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.

You've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.

When you're looking at the post-fundoplication patient, if they have a G tube, you have to image them both ways: putting barium through the G tube and also giving them barium from above via a nasoesophageal tube to see if the esophagus is emptying.

A study out of 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 has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.

When you look at rates of reflux post-Nissen, it's somewhere between 10 and 20 reflux episodes per 24-hour period on impedance probe, and if I see that, I'm pretty happy that the Nissen is still doing its job.

Patients who ruminate describe vomiting 50 to 100 times a day, typically within minutes of starting a meal or for the hour after a meal; esophageal motility study shows simultaneous contraction of the stomach with bolus movement up into the esophagus.

If you wrap patients who ruminate, they continue to do this even with a wrap in place, so fundoplication does not help.