What is the next step in managing a 6-month-old child with cerebral palsy (CP) and recurrent pneumonia, with a suspected diagnosis of Gastroesophageal Reflux Disease (GERD)?

Management of Suspected GERD in a 6-Month-Old with Cerebral Palsy and Recurrent Pneumonia

In a 6-month-old with cerebral palsy and recurrent pneumonia with suspected GERD, the next step is upper endoscopy with esophageal biopsy to establish GERD-related injury and exclude other conditions, rather than empirical PPI therapy. 1

Rationale for Diagnostic Testing Before Treatment

Diagnostic studies should be performed when they can help establish a causal relationship between reflux and symptoms, particularly in patients with associated chronic disease such as cerebral palsy and recurrent pneumonia. 1 This high-risk infant requires definitive diagnosis rather than empirical treatment for several critical reasons:

Why Upper Endoscopy is the Preferred Next Step

• Upper endoscopy with esophageal biopsy is the primary method for establishing GERD-related esophageal injury and excluding other conditions that can mimic GERD symptoms in high-risk infants. 1
• This approach allows direct visualization of esophageal mucosa and histologic evaluation to determine if erosive esophagitis is present. 2
• Approximately 25% of infants younger than 1 year will have histologic evidence of esophageal inflammation, which cannot be determined without biopsy. 2
• Upper endoscopy is specifically indicated in patients with GERD who present with recurrent pneumonia, as this represents a potential life-threatening complication. 2

Why Not Empirical PPI Trial First

Overuse or misuse of PPIs in infants with reflux is a matter for great concern, particularly in this age group. 2 Several factors argue against empirical PPI therapy:

• Placebo-controlled trials in infants have not demonstrated superiority of PPIs over placebo for reduction in irritability. 2
• Acid suppression with either H2RAs or PPIs may be a risk factor for pediatric community-acquired pneumonia, gastroenteritis, candidemia, and necrotizing enterocolitis in preterm infants. 2
• Infants may be at increased risk of lower respiratory tract infections with PPI use. 2
• In cerebral palsy patients specifically, if acid suppression with PPIs is ineffective, the accuracy of the diagnosis of GERD should be reassessed, because fundoplication may not produce optimum clinical results. 2

Additional Diagnostic Considerations

• 24-hour esophageal pH monitoring can quantify GER and detect pathologic reflux, and may be considered as an adjunct or alternative to upper GI series for infants with persistent respiratory symptoms. 1
• Combined pH/multiple intraluminal impedance (MII) testing is evolving into the test of choice to detect temporal relationships between specific symptoms and reflux of both acid and nonacid gastric contents. 2
• Feeding disorders such as GERD and oropharyngeal dysfunction are more prevalent in children with cerebral palsy, especially those with severe gross motor disabilities, and clinical manifestations can be similar, requiring accurate diagnostic methods. 3

Treatment Algorithm After Diagnosis

If Erosive Esophagitis is Confirmed

• If erosive esophagitis is confirmed, PPI therapy is appropriate. 1
• PPIs are considered safe and generally well tolerated with relatively few adverse effects in confirmed disease. 2
• Effective dosage range of omeprazole in children is 0.7 to 3.3 mg/kg daily based on improvement in clinical symptoms. 2

If pH Monitoring Confirms Pathologic Reflux Without Erosive Disease

• Consider H2 receptor antagonists as first-line therapy, such as ranitidine or famotidine. 1
• H2RAs decrease acid secretion and have been shown in trials to be superior to placebo for treatment of erosive esophagitis in children. 2
• The acid-inhibiting effects last approximately 6 hours, making them effective when administered 2 or 3 times daily. 2

If Severe Disease Persists Despite Medical Therapy

• Surgical consultation for fundoplication may be warranted, but careful patient selection is critical due to higher surgical complication rates in cerebral palsy patients. 1
• Cerebral palsy patients have higher surgical complication rates, and direct aspiration of oral contents will not improve with fundoplication. 1

Important Caveats

Oropharyngeal Dysfunction Must Be Considered

• Oropharyngeal dysphagia was estimated at 82% prevalence in children with cerebral palsy presenting with gastrointestinal symptoms, and 52% were affected by both GERD and oropharyngeal dysfunction. 3
• Modified barium swallow (videofluoroscopy) can identify silent dysphagia that may cause recurrent aspiration pneumonia independent of GERD. 4
• This is critical because fundoplication will not address direct aspiration of oral contents. 1

Conservative Measures Should Continue

• Conservative measures such as positioning, feeding modifications, and thickened feedings should continue as important adjuncts to medical therapy. 1
• These include raising the head of the bed, reducing exposure to smoke, and considering formula changes if milk protein allergy is suspected. 2, 5

Avoid Prokinetic Agents

• Avoid prokinetic agents such as metoclopramide due to adverse effects and insufficient evidence to support routine use in infants. 1, 6