GERD & Acid Reflux in Children: When Surgery Is Needed

Paediatric Surgery | Professor Mohamed Elbarbary, FRCSEd — Cairo University

Acid reflux is extremely common in infants and young children, and the vast majority manage it with conservative measures and medication. However, a small number of children have severe gastro-oesophageal reflux disease (GERD) that does not respond to medical treatment and requires surgical correction. Professor Mohamed Elbarbary — Cairo University Professor of Paediatric Surgery, FRCSEd Fellow (2026), and specialist with over 36 years of experience — performs the Nissen fundoplication and related anti-reflux procedures in children using both open and laparoscopic techniques.

What Is GERD in Children?

Gastro-oesophageal reflux disease (GERD) occurs when stomach contents flow back (reflux) into the oesophagus regularly enough to cause symptoms or complications. In infants, some degree of reflux is entirely normal — the lower oesophageal sphincter (the valve between the oesophagus and stomach) is immature and often allows small amounts of milk to come back up. This is called physiological reflux or "possetting" and typically resolves by 12–18 months without treatment.

GERD, in contrast, refers to pathological reflux that causes:

• Irritability and crying, particularly after feeding ("silent reflux" — when stomach contents reach the oesophagus but not the mouth)

• Vomiting that is frequent, large volume, or projectile

• Arching of the back during or after feeds (Sandifer syndrome)

• Poor weight gain or failure to thrive

• Recurrent chest infections or wheezing due to aspiration of refluxed material

• In older children: heartburn, chest pain, chronic cough, or hoarseness

Non-Surgical Management

For most children with GERD, management is medical and dietary:

• Positioning: keeping infants upright during and after feeds

• Feeding modifications: smaller, more frequent feeds; thickened feeds in infants

• Acid suppressants: proton pump inhibitors (PPIs) such as omeprazole or lansoprazole, or H2 blockers, are the mainstay of medical treatment

• In formula-fed infants: hydrolysed or amino-acid-based formula trials for cow’s milk protein allergy (which can mimic GERD)

The large majority of infants improve with these measures or with time as the lower oesophageal sphincter matures.

When Is Surgery Needed?

Surgical anti-reflux surgery (most commonly Nissen fundoplication) is reserved for children with:

• GERD that causes significant morbidity despite optimal medical treatment for 3–6 months

• Recurrent aspiration pneumonia — stomach contents entering the lungs, causing repeated chest infections

• Life-threatening episodes of apnoea (cessation of breathing) related to reflux in infants

• Oesophageal complications of chronic reflux: oesophagitis, stricture, or Barrett’s oesophagus

• Children with neurological impairment (cerebral palsy, etc.) who have profound GERD alongside swallowing difficulties — this group most commonly requires surgical intervention

• Children dependent on a feeding tube (gastrostomy) in whom reflux makes tube feeds unsafe without anti-reflux surgery

The Nissen Fundoplication

The Nissen fundoplication is the standard surgical treatment for GERD in children. In this operation, the upper part of the stomach (the fundus) is wrapped 360° around the lower oesophagus, creating a valve that prevents stomach contents from refluxing back up.

Prof. Elbarbary performs this procedure laparoscopically (keyhole) in suitable patients, which significantly reduces pain, hospital stay, and recovery time compared with open surgery. The operation takes approximately 1.5–2.5 hours under general anaesthesia.

A gastrostomy (feeding tube placed directly into the stomach) may be placed at the same operation if the child requires long-term tube feeding — this is often the case in neurologically impaired children.

Recovery After Anti-Reflux Surgery

• Most children spend 1–3 nights in hospital after laparoscopic fundoplication

• Feeding resumes within 24–48 hours, starting with liquids

• A soft or blended diet is recommended for the first 2–4 weeks while the wrap heals and swelling reduces

• Temporary difficulty swallowing (dysphagia) is common in the first few weeks and almost always resolves

• Follow-up at 4–6 weeks confirms symptom resolution and allows dietary advancement

Frequently Asked Questions

Does surgery cure GERD permanently?

For most children, yes — fundoplication provides durable relief of GERD symptoms. Reported success rates at 5 years are 85–90% in neurologically normal children. In children with neurological impairment, re-operation rates are higher (up to 15–20%) due to the more severe and multifactorial nature of their beflux. A small number of children require repeat surgery or return to medication.

Can surgery be done by keyhole (laparoscopy)?

Yes. Prof. Elbarbary performs laparoscopic fundoplication for appropriate candidates. The advantages — smaller scars, less pain, faster recovery — are significant. Open surgery is reserved for cases requiring complex revision, or when the anatomy makes laparoscopic access unsafe.

My child has cerebral palsy — is surgery safe?

Children with neurological impairment frequently have the most severe GERD and are often the children who most benefit from fundoplication. Surgical risk is higher in this group due to respiratory complications, nutritional status, and anaesthetic considerations — but with careful pre-operative assessment and a specialist team, surgery can be performed safely and dramatically improves quality of life for both child and carer.

Is there a risk the wrap is too tight?

Temporary dysphagia (difficulty swallowing) after fundoplication is common and expected in the first few weeks. Persistent severe dysphagia requiring dilation or reoperation occurs in approximately 3–5% of cases. Prof. Elbarbary calibrates the wrap carefully to minimise this risk, and the laparoscopic approach allows precise control of wrap tightness.

drmohamedelbarbary.com | Cairo University — Kasr Al-Ainy | FRCSEd 2026