Presentation is loading. Please wait.

Presentation is loading. Please wait.

Gastroesophageal Reflux in infants & Proton Pump Inhibitors By: Khalil Ebrahim Manal Darwish Shihadeh, MD, FAAP Gastroesophageal Reflux in infants & Proton.

Similar presentations


Presentation on theme: "Gastroesophageal Reflux in infants & Proton Pump Inhibitors By: Khalil Ebrahim Manal Darwish Shihadeh, MD, FAAP Gastroesophageal Reflux in infants & Proton."— Presentation transcript:

1

2 Gastroesophageal Reflux in infants & Proton Pump Inhibitors By: Khalil Ebrahim Manal Darwish Shihadeh, MD, FAAP Gastroesophageal Reflux in infants & Proton Pump Inhibitors By: Khalil Ebrahim Manal Darwish Shihadeh, MD, FAAP

3 Clinical Cases 5 month old who effortlessly spits-up 6–10x/day, but seems comfortable and is growing well 4 month old who is losing weight is reported to vomit 2–3x/day, and seems increasingly fussy with feeds 15 year old who presents complaining of heartburn

4 Gastroesophagyeal Reflux GER without D GER is a physiologic Phenomenon that occurs at all ages and it allows depressurization of the stomach

5 GER Gastroesophageal Reflux – The passage of gastric contents into the esophagus – Occurs with/without regurgitation and vomiting GER is a normal physiologic process – Several times/day in healthy infants, children, and adults

6 Physiology of GER GER occurs during transient relaxations of the lower esophageal sphincter (LES) – Relaxation of the LES that is unaccompanied by swallowing permits gastric contents into the esophagus LES is not a “true” sphincter – Comprised of crural support, an intra ‑ abdominal segment, and the “angle of His” The main underlying mechanism that allows GER to occur across all ages Allows air to vent from the stomach

7 Composition of the LES Healthy adult – LES 3cm in length, at level of diaphragm Neonate – LES 1.5cm in length, above the diaphragm

8 Adult Esophageal Capacity Shorter esophagus Smaller capacity Gravity Infant

9 Most Episodes of GER Last < 3 minutes Occur in the postprandial period Cause few or no symptoms GER can cause vomiting – A coordinated autonomic and voluntary motor response with forceful expulsion of gastric contents Regurgitation (“spitting up”) is the most visible symptom of GER – Occurs daily in 50% of infants < 3 months of age – Resolves spontaneously in most by 12–14 months

10 Prevalence of Regurgitation in Infancy Age (months) % of Infants  1 time a day  4 times a day Adapted from Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997;151(6):569–572 n=948

11 WHEN DOES GER “become” GERD Aberrance in normal physiology – Insufficient clearance and buffering of refluxate – Decreased rate of gastric emptying – Abnormalities in efficacy of epithelial repair – Decreased neural protective reflexes

12 Risk Factors for GERD Hiatal Hernia Neurodevelopmental Delay Anatomic Abnormalities: -TEF Obesity Delayed Gastric emptying??? -Pro-motility agents have not proven to reduce bolus GER

13 Genetics of Reflux Cluster studies suggest inheritability of GER/GERD and their complications – Hiatal hernia – Erosive esophagitis – Barrett’s esophagus – Esophageal adenocarcinoma Swedish Twin Registry – Increased concordance in monozygotic vs. dizygotic Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

14 How much reflux is too much? Gastroesophageal Reflux, as Measured By 24- Hour pH Monitoring, in 509 Healthy Infants Screened for Risk of Sudden Infant Death Syndrome Pediatrics 1991 Yvan Vandenplas, MD, PhD; Harry Goyvaerts, RN*; Rudy Helven, RN; and Liliane Sacre, MD From the Academisch Ziekenhuis Kinderen, Vrije Universiteit Brussel and *Janssen Pharmaceuticals, Belgium

15 Frequency of Reflux in 24hour among Infants Percentile Reflux Index Number

16 Physician beliefs, according to specialty, based on overall clinical impression. Golski C A et al. Pediatrics 2010;125: ©2010 by American Academy of Pediatrics

17 Acta Paediatr October; 100(10): e178–e180. doi: /j x PMCID: PMC Gastroesophageal reflux disease at any cost: a dangerous paediatric attitude Andrea Taddio, 1 Chiara Bersanini, 2 Lucio Basile, 3 Massimo Fontana, 2 and Alessandro Ventura 1 1 Department of Pediatrics, Institute of Child Health IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy /j x Andrea TaddioChiara BersaniniLucio BasileMassimo FontanaAlessandro Ventura Acta Paediatr October; 100(10): e178–e180. doi: /j x PMCID: PMC Gastroesophageal reflux disease at any cost: a dangerous paediatric attitude Andrea Taddio, 1 Chiara Bersanini, 2 Lucio Basile, 3 Massimo Fontana, 2 and Alessandro Ventura 1 1 Department of Pediatrics, Institute of Child Health IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy /j x Andrea TaddioChiara BersaniniLucio BasileMassimo FontanaAlessandro Ventura CASES OF INFANTS WITH INFANTILE SPASMS MISDIAGNOSED AS GERD

18 A GLOBAL, EVIDENCE-BASED CONSENSUS ON THE DEFINITION OF GASTROESOPHAGEAL REFLUX DISEASE IN THE PEDIATRIC POPULATION GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of 8 years

19 Troublesome symptoms or complications of reflux Recurrent vomiting and poor weight gain in infant Recurrent vomiting and irritability in infant Recurrent vomiting in older child Heartburn in child/adolescent Esophagitis Dysphagia or feeding refusal Apnea or ALTE Asthma Recurrent pneumonia Upper airway symptoms Unusual arching or seizure-like movements (Sandifer syndrome)

20 What about complications of GERD? e.g. Is there a danger to not recognizing and treating it?

21 Complications of Reflux Normal mid- and distal esophagus Erosive esophagitis: grade 2 and grade 4 Z-line Erosions

22 Esophageal stricture secondary to GERD: radiography and endoscopy Barrett’s esophagus: endoscopy and histology Normal Barrett’s Normal Stricture Complications of Reflux

23 Diagnostic Approach Upper GI Radiography Cannot discriminate between physiologic and nonphysiologic GER episodes Limitation Useful for detecting anatomic abnormalities Advantage

24 Pyloric stenosis Malrotation

25 Esophagogastroduodenoscopy (EGD) Need for sedation or anesthesia Endoscopic grading systems not yet validated for pediatrics Poor correlation between endoscopic appearance and histopathology Generally not useful for extra-esophageal GERD Limitations Enables visualization and biopsy of esophageal epithelium Determines presence of esophagitis, other complications Discriminates between reflux and non- reflux esophagitis Advantages

26 Esophageal pH Monitoring Cannot detect nonacidic reflux Cannot detect GER complications associated with “normal” range of GER Not useful in detecting association between GER and apnea unless combined with other techniques Limitations Detects episodes of reflux Determines temporal association between acid GER and symptoms Advantages

27 Multiple Intraluminal Electrical Impedance Measurement Advantages Detects nonacidic GER episodes Detects brief (< 15 s) acidic GER episodes Useful for studying respiratory symptoms and GER in infants Limitations Normal values in pediatric age groups not yet defined Analysis of tracings time-consuming Portable device unavailable for outpatient studies pH channel pH 4 Impedance channels Z 1 Z 4

28 Non-Acid Reflux

29 History and Physical Exam Symptoms and signs associated with GER are non- specific – i.e. Not all children with GER have heartburn or irritability – Conversely, heartburn and irritability can be caused by conditions other than GER Major roles of History/Physical Exam when evaluating GERD – To exclude other worrisome disorders that present with vomiting – To recognize complications of GERD

30 Important to Obtain a Feeding and Vomiting History Feeding and dietary history Amount/frequency (overfeeding) Preparation of formula Recent changes in feeding type or technique Position during feeding Burping Behavior during feeding: choking, gagging, cough, arching, discomfort, refusal Pattern of vomiting Frequency/amount Pain Forceful or not Blood or bile Associated fever, lethargy, diarrhea

31 History/Physical Examination Severity of reflux or esophagitis found on diagnostic testing does not directly correlate with symptom severity In infants and toddlers, there is no symptom or group of symptoms that can reliably diagnose GERD or predict treatment response In older children and adolescents, history and physical examination are generally sufficient to reliably diagnose GERD and initiate management Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

32 Treatment with PPI’s

33 >11 fold increase in new PPI prescriptions( ) A liquid formulation of a PPI saw a 16-fold increase( ) despite the fact that PPI are not FDA approved for use infants 25% of extremely LBW infants discharged on antisecretory meds. Drugs on which most advertising spent: PPI In 2005, PPI sales grossed approx $13 billion in US alone.

34 Twenty-Four Hour Esophageal Impedance-pH Monitoring in Healthy Preterm Neonates: Rate and Characteristics of Acid, Weakly acidic, and weakly alkaline Gastroesophageal Reflux Pediatrics Preterm neonate mean gestational age 32 weeks. Non acid Reflux > acid Median 70 events Majority reached proximal esophagus No difference between healthy and those with cardio respiratory events

35 Esophageal pH-Impedance Monitoring in Patients With Therapy-Resistant Reflux Symptoms: 'On' or 'Off' Proton Pump Inhibitor? Gerrit J.M. Hemmink, M.D., Albert J. Bredenoord, M.D., Ph.D., Bas L.A.M. Weusten, M.D., Ph.D., Jan F. Monkelbaan, M.D., Robin Timmer, M.D., Ph.D., André J.P.M. Smout, M.D., Ph.D. Disclosures Am J Gastroenterol. 2008;103(10): RESULTS: The total number of reflux episodes and proximal extent were not affected by PPI therapy. On PPI, there were fewer acid reflux episodes while more weakly acidic reflux episodes were identified.

36 Combined Esophageal Intraluminal Impedance, pH and Skin Conductance Monitoring to Detect Discomfort in GERD Infants Discomfort was significantly associated with reflux events and did not differ between weakly acidic and acid refluxes. The results may raise concerns about the over-prescription use of antacid drugs in the management of gastroesophageal reflux symptoms in infancy.

37 Proton pump inhibitor use in infants: FDA reviewer experience. Division of Gastroenterology and Inborn Errors Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD , USA. The Food and Drug Administration has completed its review of 4 clinical trials evaluating the use of proton pump inhibitors (PPIs) in infants (ages 1 month to <12 months) for the treatment of gastroesophageal reflux disease (GERD) in November Advisory Committee members agreed that PPIs should not be administered to treat the symptoms of GERD in the otherwise healthy infant without the evidence of acid-induced disease. Use of PPIs should be reserved for infants with an endoscopically documented acid-induced condition such as erosive esophagitis. The risk/benefit relation of administration of PPIs in infants with GER or GERD without a documented acid-induced condition is not favorable because no benefit can be attributed to the PPI. Furthermore, there may be risks associated with long-term PPI use that require further study in this young population PMID: [PubMed - indexed for MEDLINE]

38 Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking. Pediatrics 2011;127:925–935

39 PPI The Wolf in Sheep’s clothing

40 Reported Adverse Events of Acid suppression 1- C. difficile infection 2- Community acquired pneumonia Necrotizing enterocolitis Osteopenia/ osteoporosis Candidemia Infant pneumonia Bacterial Overgrowth Vitamin B12 deficiency Hypomagnesaemia Interstitial nephritis

41 Pediatrics 2012;129;e40; originally published online December 12, 2011; Salvia, Laura Lega, Francesco Messina, Roberto Paludetto and Roberto Berni Canani Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns

42 FDA Drug Safety Communication: Clostridium difficile- associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs) Safety Announcement [ ] The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve.

43 New Evidence: PPI Stomach Acid Drugs Cause Pneumonia Sunday, May 31, 2009 by: S. L. Baker, features writer a new study just published in the Journal of the American Medical Association (JAMA) concludes that by disrupting the body's natural balance, PPIs may cause deadly pneumonia.

44

45 Proton pump inhibitor side effects and drug interactions: Much ado about nothing? Ryan D. Madanick, MD, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, CB #7080, Chapel Hill, NC 27599;

46 Available Prokinetic Agents Are Unproven or Ineffective Cisapride: withdrawn Bethanechol: only 1 randomized controlled trial (RCT) Erythromycin: no RCT Domperidone: available in Canada, no RCT Metoclopramide: –Esophageal pH improvement in 1 of 6 RCT –Clinical improvement in 1 of 4 RCT –High incidence (~30% prevalence) of adverse events Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

47 Increasing Concern about Safety of Prokinetics ProkineticAdverse Events BethanecholMalaise, abdominal cramps, colicky, pain, nausea and belching, diarrhea, urinary urgency; contraindicated in hyperthyroidism, bronchial asthma, and other conditions DomperidoneHyperprolactinemia, dry mouth, rash, headache, diarrhea, nervousness ErythromycinAbdominal pain, nausea, vomiting, diarrhea, pyloric stenosis MetoclopramideRestlessness, drowsiness, fatigue and lassitude (10%); insomnia, headache, confusion, dizziness, mental depression; extrapyramidal reactions including parkinsonian-like symptoms, tardive dyskinesia, and motor restlessness; galactorrhea, gynecomastia, cardiovascular effects, nausea, diarrhea Prescribing Information for Reglan® and Urecholine®; Curry JI, Lander TD, Stringer MD. Erythromycin as a prokinetic agent in infants and children. Aliment Pharmacol Ther 2001;15(5):595–603; Ramirez B, Richter JE. Review article: promotility drugs in the treatment of gastro-oesophageal reflux disease Aliment Pharmacol Ther. 1993;7(1):5–20

48 For Infants For Older Children Conservative Therapy for GER Avoid large meals Do not lie down immediately after eating Lose weight, if obese Avoid caffeine, chocolate, and spicy foods that provoke symptoms Eliminate exposure to tobacco smoke Normalize feeding volume and frequency Consider thickened formula Consider non-prone positioning during sleep Consider trial of hypoallergenic formula

49 Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. Orenstein SR, McGowan JD. Source University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. Orenstein SRMcGowan JD Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. Orenstein SR, McGowan JD. Source University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. Orenstein SRMcGowan JD Abstract OBJECTIVE: To determine the efficacy of non-pharmacologic conservative therapy for infant gastroesophageal reflux disease (GERD). STUDY DESIGN: : feeding modifications, positioning, and tobacco smoke avoidance Consenting parents of the first 50 screened infants who met inclusion/exclusion criteria including abnormal (>16/42) scores on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R; n = 40) were taught conservative therapy measures by each site's study nurse : feeding modifications, positioning, and tobacco smoke avoidance. We compared I-GERQ-R scores and symptom response details before and 2 weeks after institution of these measures with 2-tail Wilcoxon signed ranks test in the 37 infants (age range, 4-43 weeks; median age, 13 weeks) who completed the run-in. RESULTS: The median initial and final scores were 23 (16-36) and 18 (7-34; P < ). The median score change was -5 (+6--16). Scores of 78% improved at all; 59% improved at least the threshold of 5 points; 24% became normal. Scores for individual symptoms related to regurgitation, crying, and arching improved significantly.CONCLUSIONS: Two weeks of conservative therapy measures taught in primary care improved 59% beyond the 5-point threshold and normalized 24% of infants with symptom severity diagnostic for GERD, as substantiated with a responsiveness-validated instrument. Two weeks of conservative therapy measures taught in primary care improved 59% beyond the 5-point threshold and normalized 24% of infants with symptom severity diagnostic for GERD, as substantiated with a responsiveness-validated instrument. Abstract OBJECTIVE: To determine the efficacy of non-pharmacologic conservative therapy for infant gastroesophageal reflux disease (GERD). STUDY DESIGN: : feeding modifications, positioning, and tobacco smoke avoidance Consenting parents of the first 50 screened infants who met inclusion/exclusion criteria including abnormal (>16/42) scores on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R; n = 40) were taught conservative therapy measures by each site's study nurse : feeding modifications, positioning, and tobacco smoke avoidance. We compared I-GERQ-R scores and symptom response details before and 2 weeks after institution of these measures with 2-tail Wilcoxon signed ranks test in the 37 infants (age range, 4-43 weeks; median age, 13 weeks) who completed the run-in. RESULTS: The median initial and final scores were 23 (16-36) and 18 (7-34; P < ). The median score change was -5 (+6--16). Scores of 78% improved at all; 59% improved at least the threshold of 5 points; 24% became normal. Scores for individual symptoms related to regurgitation, crying, and arching improved significantly.CONCLUSIONS: Two weeks of conservative therapy measures taught in primary care improved 59% beyond the 5-point threshold and normalized 24% of infants with symptom severity diagnostic for GERD, as substantiated with a responsiveness-validated instrument. Two weeks of conservative therapy measures taught in primary care improved 59% beyond the 5-point threshold and normalized 24% of infants with symptom severity diagnostic for GERD, as substantiated with a responsiveness-validated instrument.

50 Thickened formula Unthickened formula

51 Thickening a 20Kcal/oz infant formula with 1 Tbp/2oz kcal/oz 1Tbp/1oz kcal/oz

52 Effect of Thickening Milk Formula Feedings With Rice Cereal Adapted from Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr. 1987;110(2):181–186 Caloric Density (cal/cc) Emesis (episodes/90 min) Sleep Time (min asleep/90 min) Crying Time (min crying/90 min) UnthickenedThickened p=.015p=.026p=.042 n=20

53 Positioning and GER Sitting Supine Prone 60° Adapted from Ramenofsky ML, Leape LL. Continuous upper esophageal pH monitoring in infants and children with gastroesophageal reflux, pneumonia, and apneic spells. J Pediatr Surg. 1981;16(3):374–378

54 Effect of Sleep Position on GER in Infants and Sudden Infant Death Syndrome (SIDS) Mortality Reflux Index 1 (% time pH <4) Supine * Left side * † Right side * † Prone *Mortality rate for all non-prone positions combined † Combined odds ratio 1 Tobin JM, McCloud P, Cameron DJ. Posture and gastro-oesophageal reflux: a case for left lateral positioning. Arch Dis Child. 1997;76(3):254–358 2 Skadberg BT, Morild I, Markestad T. Abandoning prone sleeping: Effect on the risk of sudden infant death syndrome. J Pediatr. 1998;132(2):340–343 3 Oyen N, Markestad T, Skaerven R, et al. Combined effects of sleeping position and prenatal risk factors in sudden infant death syndrome: the Nordic Epidemiological SIDS Study. Pediatrics. 1997;100(4):613–621 SIDS Mortality 2 (per 1000 live births) Reflux Index Odds Ratio SIDS Mortality Odds Ratio 3

55 Allergic gastroenteropathy in preterm infants. D'Netto MA, Herson VC, Hussain N, Ricci A Jr, Brown RT, Hyams JS, Justinich CJ. Division of Neonatology, Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT 06106, USA. D'Netto MAHerson VCHussain NRicci A JrBrown RTHyams JSJustinich CJ Allergic gastroenteropathy in preterm infants. D'Netto MA, Herson VC, Hussain N, Ricci A Jr, Brown RT, Hyams JS, Justinich CJ. Division of Neonatology, Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT 06106, USA. D'Netto MAHerson VCHussain NRicci A JrBrown RTHyams JSJustinich CJ Abstract OBJECTIVES: To determine the clinical presentation, histopathologic features, and outcome of biopsy-proven allergic gastroenteropathy (AGE) in preterm infants. We hypothesized that AGE is a more frequent cause of gastrointestinal disease in this population than previously suspected. STUDY DESIGN: The retrospective portion of the study, from 1992 to 1997, included preterm infants <37 weeks' gestation who underwent biopsy because of suspected AGE. The prospective portion, from January to December 1998, included 20 infants undergoing endoscopy and biopsy because of suspected AGE. RESULTS: Twenty-five infants (12 retrospective/13 prospective) with mean gestational age of 29 weeks at birth and mean postnatal age at diagnosis of 78 days were diagnosed with AGE. Three clinical patterns of presentation were noted: group 1, gastroesophageal reflux disease (n = 5); group 2, non-specific feeding intolerance (n = 8); and group 3, lower gastrointestinal bleeding (n = 12). Ten patients had negative biopsy findings (3 retrospective/7 prospective) and had clinical features indistinguishable from those of groups 1 and 2. Patients in group 3 were most likely to have positive biopsy findings (12 of 12). Fifteen patients responded to a casein hydrolysate formula, and 10 patients required an amino acid-based formula. Patients with AGE who had eosinophilic infiltration and villous atrophy took longer to recover than those with eosinophilic infiltration alone (P <.03). Subsequently, most have tolerated formula challenges and are currently tolerating cow's milk.CONCLUSIONS: AGE may be an under-recognized cause of gastrointestinal symptoms in preterm infants. Confirmation with endoscopy and biopsy can be done safely and provides the basis for appropriate dietary management. AGE may be an under-recognized cause of gastrointestinal symptoms in preterm infants. Confirmation with endoscopy and biopsy can be done safely and provides the basis for appropriate dietary management. J Pediatr Oct;137(4):480-6 J Pediatr. Abstract OBJECTIVES: To determine the clinical presentation, histopathologic features, and outcome of biopsy-proven allergic gastroenteropathy (AGE) in preterm infants. We hypothesized that AGE is a more frequent cause of gastrointestinal disease in this population than previously suspected. STUDY DESIGN: The retrospective portion of the study, from 1992 to 1997, included preterm infants <37 weeks' gestation who underwent biopsy because of suspected AGE. The prospective portion, from January to December 1998, included 20 infants undergoing endoscopy and biopsy because of suspected AGE. RESULTS: Twenty-five infants (12 retrospective/13 prospective) with mean gestational age of 29 weeks at birth and mean postnatal age at diagnosis of 78 days were diagnosed with AGE. Three clinical patterns of presentation were noted: group 1, gastroesophageal reflux disease (n = 5); group 2, non-specific feeding intolerance (n = 8); and group 3, lower gastrointestinal bleeding (n = 12). Ten patients had negative biopsy findings (3 retrospective/7 prospective) and had clinical features indistinguishable from those of groups 1 and 2. Patients in group 3 were most likely to have positive biopsy findings (12 of 12). Fifteen patients responded to a casein hydrolysate formula, and 10 patients required an amino acid-based formula. Patients with AGE who had eosinophilic infiltration and villous atrophy took longer to recover than those with eosinophilic infiltration alone (P <.03). Subsequently, most have tolerated formula challenges and are currently tolerating cow's milk.CONCLUSIONS: AGE may be an under-recognized cause of gastrointestinal symptoms in preterm infants. Confirmation with endoscopy and biopsy can be done safely and provides the basis for appropriate dietary management. AGE may be an under-recognized cause of gastrointestinal symptoms in preterm infants. Confirmation with endoscopy and biopsy can be done safely and provides the basis for appropriate dietary management. J Pediatr Oct;137(4):480-6 J Pediatr.

56 Cow’s Milk Allergy -Symptoms may be identical to GERD -Atopic families -Eczema -History of crying when swallowing -2week trial with hydrolysate formula

57 Conclusions It is important to clarify whether a pediatric patient has physiologic GER or pathologic GERD There are guidelines for appropriate testing and treating of children with reflux disease…

58 Recommended Approach to the Infant With Recurrent Regurgitation and Vomiting Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

59 Recommended Approach to the Infant With Recurrent Regurgitation and Weight Loss Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

60 GERD in older Children Heartburn, epigastric pain, and regurgitation Explore lifestyle in adolescents – cigarettes, alcohol.. PPI if symptoms are typical and the child is old enough to express the symptoms - 2,4 weeks and if symptoms resolve continue and stop in 3 months - wean off PPI

61 Recommended Approach to the Older Child or Adolescent With Heartburn Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

62

63 Thank you Special thanks to Dr. Manal Darwish


Download ppt "Gastroesophageal Reflux in infants & Proton Pump Inhibitors By: Khalil Ebrahim Manal Darwish Shihadeh, MD, FAAP Gastroesophageal Reflux in infants & Proton."

Similar presentations


Ads by Google