PEDIATRIC GERD

INTRODUCTION

Gastroesophageal reflux
Gastroesophageal reflux disease
Mechanism and
Pathophysiology of Reflux
• Transient relaxation of the lower
esophageal sphincter
• The short infant esophagus has limited
volume
• Predominantly recumbent position of
infants
• Delayed emptying
• Increased abdominal pressure
Prevalence of Regurgitation in
Healthy Infants
Infants (%)
100

1 time a day
4 times a day

0
0-3 4-6 7-9 10-12

Age (months)
Prevalence of GERD in infants
 Premature infants (by pH-metry) >85%
-3-10%: apnea, bradycardia,
bat
exacerbation of BPD
 Infants <3 months (by Hx) 20-100%
-33% receive medical attention
-80% resolve with minimal intervention
and no diagnostic evaluation
Genetic Predisposition for GERD
 Familial clustering
 Concordance for acid regurgitation
 Proposed genetic links
Chromosome 13 locus (13q14)
Chromosome 9 locus
PRESENTING SYMPTOMS AND
SIGNS OF GERD
INFANTS
-Feeding refusal
-Recurrent vomiting
-Poor weight gain
-Irritability
-Apnea or ALTE
-Arching or head tilting (“pseudo-torticollis”)
PRESENTING SYMPTOMS AND
SIGNS OF GERD
 Preschool
Intermittent vomiting or regurgitation
Less commonly respiratory complica-
tions
Decreased food intake without any
other complaints may be a symptom
of esophagitis
Presenting Symptoms and Signs
of GERD
 Older Children and Adolescents
Heartburn Chronic cough
Regurgitation Nausea/epigastric
Esophagitis pain
Asthma
Recurrent Pneumonia
Hoarseness
Frequency of presenting symptoms in
76 children with GERD
Percentage of subjects
70 Heartburn or
60 epigastricpain
63.9
Recurrent
50 abdominal pain
Respiratory
40 symptoms
30 34
Regurgitation
29
20 Retrosternal pain
22
18 16
10
Vomiting
0
 Supraesophageal symptoms of
GERD in children
Apnea/bradycardia

Chronic cough
Wheezing/asthma
Supra-esophageal
manifestations
of GERD Otitis/sinusitis

Chronic sore
throat Hoarseness
Dental
LESS COMMON SIGNS AND
SYMPTOMS IN CHILDREN
 Hematemesis
 Iron deficiency anemia
 Failure to thrive/grow
 Sandifer’s syndrome
 (“pseudo-torticollis,” posturing
Taking a History for a child with
Suspected GERD
 History
Feeding History
Pattern of vomiting
Past Medical History
Psychosocial History
Family History
Growth Chart
Alarm and Signals Suggestive
of Non-GERD Diagnoses
 Recurrent vomiting

 History and physical examination

 Are there warning signals?

Common Nonreflux causes of
Vomiting
Infections
Sepsis
Meningitis
Urinary tract infection
Otitis media
Obstruction
Pyloric stenosis
Malrotation
Intussusception
Common Nonreflux causes of
vomiting (continuation)
Gastrointestinal
Eosinophilic esophagitis
Peptic ulcer disease
Achalasia Pill esophagitis
Gastroparesis Crohn disease
Gastroenteritis
Gall bladder disease
Pancreatitis
Celiac disease
Common Nonreflux Causes of
Vomiting (continuation)
Metabolic/Endocrine
Galactosemia
Fructose intolerance
Urea cycle defects
Diabetic ketoacidosis
Toxic
Lead poisoning
Common Nonreflux Causes of
vomiting (continuation)
Neurologic
Hydrocephalus and shunt
malfunctioning
Subdural hematoma
Intracranial hemorrhage
Tumors
Migraine
Common Nonreflux Causes of
Vomiting (continuation)
Allergic
Dietary protein intolerance
Respiratory
Posttussive emesis
Pneumonia
Renal
Obstructive uropathy
Renal insufficiency
Common Nonreflux Causes of
Vomiting
Cardiac
CHF and disease
Recreational drugs and alcohol
consumption
Pregnancy
Other
Overfeeding
Self-induced emesis
Diagnostic Approach to GER
 History and Physical examination
 Diagnostic studies
Contrast Radiographs
Esophageal ph monitoring
Endoscopy
Multichannel intraluminal impedance
Scintigraphy
GOALS IN THE TREATMENT
OF REFLUX
 Eliminate symptoms quickly
 Heal esophagitis
 Manage or prevent complications
 Maintain remission
Expert Recommendations for
Empiric Therapy in GERD
 Empiric therapy can be used as a “test”
to determine if GERD is causing a specific
symptom
-No gold standard test for GERD
-Avoids invasive testing
-Can have GERD despite normal
diagnostic tesitng
-Problem:placebo effect
Empiric Therapy in GERD
(continuation)
 Consideration for dose, duration, and
type of medication
-Severity of disease
-Cost and insurance requirements
-Risk of underlying conditions
(eg. Asthma)
Empiric Therapy in GERD
(continuation)
 Define goals and length of empiric
trial before initiation of therapy
 Stop treatment if empiric therapy fails
Strategies for the Empiric
Trial: Step-up Therapy
 High-dose
 PPI
 PPI
 H2Ra
 Lifestyle
 Modicifations*
 Important to implement with medications as well
 No studies evaluating these strategies in children
Management of Mild GERD
Symptoms
 Explanation and reassurance
 Diet and lifestyle
 Antacids
Lifestyle Management of Mild
GERD Symptoms
Infants
 Normalize feeding volume and frequency
 Consider thickened formula
 Positioning
-Upright after meals
-Avoid car seats at home
 Consider 2-4 week trial of hypoallergenic
formula
Rudolph CD, et al.Jpediatr Gastroenterol Nutr.2001:32(suppl2):S1
Lifestyle Management of Mild
GERD Symptoms
 Older Children and Adolescents
 Avoid large meals (especially prior to
exercising
 Do not eat or drink 2 hours prior to bedtime
 If obese, weight loss program
 Limit food and drink that provoke GERD
 Symptoms
 Rudolph CD, et al. Jpediatr Gastroenterol Nutr,.2001:32(suppl
2):S1
Management of Mild-to-
Moderate GERD Symptoms
Prokinetics
- Metoclopramide - Cisapride
H2Receptor Antagonists
- Cimetidine - Nizatidine
- Famotidine - Ranitidine
Proton Pump Inhibitors
-Omeprazole -Lansoprazole
Acid Suppression Options for
GERD in Children
Therapy Medications Considerations
Histamine2 Cimetidine -Available for
receptor Famotidine infants,children
antagonists Nizatidine and adolescents
(H2RAs) Ranitidine -Less potent acid
suppression
compared with PPIs
-Tolerance is an issue
Acid suppression Options for
GERD in Children
Therapy Medications Considerations
Proton Esomeprazole -Available for
Pump Lansoprazole children and
Inhibitors Omeprazole adolescents
(PPIs) -Superior efficacy to
H2RA’s to H2RAs for
healing and ph
control
-Cost and managed
care restrictions
FDA Labeling for Rx H2RA
Therapy for Pediatric GERD
Indicated Ages Dosing
Ranitidine 1 month to 5-10 mg/kg/day
16 years divided BID
Famotidine 1 year to 1 mg/kg/day
16 years divided BID up
to 40 mg. BID
Nizatidine >12 years 150 mg. BID
Cimetidine >16 years 800 mgBID or
400 mg. QID
3
PPIs Approved for Rx of
Pediatric GERD (FDA Labeling)
Omeprazole
Weight Dosing Duration Indicated Ages
<20 kg 10mg QD up to 2yrs-16yrs
12 wks
>20 kg 20mg QD up tp 2yrs-16yrs
Lansoprazole
<30 kg 15 mg QD up to 12mo.-11yrs
>30kg 30mg QD 12 wks 12mo-11yrs
Nonerosive esophagitis-up to 8wks 12-17yrs
Importance of timing of
PPIdose
Dosing Administer PPI
QD 30 min. before breakfast
BID 30 min before breakfast
and evening meal
H2RAs and Tachyphylaxis
H2RAs develop loss of efficacy in
antisecretory potency
-Might occur as early as second dose
of H2RA increasing to 29 days of
dosing
Tolerance phenomenon is not overcome
by an increase in dosage
Observed Adverse Events with
PPI
 PPI Adverse Events
 Lansoprazole Headache (3%)
Constipation (5%)
Diarrhea,abdominal pain
nausea
 Omeprazole Headache (2.4% Rash(1.1%)
Diarrhea(1.9%)
Abdominal pain, nausea
constipation
Observed Adverse Events with
PPIs
 No reported long-term side effects with
PPIs
 Adverse events reported with PPIs are
similar to those reported with placebo

Scott LJ et al.Drugs.2002;62:1503.
Gold b. Pediatric Drugs. 2002;4:673
Rudolph CD., et al. Jpediatr GassstroenterolNutr.2001;32:S1
Klinkenberg- KknolEC, et al.Gastroenterology2000;118(4):661. l
The Role of Metoclopramide in
the Treatment of GERD
 High incidence of adverse events
 Medication crosses the blood brain barrier
Tardive dyskinesia (amy be irrever-
sible)
Lethargy
Irritability
 Evidence suggests poor clinical efficacy
Children at Risk for Long-term
Complications of GERD
 Asthma
 Cystic fibrosis
 Esophageal atresia
 Down’s syndrome
 Erosive esophagitis
 Neurologic impairment
Asthmatic Children without
GERD Symptoms
 Indications for work-up
Radiographic evidence of recurrent
pneumonia
Nocturnal asthma that occurs more
than once weekly
Continuous oral or high-dose inhaled
corticosteroids
Asthmatic Children without
GERD Symptoms
Indications for work-up (continuation)
More than 2 courses of oral
corticosteroid required per year
Exacerbation of asthma whenever
medications are decreased
Complications of GERD
 Esophagitis
 Peptic Stricture
 Failure to thrive
 Pulmonary/ENT disease
 Barrett’s esophagus
 Adenocarcinoma
Considerations for Testing or
Referral to a GI Specialist
 No response to PPI therapy
 Patient is unable to be weaned from
medical therapy or has significant side
effects
 Signs of complications or severe disease
-Alarm signs or sxs present(eg.blood
loss,Significant growth problems and
-Life threatening issues (eg.respiratory)
SUMMARY
Pediatric reflux is a common condition in
children
Children less than 18 months old with
GER rarely develop GERD
GERD in children presents as a variety of
symptoms
Summary
 Complications of GERD include:
-Asthma
-Erosive esophagitis
-Stricture
-Barrett’s esophagus
-Adenocarcinoma
SUMMARY
 Early detection and intervention may
prevent life-long complications
 An empiric trial of acid suppression can
be diagnostic and therapeutic
 PPI therapy is the most effective for
GERD symptom relief and esophageal
healing
SUMMARY
 Children with cystic fibrosis, esophageal
atresia, or neurologic impairment may
be at greater risk of complications of
GERD
 Safe and effective treatments exist for
long-term suppression of acid
Summary
 Children less than 18 months old with
GER rarely develop GERD
 Complications of GERD :

-Asthma Adenocarcinoma
-Erosive esophagitis
-Stricture
-Barrett’s esophagus
Summary
 Children with cystic fibrosis, esophageal
atresia,or neurologic impairment may
be at greater risk for complications of
GERD
 Safe and effective treatments are
available for long term acid suppression
and should be used
 Shawn is 9 months old brought for the first
time for check up. He spits up frequently, has
frequent otitis media and congestion. BW
was 3kg. Current wt. Is 6 kg.
 Peter is 3 years old complaint of intemittent
periumbilical pain that occurs daily worse
after meals. He vomits 1-2x a week and
refuses to eat s-3 meals/week. He has history
of frequent spitting up during the first 2 years
 of like and was treated with ranitidine.