Gastroesophageal Reflux (GERD)

Presentation

• Frequent regurgitation ('spit-ups') following feeds
• GER (normal physiologic) vs GERD (disease causing complications)
• GERD Danger signs: Arching of back (Sandifer syndrome), excessive irritability during feeds, poor weight gain
• Respiratory complications: Apnea, recurrent aspiration pneumonia, chronic cough

Workup

• Primarily a clinical diagnosis
• Upper GI Study (fluoroscopy) to rule out anatomic abnormalities like Malrotation or Pyloric Stenosis (NOT diagnostic for GERD)
• pH/impedance probe study (rarely necessary, but gold standard for quantifying acid/non-acid reflux)

Management

• Step 1 (Conservative): Upright positioning post-feeds, smaller/more frequent feeds, eliminate cow's milk protein from maternal diet (if breastfeeding) or use extensively hydrolyzed formula trial
• Step 2: Thickened feeds (e.g., adding oatmeal cereal, using AR formula) if appropriate
• Step 3 (Pharmacologic - highly restricted): Proton Pump Inhibitors (PPIs) ONLY for documented esophagitis or severe medically refractory cases
• Avoid acid suppressants optimally (increases risk for NEC, pneumonia, and altered microbiome)

Nutritional & GI Surgical Protocol

• NPO protocol: Replogle or Salem sump exactly at 10-14 cm mark hooked to low continuous suction (20-40 mmHg).
• TPN Initiation: Start amino acids at 2-3 g/kg/day, lipids at 1 g/kg/day within 24 hours of NPO status.
• X-Ray monitoring: Cross-table lateral and AP abdominal decubitus Q12h when concerned for perforation.
• Monitor daily abdominal girth measurements accurately marked by an indelible pen line at the umbilicus.
• Guaiac test all macroscopic bloody stools immediately.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• GERD Management Step-Up: [START] Frequent emesis/spitting -> [STEP 1] Upright positioning + Thickened feeds -> [DECISION] Failure to thrive or severe A/B? -> [YES] Trial of PPI (Omeprazole) -> [NO] Continue conservative

References

1. Rosen R, Vandenplas Y, Singendonk M, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the NASPGHAN and the ESPGHAN. J Pediatr Gastroenterol Nutr.