Clinicians often have difficulty diagnosing GERD and discriminating it from physiologic regurgitation, especially in the pediatric population. “Childhood GERD is diagnosed commonly by clinical evaluation and often without the use of objective measures,” explains Cabrini LaRiviere, MD, MPH. A GERD diagnosis may remain, especially in young infants, until symptoms wane as part of the natural history of regurgitation or until an objective test disproves the presence of the disease.
Helpful New Data
Some studies have suggested that infants with GERD are more likely than older children to undergo anti-reflux procedures. However, information is lacking on these trends and often does not control for other comorbidities that can serve as indicators for anti-reflux procedures. In JAMA Surgery, Dr. LaRiviere and colleagues published work that examined infants and children with GERD who required inpatient hospitalization and a subpopulation that progressed to anti-reflux procedures. The analysis included 141,190 children with GERD, 8.2% of whom underwent anti-reflux procedures during the 9-year study period. More than half of patients undergoing these procedures were 6 months of age or younger. Although about two-thirds of children receiving anti-reflux procedures had preoperative upper gastrointestinal tract fluoroscopy, the study found that these patients did not undergo a uniform workup.
“Physiologic regurgitation is common in infancy,” says Dr. LaRiviere. “In most infants, this doesn’t lead to prolonged medication use or hospitalization. In fact, this reflux in infancy typically resolves spontaneously. The challenge is that pediatricians and surgeons must determine which cases of regurgitation represent pathologic GERD and which cases might ultimately require operative intervention. We still need a clearer understanding of the role of patient age in GERD to improve care for all pediatric patients who suffer with reflux.”
More Work Needed
The diagnosis and treatment of GERD in adults are fairly well established because the symptoms are clear and easily communicated by most patients, according to Dr. LaRiviere. “However,” she says, “this approach is more difficult in children—especially in infants—because they can’t communicate symptoms.” In addition, the lack of clearly established objective diagnostic criteria in children makes diagnosis and treatment less well-understood.
“Given what our study showed, greater efforts are needed to develop and disseminate best-practice standards for diagnosing and treating children with possible GERD,” Dr. LaRiviere says. “We also need to clarify the indications for anti-reflux procedures for this patient population. The implications of inappropriately selecting or not recommending an operative procedure in infants and children are significant. Better diagnostic criteria should be established so that we never leave GERD untreated in the youngest patients. Doing so can lead to consequences that could potentially be deadly.”
Readings & Resources (click to view)
McAteer J, Larison C, LaRiviere C, Garrison MM, Goldin AB. Antireflux procedures for gastroesophageal reflux disease in children: influence of patient age on surgical management. JAMA Surg. 2014;149:56-62. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1763595.
LaRiviere CA, Parimi C, Huaco JC, Acierno SA, Garrison MM, Goldin AB. Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons. J Pediatr Surg. 2011;46:1093-1098.
Golski CA, Rome ES, Martin RJ, et al. Pediatric specialists’ beliefs about gastroesophageal reflux disease in premature infants. Pediatrics. 2010;125:96-104.
Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD; SAGES Guidelines Committee. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010;24:2647-2669.
Ngerncham M, Barnhart DC, Haricharan RN, Roseman JM, Georgeson KE, Harmon CM. Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg. 2007;42:1478-1485.
Vandenplas Y, Rudolph CD, Di Lorenzo C, et al; North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; European Society for Pediatric Gastroenterology, Hepatology and Nutrition. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49:498-547.