GERD

Gastroesophageal reflux, or GER, means that stomach contents move back into the esophagus.

This is common in infants and may appear as small amounts of milk coming back up after feeds.

When an infant:

• Spits up easily.
• Feeds comfortably.
• Gains weight appropriately.
• Shows no significant distress or complications.

this is often considered uncomplicated infant reflux.

Gastroesophageal reflux disease, or GERD, is considered when reflux causes:

• Persistent irritability or discomfort associated with feeds.
• Feeding refusal or significant difficulty feeding.
• Poor weight gain or growth concerns.
• Signs suggestive of esophageal inflammation.
• Respiratory symptoms related to reflux in selected children.

The difference depends on the effect of reflux on the child's health, feeding and growth rather than simply the amount of visible spit-up.

GERD symptoms vary with age.

Infants and younger children may have features such as:

• Recurrent regurgitation or vomiting associated with other problems.
• Feeding refusal or feeding difficulty.
• Crying, arching of the back or signs of discomfort during or after feeds.
• Poor weight gain.
• Recurrent respiratory symptoms, chronic cough or wheezing related to reflux in some children.

Older children may report:

• Heartburn or a burning sensation in the chest.
• Pain in the upper abdomen or chest.
• Sour fluid or food coming back into the mouth.
• Difficulty or discomfort when swallowing.

No single symptom confirms GERD because many other conditions can produce similar complaints.

Some symptoms are not typical of simple reflux and may indicate another condition requiring prompt assessment.

Medical evaluation is important if a child develops:

• Green or bilious vomiting.
• Blood in the vomit or bowel movements.
• Persistent, forceful vomiting.
• Fever, lethargy or signs of general illness.
• Significant abdominal swelling or tenderness.
• Severe difficulty swallowing or choking during feeds.
• Noticeable faltering growth or weight loss.

These symptoms can have causes other than GERD, so vomiting or regurgitation should not automatically be attributed to reflux.

In many children, GER and GERD can be assessed using:

• Medical history.
• Description and timing of symptoms.
• Feeding history.
• Growth and weight assessment.
• Physical examination.

Further testing is not required for every infant.

Additional investigations may be considered when warning signs are present, the diagnosis is unclear, symptoms are severe or standard management has not helped.

Depending on the child's situation, investigations may include:

• Esophageal pH or impedance-pH monitoring to assess acid and non-acid reflux.
• Upper endoscopy with biopsy to look for esophagitis, infection, eosinophilic esophagitis or anatomical differences.
• Upper gastrointestinal contrast study to check for anatomical abnormalities, such as malrotation, stricture or hiatal hernia.

An upper GI contrast study is not routinely used simply to prove that GERD is present.

Treatment depends on the child's age, symptoms and whether complications are present.

Infants:

Many infants with uncomplicated reflux do not need medication.

Management may include medical guidance on:

• Avoiding overfeeding.
• Adjusting feed volumes and frequencies when appropriate.
• Using thickened feeds where suitable.
• A supervised trial of an extensively hydrolyzed formula or maternal dietary changes when cow's milk protein allergy is suspected.

Safe sleep recommendations must always be followed.

Infants should be placed on their backs to sleep on a firm, flat mattress, and unsafe sleep positions should not be used as a treatment for reflux.

Older Children:

Management may include:

• Avoiding large meals close to bedtime.
• Modifying foods that clearly trigger symptoms.
• Addressing overweight if relevant.
• Avoiding tobacco smoke exposure.

Medications:

In selected children with confirmed or strongly suspected GERD, a clinician may consider medications that reduce stomach acid, such as proton pump inhibitors (PPIs) or H2 receptor antagonists.

Acid-suppressing medications are not recommended for routine use in healthy infants who simply spit up without other complications.

The decision depends on symptoms, diagnosis and whether clinically important acid-related disease or esophagitis is suspected.

Surgery is not the first-line treatment for most children with GERD.

Anti-reflux surgery is reserved for selected children after the diagnosis has been carefully evaluated and other causes of the symptoms have been considered.

Surgery may be discussed when a child has severe GERD or significant complications that have not responded to appropriate medical and supportive management, or when medical therapy cannot be used or maintained safely over time.

The most common anti-reflux operation is fundoplication.

During this procedure, the upper part of the stomach is wrapped around the lower esophagus to reinforce the anti-reflux barrier.

It can often be performed using laparoscopic techniques.

However, surgery has both benefits and risks, and some children may experience:

• Difficulty swallowing.
• Bloating and difficulty burping.
• Persistent or recurrent reflux symptoms.
• Changes in the repair over time.

The decision requires careful assessment and discussion of expectations, potential complications and expected outcomes.

When anti-reflux surgery is being considered, the diagnosis and previous treatment are reviewed carefully.

Assessment may include:

• Severity of symptoms.
• Growth and nutritional status.
• Presence of esophagitis.
• Reflux testing results when performed.
• Evaluation of anatomy to exclude other conditions.
• Pre-anesthesia evaluation.

Fasting instructions and medication recommendations before anesthesia must be followed carefully.

Parents should let the surgical team know if the child:

• Takes regular medications.
• Has known allergies.
• Has any bleeding concern.
• Develops a fever, cough or illness shortly before the scheduled procedure.

Before surgery, families can discuss:

• Why surgery is considered suitable.
• Potential alternatives.
• The surgical approach planned.
• Feeding plans after the operation.
• Expected hospital stay and follow-up.

After anti-reflux surgery, the child is monitored for comfortable breathing, swallowing, feeding and adequate pain control.

The postoperative feeding plan varies according to the child's age, medical condition and surgical technique.

Liquids are usually started first and advanced according to the surgical team's guidance.

Instructions should be followed regarding:

• Medications.
• Wound care.
• Dietary progression.
• Activity.
• Bathing.
• Return to school or daily routines.

Some children feel fuller or experience more bloating than usual during the initial recovery period.

Families should contact the medical team if the child develops:

• Severe or worsening difficulty swallowing.
• Repeated vomiting.
• Inability to drink fluids.
• Fever.
• Increasing wound redness, pain or discharge.
• Any unexpected symptoms related to the operation.

Follow-up visits are important to evaluate feeding, growth, symptom relief and long-term recovery.