Collection
Gastroesophageal Reflux Disease
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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7 items
Esophagogastric Dissociation for GERD in Severe Neurodisability
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Dr. Ian Glenn and Dr. Todd Ponsky discuss an article comparing esophagogatric dissociation and laparoscopic Nissen fundoplication in patients with severe gastroesophageal reflux disease (GERD) and severe neurodisability
video2:49 · Oct 2018
Esophagogastric Dissociation for GERD in Severe Neurodisability
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Dr. Ian Glenn and Dr. Todd Ponsky discuss an article comparing esophagogatric dissociation and laparoscopic Nissen fundoplication in patients with severe gastroesophageal reflux disease (GERD) and severe neurodisability
video2:49 · Jan 2019
Gastroesophageal Reflux Disease
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This podcast is a multidisciplinary discussion on a controversial topic, management of pediatric Gastroesophageal Reflux Disease, amongst Dr. Todd Ponsky, Dr. Rachel Rosen, and Dr. George "Whit" Holcomb.Dr. Rachel Rosen is Director of the A
podcast1:21:04 · Dec 2020
Pediatric Gastroesophageal Reflux Disease
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This podcast is a multidisciplinary discussion on a controversial topic, management of pediatric Gastroesophageal Reflux Disease, amongst Dr. Todd Ponsky, Dr. Rachel Rosen, and Dr. George "Whit" Holcomb.Dr. Rachel Rosen is Director of the A
podcast1:21:04 · Sep 2018
Esophageal Disconnect for Severe GERD in Neurologically-Impaired Children:...
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At the 5th Annual Stay Current Pediatric Surgery Update Course in 2017, Dr. David Lanningdiscusses gastroesophageal disconnection in treatment of severe GERD in neurologically-impaired children. He touches on initial management of neurologi
video34:38 · Sep 2018
Gastroesophageal Reflux: Contemporary Management Pediatric Surgery Update...
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Dr. Timothy Kane, chief of general and thoracic surgery at Children's National Medical Center, Washington D.C., discusses gastroesophageal reflux.His presentation of clinical cases includes Collis Nissen fundoplication to lengthen the esoph
video32:14 · Sep 2018
Gastoesophageal Reflux: Update Course 2015
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Dr. Mac Harmon presents on gastoesophageal reflux. His discussion includes topics onsurgical approaches to GERD, AAP GERD guidelines, fundoplication and gastrostomy versus percutaneous gastrojejunostomy, laparoscopic versus open nissen fund
video30:06 · Nov 2018
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Pediatric GERD is overdiagnosed: most infants with vomiting and respiratory symptoms have oropharyngeal dysphagia rather than reflux [e289-c1, e359-c1], and physiologic reflux peaks at 4–6 months . PPIs are ineffective in infants under 1 year because they reflux non-acidic milk, not acid [e289-c3, e359-c3], and both PPIs and H2 blockers increase infection risk including sepsis, NEC, and C. diff [e289-c5, e359-c4]. Eosinophilic esophagitis presents as chronic cough in young children and is found in 10% of those scoped for respiratory symptoms; pre-operative endoscopy is mandatory before fundoplication [e289-c6, e289-c7, e289-c8, e359-c5, e359-c6, e359-c8]. For surgical candidates, laparoscopic Nissen with minimal esophageal mobilization reduces wrap transmigration from 12% to 5% [e289-c22, e359-c20]; the wrap must sit cephalad to the left gastric artery [e289-c23, e359-c22]. Blenderized feeds via G-tube effectively treat post-fundoplication retching [e289-c26, e359-c24], and pyloric Botox addresses the sensory trigger for retching even without improving emptying [e289-c27, e359-c26]. Esophagogastric dissociation shows lower failure rates (4% vs 21%) and reduced PPI dependence (17% vs 54%) compared to Nissen in neurologically impaired children, though operative morbidity is higher [e563-c4, e563-c5, e563-c7, e563-c8, e962-c5, e962-c7].
- Most infants with vomiting/wheezing have oropharyngeal dysphagia, not GERD; PPIs are ineffective and increase infection risk in this population. [e289-c1, e289-c3, e289-c5, e359-c1, e359-c3, e359-c4]
- Scope all children before fundoplication to exclude eosinophilic esophagitis, which presents as chronic cough in 10% of young children with respiratory symptoms. [e289-c6, e289-c7, e289-c8, e359-c5, e359-c6, e359-c8]
- Minimal esophageal mobilization during Nissen reduces wrap transmigration from 12% to 5%; position the wrap cephalad to the left gastric artery. [e289-c22, e289-c23, e359-c20, e359-c22]
- Blenderized G-tube feeds and pyloric Botox effectively treat post-fundoplication retching by addressing gastric accommodation and sensory triggers. [e289-c26, e289-c27, e359-c24, e359-c26]
- Esophagogastric dissociation in neurologically impaired children shows 4% failure vs 21% for Nissen, with significantly lower PPI dependence (17% vs 54%). [e563-c4, e563-c5, e563-c7, e563-c8, e962-c5, e962-c7]
For patients & families
Gastroesophageal reflux (when stomach contents come back up into the esophagus) is very common in babies, affecting more than two-thirds of healthy infants and coming up at one in four six-month checkups . The peak age is between 4 and 6 months . Most babies outgrow reflux by 3 to 4 months of age [e289-c13, e359-c12]. However, if reflux continues beyond age 3 or 4, it's more likely to be a long-term issue [e289-c19, e359-c18]. Doctors have learned that many symptoms parents worry about — vomiting, wheezing, breathing problems — are more often caused by swallowing difficulties (oropharyngeal dysphagia) than by reflux [e289-c1, e359-c1]. In babies under one year old, acid-blocking medications (PPIs and H2 blockers) usually don't help because infants reflux milk, not acid [e289-c3, e359-c3]. These medications can actually increase the risk of infections [e289-c5, e359-c4]. When reflux doesn't improve with feeding changes and time, doctors may recommend surgery (fundoplication), which wraps part of the stomach around the lower esophagus to prevent reflux . Before surgery, doctors often test whether a feeding tube helps, which can predict whether surgery will be needed [e670-c21, e670-c22].
Gastroesophageal reflux (when stomach contents come back up into the esophagus) is very common in babies, affecting more than two-thirds of healthy infants and coming up at one in four six-month checkups . The peak age is between 4 and 6 months . Most babies outgrow reflux by 3 to 4 months of age [e289-c13, e359-c12]. However, if reflux continues beyond age 3 or 4, it's more likely to be a long-term issue [e289-c19, e359-c18]. Doctors have learned that many symptoms parents worry about — vomiting, wheezing, breathing problems — are more often caused by swallowing difficulties (oropharyngeal dysphagia) than by reflux [e289-c1, e359-c1]. In babies under one year old, acid-blocking medications (PPIs and H2 blockers) usually don't help because infants reflux milk, not acid [e289-c3, e359-c3]. These medications can actually increase the risk of infections [e289-c5, e359-c4]. When reflux doesn't improve with feeding changes and time, doctors may recommend surgery (fundoplication), which wraps part of the stomach around the lower esophagus to prevent reflux . Before surgery, doctors often test whether a feeding tube helps, which can predict whether surgery will be needed [e670-c21, e670-c22].
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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.
clinicalRachel Rosen3:23 ↗
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.
clinicalRachel Rosen5:39 ↗
Proton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid.
clinicalRachel Rosen5:26 ↗
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.
epidemiologicalRachel Rosen7:21 ↗
Eosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms.
epidemiologicalRachel Rosen9:53 ↗
In children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive.
clinicalRachel Rosen9:41 ↗
In older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia.
clinicalRachel Rosen10:08 ↗
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.
guidelineRachel Rosen10:54 ↗
About 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy.
epidemiologicalRachel Rosen12:02 ↗
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.
clinicalRachel Rosen16:28 ↗
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.
clinicalRachel Rosen17:48 ↗
The majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age.
clinicalRachel Rosen28:21 ↗
In kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy.
epidemiologicalRachel Rosen28:42 ↗
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.
epidemiologicalRachel Rosen29:37 ↗
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.
clinicalWhit Holcomb22:32 ↗
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.
epidemiologicalWhit Holcomb23:19 ↗
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.
guidelineRachel Rosen43:42 ↗
If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term.
clinicalRachel Rosen45:31 ↗
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.
epidemiologicalWhit Holcomb46:40 ↗
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.
epidemiologicalWhit Holcomb57:32 ↗
The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.
clinicalWhit Holcomb59:22 ↗
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.
clinicalWhit Holcomb1:00:49 ↗
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.
clinicalRachel Rosen1:02:02 ↗
A study out of Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching.
clinicalRachel Rosen1:03:07 ↗
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.
clinicalRachel Rosen16:28 ↗
Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching.
clinicalRachel Rosen54:19 ↗
Cyproheptadine (periactin) helps with gastric accommodation and can control retching in kids.
clinicalRachel Rosen54:26 ↗
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.
clinicalRachel Rosen49:02 ↗
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.
clinicalRachel Rosen35:28 ↗
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.
epidemiologicalWhit Holcomb1:03:46 ↗
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