Gastroesophageal reflux and its clinical manifestation at gastroenteric and respiratory levels in childhood: physiology, signs and symptoms, diagnosis and treatment.

Gastroesophageal reflux (GER) is a physiological process occurring with different frequency and characteristics in healthy infants, children and adults, most episodes being brief and asymptomatic. By contrast, GER disease (GERD) occurs when this normal event results in the occurrence of symptoms/signs or complications involving the upper portion of the gastroenteral tract and the respiratory system. Transient relaxations of the lower esophageal sphincter represent the major mechanism responsible for reflux episodes, possibly associated with gastroesophageal dysfunctional motility, excessive gastric acid secretion or anatomic abnormalities. The diagnosis of GERD, that is, a causal relationship between reflux and GERD symptoms, may be difficult to determine and make clinically, with support needed from diagnostic evaluations, and final confirmation by response to treatment. Management of GER/GERD should follow a stepwise approach: lifestyle modifications, pharmacologic therapy and surgical procedures; some of these steps may occur simultaneously. In children with mild symptoms and without anatomic abnormalities, the initial choice should be lifestyle modifications and pharmacologic therapy with prokinetic agents, antacids and histamine-2-receptor antagonists. For severe GERD, therapeutic options include proton pump inhibitors and antireflux surgery. In determining the best approach for each individual patient, efficacy, safety, morbidity, compliance and cost must be considered.