Let’s switch gears once more
to a much more common problem
but a disease that isn’t as
common as we might think,
and that’s gastroesophageal
So, here’s a classic example.
A nine-month-old child is presenting with
frequent vomiting and poor weight gain.
This nine-month-old boy
has cerebral palsy
and a history of prematurity and is
brought to the emergency department
presenting with wheezing,
stridor, and cough.
His parents are worried about
his respiratory symptoms
but also mentioned that his vomiting has
been preventing him from gaining weight.
So, important key history
points here that one would note
are vomiting has been
preventing from gaining weight,
irritable and refusing feeds,
and wheezing, stridor and cough,
which remarkably, can be a sign of
reflux not respiratory disease.
This is probably
gastroesophageal reflux disease.
So GERD or gastroesophageal
is when stomach contents leak
backward up into the esophagus.
Now, I want to distinguish this from GER,
which is just gastroesophageal reflux.
Gastroesophageal reflux is a normal
physiologic process in young infants.
There is not an infant in the world
who has never spat up a meal.
That is normal reflux.
It becomes a disease when the child
has sequelae of that disease.
So if you remember our
example of our case,
that child was having respiratory symptoms,
was having difficulty gaining weight.
Now, it’s a disease.
Remember that 60% of infants
regurgitate at least once a day.
Only 5% still regurgitate
at 10 to 12 months,
but that’s still normal.
Five to eight percent of older
children and adolescents
report reflux disease
symptoms such as heartburn,
but only about 1% are actually treated.
So, reflux is common,
disease is rare.
The key question to ask is, is
this reflux causing disease
or is it causing
distress to the parents?
The reason why that’s important is
because the treatment of reflux disease
has complications and risks associated
with it that we have to know.
One way to distinguish this is
to check the growth curves.
If you’re following those growth
curves and that child is growing well,
this is unlikely
to be a disease.
A baby who spits up,
even if they spit up every single feed and
the parents swear it’s the entire feed,
if that child is still growing, that
child does not require a therapy.
A child who is spitting up all
their feeds does not grow.
what causes gastroesophageal
For reasons that are unclear,
the child will have an inappropriate
relaxation of the lower esophageal sphincter.
This will be exacerbated by mucosal
damage of the lower esophagus
from exposure to gastric acid.
It’s almost like a vicious cycle.
Also, esophageal peristalsis and the diaphragm
are important in preventing reflux.
And if the child was having a problem
with those muscles or those problems
such as a child with nerve damage,
that may exacerbate the problem.
So, risk factors for GERD include
children with neurologic impairment,
such as cerebral palsy
or Down syndrome.
Obesity is an independent
risk factor of a GERD.
Additionally, children may
have esophageal anomalies
such as atresia or congenital
diaphragmatic hernia or achalasia,
and all of those things can predispose a
child to gastroesophageal reflux disease.
Children with chronic lung disease or cystic
fibrosis may also be a risk for this,
and premature infants
are also at risk.
So historically, we need to
ask the following questions.
Does this child have recurrent
regurgitation or vomiting?
Has the child had weight
loss or poor weight gain?
Those are the key
questions to ask.
material for your test.
Children may also be irritable.
They may have feeding refusal or anorexia.
They may have rumination.
Remember, to ruminate is not only
to think, it’s also what cows do.
You can see them swallowing their
cud and bringing it back up.
This can happen with children
with bad reflux too.
They may actually regurgitate
their meal and swallow it again.
Lastly, older children should be complaining
of heartburn or chest pain around mealtime
because that esophagitis
will be bothersome.
In very severe cases, children
may develop hematemesis.
They may have dysphagia or odynophagia,
which is pain with eating.
Children with reflux
disease that’s very bad,
and these are usually the ones with severe
cerebral palsy or other neurologic problems
may also develop recurrent pneumonia as
they aspirate their abdominal contents.
This can cause a recurrent
wheezing and stridor
as well as the upper airways are irritated
by the acid that’s being aspirated.
It is important to note that
is associated with briefly
resolved unexplained events,
which was what we
used to call ALTE.
I’m covering this in another lecture
and I would urge you to look at that lecture
to fully understand this connection.
So in children with GERD, we expect
to see Sandifer syndrome.
happens in infants
as they’re literally trying to
escape the pain of their reflux.
You will notice children arcs their
back and turn their head to their side
as a way to sort of extend the
esophagus to get out of the way.
If parents report that an
infant is arching his back
and turning his head after feeds routinely,
this is probably Sandifer syndrome,
and probably relates to reflux.
Patients may have pharyngeal inflammation
and complain of sore throat.
And again, they may have these
briefly resolved unexplained events,
or they may have apnea or
breath holding after feeds.
So when you’re taking a
multiple choice exam,
there are many findings that they will
have that are clues to
a diagnosis of reflux.
However, real world, we
don’t see these very often.
It is in fact rare to see
wheezing, coughing, stridor,
or hoarseness of voice in an infant
with gastroesophageal reflux,
or even in children
with reflux disease.
Not unheard of but not common.
The vast majority don’t have it.
Test will report children with anemia.
That’s from a chronic GI bleed,
or sometimes a chronic GI bleed
and not getting enough iron
so they have an iron
Also, test will reveal dental erosions.
That’s almost unheard of in children but
may be more common in older adults.
So, what is seen in patients with
gastroesophageal reflux is esophagitis and pain,
and some respiratory symptoms which may
be refluxate going into an airway,
and that’s really specific to those
children with gross neurologic problems.
In very severe cases, children
may develop failures to thrive,
and they don’t want to eat and
they get used to not eating
and then they have a real
hard time gaining weight.