GER is characterized by the retrograde movement of gastric contents into the lower esophagus.  This is a result of an incompetent lower esophogeal sphincter (LES). Benign GER or "spitting up" is considered physiologic and the infant or child is free of symptoms and grows appropriately.  Pathologic reflux, gastroesophageal reflux disease (GERD) is associated with weight loss, pulmonary, GI, neurologic, and behavior symptoms.

Infants
    1. GER
        a.. 40% of healthy infants regurgitate more than once a day.  This does not produce weight loss, irritability, or respiratory disease.
        b. Usually begins at about 4 weeks of life, peaks at 4 months, and resolves in the majority of infants by one year of age as the infant eats more solids and becomes ambulatory.
        c. Treatment
          i. avoidance of tobacco smoke- relaxes LES
          ii. Leave the child prone after feeds and avoid "car seat" position
          iii. Thicken feeds with 1 Tbsp. of cereal per ounce of formula and burp frequently during feeds
          iv. avoid jostling during and after feeding.
          v. hypoallergenic formulas have been tried without proof of their success
          vi. reassurance
     2. GERD
       a. symptoms
         i. poor weight gain
         ii. irritability, arching, poor feeding
         iii. Respiratory symptoms including choking, wheezing, cyanotic spells, stridor, hiccups, and hoarseness.
         iv. anemia secondary to blood loss and hemetemesis.
         v. seizure like activity, apnea
         vi. may develop strictures leading to esophageal obstruction.
      b. There is a higher incidence of GERD in developmentally delayed children

Older Children
     1. During the second to third year of life, children may begin to manifest pain as the presentation of GERD.  Symptoms may include substernal or epigastric pain, dysphagia, and symptoms of reactive airway disease.
     2. Treatment
         a. Mild symptoms of reflux may be treated empirically with an antacid such as Tums, Maalox, Mylanta, and  Gaviscon.  Use of an acid producing suppressor  agent  may be tried.  If symptoms persist then a full diagnostic evaluation should be pursued.
        b. Avoid large meals and don't eat before going to sleep.
        c. Diet modifications may help including avoidance of caffeine, fatty foods, citrus foods, and carbonated beverages
        d. avoid tobacco smoke
        e. Course is usually chronic with remissions and exacerbations.

Diagnosis
1. Consultation with a gastroenterologist is important because the workup will include tests that only experienced individuals are capable of interpreting.
2. Upper GI- to evaluate anatomy
3. Scintgraphy- evaluate motility
4. pH probe- associate symptoms with temporal changes
5. esphogoscopy and biopsy- evaluated for infection, Eosinopilic esophagitis, Crohns disease

Differential Diagnosis
1. Vomiting-drugs, toxins, increased intracranial pressure, gi obstruction, achalasia, liver and gall bladder disease
2. Pain- chest pain, ulcer disease, functional, colic
3. Respiratory - reactive airway disease, infection, central apnea, foreign body
4. seizures.
5. Allergic- may need to eliminate milk from infants diet and from mother's diet if she is nursing.

Treatment
1. Infants- after the diagnosis is established, conservative measures have failed, and other causes of the symptoms have been ruled out, specific therapy should be instituted.
     a. Prokinetic agents- Not used often now.  Cisapride ( .2mg/kg./dose qid-max 10 mg qid. Has been associated with cardiac arrhythmia especially when given with "azole" or "mycin" antibiotics.  Must do an EKG prior to starting and check the QTc.
     b. Acid producing blockers (H2 blockers)- cimetadine(10mg./kg./dose qid ) or Ranitidine (1-2mg/kg/dose q12 hours) Reevaluate at frequent intervals and if symptoms improve, stop the antacid first.  If symptoms continue, GI consultation is advised.  Most infants are better at 12 months of age.
     c. If there is no improvement with medical management, surgical intervention should be considered.
2. Newer agents
     a. Proton pump inhibitors (omeprazol) should be used after consultation with a pediatric gastroenterologist.

References
1. Hart, John J. Pediatric Gastroesophageal Reflux. American Family Physician. December 1996.
2. Nelson SP et al. One-year Follow-up of Symptoms of Gastroesophageal Reflux during Infancy. Pediatrics. 1998; 102(6):e67.
3. Nelson SP et al. Prevalence of Symptoms of Gastroesophageal Reflux during Childhood. Archives of Pediatrics and Adolescent Medicine. 2000; 154(2):150-154.
4. Orenstein SR. Consultation with the Specialist: Gastroesphogeal Reflux. Pediatrics in Review. 1999; 20:24-28.
5. Christian F. Poets Gastroesophageal Reflux: A Critical Review of Its Role in Preterm Infants Pediatrics, Feb 2004; 113: e128 - 132.
6. Arie Levine, Tamir Milo. Influence of Helicobacter pylori Eradication on Gastroesophageal Reflux Symptoms and
     Epigastric Pain in Children and Adolescents. Pediatrics, Jan 2004; 113: 54 - 58.
7. Braganza S. Gastroesophageal Reflux.  Pediatrics in Review August 2005
8. Khoshoo V. et al. Are We Overprescribing Antireflux Meidacations for Infants with Regurgitation?  Pediatrics Nov 2007
9. Gastroesophegeal Reflex.  Pediatrics in Review March 2008
10.J Pediatr Gastroenterol Nutr, Vol. 49, No. 4, October 2009 Pediatric Gastrointestinal Reflux Clinical Practice Guidelines