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Gastro-oesophageal reflux in children and fundoplication
Regurgitation in an infant who grows well is physiological reflux that resolves on its own; drug treatment is kept for reflux disease with complications, and fundoplication for life-threatening complications, treatment failure or high-risk children such as those with neurological impairment or after oesophageal atresia repair.
Why it matters in the exam
Physiological reflux in infants is very common, peaks at about 4 months of age and usually resolves by one year to one and a half years. The main mechanism is transient lower oesophageal sphincter relaxations (TLESR). Under the 2018 NASPGHAN/ESPGHAN guideline, the first treatment of an infant with troublesome reflux is non-pharmacological: avoid overfeeding, thicken feeds, and if there is no improvement — a 2–4 week trial of extensively hydrolysed or amino-acid formula, because cow's milk protein allergy mimics reflux. Proton pump inhibitors should not be given to an infant for crying or regurgitation alone.
Warning signs that call for another cause: green or bloody vomiting, projectile vomiting (pyloric stenosis), poor growth, fever, neurological symptoms and onset after 6 months of age. Reflux disease (GERD) presents with oesophagitis, stricture, poor growth, recurrent respiratory symptoms and aspiration, and abnormal head posture (Sandifer syndrome). pH-impedance testing assesses the link between reflux and symptoms, and endoscopy assesses oesophagitis.
Fundoplication (Nissen — a 360-degree wrap of the gastric fundus around the lower oesophagus, usually laparoscopic) is for life-threatening complications (recurrent aspiration, apnoeic events attributed to reflux), failure of optimal drug treatment and long-term drug dependence. The risk of significant reflux is especially high after oesophageal atresia repair, after CDH and in children with neurological impairment; in them fundoplication is considered together with gastrostomy. Complications of surgery: dysphagia, "gas bloat" (inability to burp or vomit), slipping or disruption of the wrap, hiatal hernia and dumping syndrome.
Key points
- Physiological reflux resolves by one year to one and a half years.
- Mechanism: transient lower sphincter relaxations.
- Non-pharmacological treatment and hydrolysed formula first.
- Fundoplication for life-threatening complications and treatment failure.
- High risk: neurological impairment, EA and CDH.
Summary table
| Condition | Feature | Treatment |
|---|---|---|
| Physiological reflux | Regurgitation, normal growth, peak around 4 months | Reassurance, avoid overfeeding |
| Troublesome reflux in an infant | Crying and vomiting, no warning signs | Thickening; 2–4 week trial of hydrolysed formula |
| GERD with complications | Oesophagitis, stricture, poor growth, aspiration | Proton pump inhibitor for a limited period |
| Treatment failure or life-threatening complication | Recurrent aspiration, apnoea | Fundoplication |
| High-risk child | Neurological impairment, after EA or CDH | Consider fundoplication and gastrostomy |
A free exam question
בן 12 מתלונן על כאבי בטן לאחר הרחבה פנאומטית של ה- Lower Esophageal Sphincter (LES) שבוצעה בשל אכלזיה. בבדיקה, יציב המודינמית ונשימתית, הבטן תפוחה עם רגישות אפיגסטרית ובצילום בטן פנאומופריטונאום. הנער נלקח ללפרוסקופיה חוקרת, בה זוהה נקב בחלק הבטני של הוושט. לאחר תפירת הנקב, מהי הגישה הניתוחית המומלצת להשלמת הניתוח? (the question as examined, in Hebrew)
- א. ביצוע מיוטומיה ע"ש הלר ופונדופליקציה ע"שניסן
- ב. כיסוי עם טלאי אומנטום
- ג. ביצוע מיוטומיה ע"ש הלר
- ד. ביצוע מיוטומיה ע"ש הלר ופונדופליקציה קדמית
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Sources
- NASPGHAN/ESPGHAN Pediatric Gastroesophageal Reflux Clinical Practice Guidelines, 2018 — Infants, children and indications for surgery
- Holcomb and Ashcraft's Pediatric Surgery, 7th edition (2019) — Gastroesophageal Reflux
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.