PEDIATRIC GERD
INTRODUCTION
Gastroesophageal refluxGastroesophageal 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
0
100
0 - 3 4 - 6 7 - 9 10-12
1 time a day4 times a day
Age (months)
Infants (%)
Nelson et al. Arch Pediatr Adolesc Med.1997;151:569
Prevalence of GERD in infants Premature infants (by pH-metry) >85% -3-10%: apnea, bradycardia, exacerbation of BPD Infants <3 months (by Hx) 20-100% -33% receive medical attention -80% resolve with minimal intervention and no diagnostic evaluation
bat
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”)
Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1
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
0
10
20
30
40
50
60
70 Heartburn orepigastricpainRecurrentabdominal painRespiratorysymptomsRegurgitation
Retrosternal pain
Vomiting
34
63.9
29
2218 16
Percentage of subjects
Supraesophageal symptoms of GERD in children
Supra-esophageal manifestations
of GERD
Chronic cough
Otitis/sinusitis
HoarsenessDental
Wheezing/asthma
Chronic sore throat
Apnea/bradycardia
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 forEmpiric 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 formulaRudolph 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 ChildrenTherapy Medications ConsiderationsHistamine2 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 ChildrenTherapy Medications ConsiderationsProton Esomeprazole -Available for Pump Lansoprazole children andInhibitors 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 DosingRanitidine 1 month to 5-10 mg/kg/day 16 years divided BIDFamotidine 1 year to 1 mg/kg/day 16 years divided BID up to 40 mg. BIDNizatidine >12 years 150 mg. BIDCimetidine >16 years 800 mgBID or 400 mg. QID3
PPIs Approved for Rx ofPediatric 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-16yrsLansoprazole <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 inantisecretory potency -Might occur as early as second
dose of H2RA increasing to 29 days of dosingTolerance phenomenon is not overcomeby 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:S1Klinkenberg- 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 withoutGERD 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.