Gastroesophageal Reflux (GER) -- in infants
GER is the passage of gastric contents into the esophagus with or without regurgitation and vomiting (Vandenplas & Rudolph, 2009). It is a normal physiologic process, and it occurs in 2/3 of healthy infants (Nelson, Chen, Synair, et al, 1997). In infants, it is most often due to the lower esophageal sphincter not being fully formed.
The following SOAP note was compiled using:
- AAP's "Gastroesophageal Reflux: Management guidance for the pediatrician" (Lightdale & Gremse, 2013)
- "Pediatric Gastroesophageal Reﬂux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition" (Vandenplas & Rudolph, 2009) -- important article for differentiating GER and GERD!
- AAFP's "Gastroesophageal Reflux in Infants and Children" (Jung, 2001)
- Pediatric's In Review article: "Gastroesophageal Reflux" (Sullivan et al, 2012) -- you need PubMed access for this one.
2.5 mo M full-term infant is brought in by his mother today for concerns about his "ongoing cough and constant spitting up of food with almost all his meals." She reports an increased irritability around meal times -- yet he can be consoled. No fever, diarrhea. There is no major family medical history, family stressors or sick contacts of note. No prenatal, perinatal complications reported. Pt currently takes Vitamin D drops daily, and he has no known allergies, as reported by his mother. He is otherwise healthy infant, and his height/weight tracks the 50th percentile.
The biggest concerns of mom is that he has a "scarier thing going on" and that he may not getting enough nutrition due to the spitting up (she has been trying to "double-up" on the feedings to compensate).
Sleep: +periods of wakefulness, 8-9 hrs/night with naps lasting 1.5-2 hrs (~15 hrs/day), sleeps flat in crib in parent's room.
Diet: Exclusively breast-feeding 4-5 oz q 3 hrs.
General: Well-developed, well-nourished and alert infant. No dysmorphic features observed.
physiologic GER, "happy spitter"
Rx: No Rx needed for GER, first line treatment is lifestyle modifications.
Dx: No diagnostic testing needed for uncomplicated GER.
Patient Ed: Parental reassurance offered regarding normal physiologic process. Expect spontaneous resolution at 12-14 months of age (latest by 18 mo). Supplied family with GIkids.com "Take Home Guide" on GER and GERD.
Anticipatory guidance included:
RTC for 4 mo WCC or PRN if any sx worsen or new sx emerge (re: red flags). If unresolved, anticipate a referral to GI for assessment and EGD, biopsy.
A good history is crucial in distinguishing regurgitation and/or vomiting from vomiting from other disorders. Red flags in the history for infants would include:
SIGNS & SYMPTOMS OF CLASSIC GER
Charts from Vandenplas & Rudolph (2009)
It is important to note that most GER episodes occur several times a day and last less than 3 minutes in healthy individuals and cause few (or no) symptoms (Vandenplas & Rudolph, 2009). If symptoms or complications continue to exist, think GERD or other possible disorders.
Graphic from Lightdale & Gremse (2013)
Interesting side note: Breast milk is generally regurgitated less than formula. Thus, it is important to stress that continuing to breastfeed is encouraged.
Gastroesophageal reflux (GER) versus gastroesophageal reflux disease (GERD)????
- GIkids.com's Reflux Checklist can help you decide GER v. GERD.
- Pediatric Gastroesophageal Reﬂux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (Vandenplas & Rudolph, 2009)