Gastroesophageal reflux.

It is now widely recognized that gastroesophageal reflux causes a number of symptoms in children. Numerous tests have been developed and document the presence of GER, but none is infallible, partially because some reflux is a normal phenomenon. A carefully obtained history and esophagram are the two most useful and available clinical tools. Other tests are useful if there is no agreement between history and esophagram, if specific problems need to be documented (esophagitis), or if more certain documentation is desired because of atypical disease or in anticipation of surgery. If two tests of esophageal function agree, presence or absence of GER is diagnosed with a high degree of accuracy. At present, there is no test that will consistently demonstrate that reflux is causing respiratory symptoms. Most cases of GER in infants will respond to therapy or benign neglect by the time the babies are 18 months of age. This is in contrast to the adult situation, where reflux exists for decades and therapy is directed at the chief symptom, heartburn. Unless there are life-threatening complications or strictures, an intensive course of medical therapy is indicated. Positional therapy is presently the keystone of medical therapy, but is less effective and harder to institute in older patients. Use of thickened feedings may have some benefit. If heartburn or esophagitis is present, attempts to neutralize gastric contents are indicated. Some experience is developing in the use of drugs to control reflux, and a trial of bethanechol is warranted in difficult cases. Since most cases will improve by 18 months of age, therapy is required for only a limited time. At present, surgery is quite safe and is very effective in controlling reflux, although there is no clear consensus on how prolonged and severe symptoms must be to justify surgery in the absence of life-threatening complications.