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Key Points

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  1. Understanding the historical perceptions and experience with gastroesophageal reflux disease (GERD) in infants and children allows the clinician to evaluate the efficacy and reasonableness of proposed treatment modalities.

  2. The presence of GERD in children can be suspected by clinical history, but confirmation requires quantitative testing, which is often invasive.

  3. The most reliable test to confirm the presence or absence of GERD in children is extended esophageal pH monitoring. This test can also give important information about the probability of spontaneous resolution of GERD with time, and the probability that respiratory symptoms associated with the risk for sudden infant death are caused by GERD.

  4. Medical therapy of childhood GERD is often successful in controlling symptoms, but may not eliminate the GERD over time.

  5. Antireflux operations in children with GERD can be performed safely with good long-term control of GERD and minimal morbidity and mortality. More than 1 approach and type of antireflux operation can be used in children to maximize the advantages and minimize the side effects.

  6. The same quantitative evaluation used preoperatively to confirm GERD in children should be used for postoperative evaluation when there is a question about whether GERD is still present or has been eliminated.

  7. Asymptomatic children may have GERD and be at risk for serious complications of GERD, particularly infants with congenital anomalies associated with a high prevalence of GERD.

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Introduction

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A simplified definition of gastroesophageal reflux disease (GERD) is the adverse effects of excessive movement of gastric contents into the esophagus due to a defective gastroesophageal junction. The key to understanding and treating this disease entity in humans is an accurate concept of what constitutes a defective gastroesophageal junction. Normal functions of the gastroesophageal junction include (1) relaxation with swallowing to allow passage of food from the esophagus into the stomach, (2) relaxation to permit eructation or vomiting when necessary to relieve gastric distention, and (3) intermittent relaxation that permits only physiological episodes of gastroesophageal reflux during the initial 2 hours after meals, primarily while awake and only rarely during sleep. Contrasting with GERD is achalasia, in which there is inadequate relaxation with swallowing and impaired esophageal emptying.

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Descriptions of childhood GERD have been recorded as early as 1828 in Paris, where children who succumbed to malnutrition with repeated emesis were found to have esophageal ulcers at autopsy. Over a century later GERD was recognized as a disease entity in children, mainly due to the descriptions of “chalasia” by Berenberg and Neuhauser in Boston and partial thoracic stomach by Astley and Carre in Belfast. These investigators noted that symptoms associated with GERD in treated children would usually disappear by 2 years of age with postural therapy and weaning to solid food. It is for this reason that GERD has been considered to be self-limiting in infants and children.

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Surgical intervention for childhood GERD was not generally considered until the 1950s because the experience ...

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