1. PEDIATRIC GERD

2. INTRODUCTION Gastroesophageal reflux Gastroesophageal reflux disease
The passage of gastric contents into the esophagus (gastroesophageal reflux) is a normalphysiologic process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause symptoms, esophageal injury or other complications. In contrast GERD is present when the reflux episodes are associated with symptoms or complications.The challenges managing reflux lay in determining what is physiologic and what is pathologic. Terms: Regurgitation, Vomiting, Rumination

3. 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

4. Prevalence of Regurgitation in Healthy Infants
During infancy GER is common and is most often manifest as vomiting. Recurrent vomiting occurs in 50% o finfantsin the first 3 months of life, in 67% of of 4 month old infants, and in 5% of month old infants.vomiting resolves spontaneously in nearly all of these infants. Patients do not usually perceive vomiting as a problem when it occurs no more often than once daily, but they are more likely to be concerned when vomitingis more frequent, the volume of vomitus is large, or when the infant cries frequently or with vomiting.
Age (months)
Nelson et al. Arch Pediatr Adolesc Med.1997;151:569

5. Prevalence of GERD in infants
Premature infants (by pH-metry) >85%
-3-10%: apnea, bradycardia,
exacerbation of BPD
Infants <3 months (by Hx) %
-33% receive medical attention
-80% resolve with minimal intervention
and no diagnostic evaluation
bat

6. Genetic Predisposition for GERD
Familial clustering
Concordance for acid regurgitation
Proposed genetic links
Chromosome 13 locus (13q14)
Chromosome 9 locus
Family clustering:GERD sx, Hiatal hernia, Erosive esophagitis, Barrett’s esophagus, Esophageal adenocarcinoma Concordance for acid regurgitation Higher in monozygotic vs. dizygotic twins proposed genetic link- Postulated chromosome 13(13q14) for severe GERD –Chromosome 9 locus (9q22-9q31) proposed for infantile esophagitis.

7. 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

8. 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

9. Presenting Symptoms and Signs of GERD
Older Children and Adolescents Heartburn Chronic cough
Regurgitation Nausea/epigastric
Esophagitis pain
Asthma
Recurrent Pneumonia
Hoarseness

10. Frequency of presenting symptoms in 76 children with GERD
Percentage of subjects
63.9 34 29 22 18 16

11. Supraesophageal symptoms of GERD in children
Apnea/bradycardia
Chronic cough
Wheezing/asthma
Supra-esophageal
manifestations
of GERD
Otitis/sinusitis
Chronic sore
throat
Hoarseness
Dental

12. LESS COMMON SIGNS AND SYMPTOMS IN CHILDREN
Hematemesis
Iron deficiency anemia
Failure to thrive/grow
Sandifer’s syndrome
(“pseudo-torticollis,” posturing

13. Taking a History for a child with Suspected GERD
Feeding History
Pattern of vomiting
Past Medical History
Psychosocial History
Family History
Growth Chart
In most infants with vomiting and most older children with regurgitation and heartburn, a history and physical examination are sufficientto reliably diagnose GER, recognize complications, and initiate management.

14. Alarm and Signals Suggestive of Non-GERD Diagnoses
Recurrent vomiting
History and physical examination
Are there warning signals?
Recurrent vomiting-Bilious or forceful, onset of vomiting after 6 months of life Hx-Hematemesis or hematochezia, diarrhea, abdominal tenderness or distention, fever, lethargy, hepatosplenomegaly, seisures, macrocephaly or microcephaly
PE-abdominal tenderness or distention Warning signals-Fever, lethargy,hepatosplenomegaly,Micro and macrocephaly, seizures

15. Common Nonreflux causes of Vomiting
Infections
Sepsis
Meningitis
Urinary tract infection
Otitis media
Obstruction
Pyloric stenosis
Malrotation
Intussusception

16. 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

17. Common Nonreflux Causes of Vomiting (continuation)
Metabolic/Endocrine
Galactosemia
Fructose intolerance
Urea cycle defects
Diabetic ketoacidosis
Toxic
Lead poisoning

18. Common Nonreflux Causes of vomiting (continuation)
Neurologic
Hydrocephalus and shunt
malfunctioning
Subdural hematoma
Intracranial hemorrhage
Tumors
Migraine

19. Common Nonreflux Causes of Vomiting (continuation)
Allergic
Dietary protein intolerance
Respiratory
Posttussive emesis
Pneumonia
Renal
Obstructive uropathy
Renal insufficiency

20. Common Nonreflux Causes of Vomiting
Cardiac
CHF and disease
Recreational drugs and alcohol
consumption
Pregnancy
Other
Overfeeding
Self-induced emesis

21. Diagnostic Approach to GER
History and Physical examination
Diagnostic studies
Contrast Radiographs
Esophageal ph monitoring
Endoscopy
Multichannel intraluminal impedance
Scintigraphy
UGI SERIES-fluoroscopic and radiologic images obtained yield functional and structural info (malrotation, esophageal or antral weds, pyloric s., congenital band
Around the esophagus (Schatki ring) associated with hiatal hernia. UGI studies cannot discriminate between physiologic and nonphysiologic reflux

22. GOALS IN THE TREATMENT OF REFLUX
Eliminate symptoms quickly
Heal esophagitis
Manage or prevent complications
Maintain remission
Pharmacologic management is successful in 95
Pharmacologic management is siccessful in 95% to 98% of patients

23. 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

24. 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)

25. Empiric Therapy in GERD (continuation)
Define goals and length of empiric
trial before initiation of therapy
Stop treatment if empiric therapy fails

26. Strategies for the Empiric Trial: Step-up Therapy
High-dose
PPI
H2Ra
Lifestyle
Modicifations*
Important to implement with medications as well
No studies evaluating these strategies in children

27. Management of Mild GERD Symptoms
Explanation and reassurance
Diet and lifestyle
Antacids

28. 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

29. 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
Limits caffeine, chocolote, spicy foods, fatty foods, acidic foods, carbonated beverages

30. Management of Mild-to-Moderate GERD Symptoms
Prokinetics
- Metoclopramide - Cisapride
H2Receptor Antagonists
- Cimetidine - Nizatidine
- Famotidine - Ranitidine
Proton Pump Inhibitors
-Omeprazole -Lansoprazole

31. 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

32. 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
PPIs-Multiple formulations, less frequent dosing

33. FDA Labeling for Rx H2RA Therapy for Pediatric GERD
Indicated Ages Dosing
Ranitidine 1 month to mg/kg/day
16 years divided BID
Famotidine 1 year to mg/kg/day
16 years divided BID up
to 40 mg. BID
Nizatidine >12 years mg. BID
Cimetidine >16 years mgBID or
400 mg. QID 3

34. PPIs Approved for Rx of Pediatric GERD (FDA Labeling)
Omeprazole
Weight Dosing Duration Indicated Ages
<20 kg 10mg QD up to yrs-16yrs
12 wks
>20 kg 20mg QD up tp 2yrs-16yrs
Lansoprazole
<30 kg 15 mg QD up to mo.-11yrs
>30kg 30mg QD 12 wks 12mo-11yrs
Nonerosive esophagitis-up to 8wks yrs

35. Importance of timing of PPIdose
Dosing Administer PPI
QD min. before breakfast
BID min before breakfast
and evening meal

36. 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

37. 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

38. 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

39. 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

40. Children at Risk for Long-term Complications of GERD
Asthma
Cystic fibrosis
Esophageal atresia
Down’s syndrome
Erosive esophagitis
Neurologic impairment

41. 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

42. 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

43. Complications of GERD Esophagitis Peptic Stricture Failure to thrive
Pulmonary/ENT disease
Barrett’s esophagus
Adenocarcinoma

44. 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)
Most patient withGERD can be treated by a primary care provider without testing

45. 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

46. Summary Complications of GERD include: -Asthma -Erosive esophagitis
-Stricture
-Barrett’s esophagus
-Adenocarcinoma

47. 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

48. 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

49. Summary Children less than 18 months old with GER rarely develop GERD
Complications of GERD :
-Asthma Adenocarcinoma
-Erosive esophagitis
-Stricture
-Barrett’s esophagus

50. 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

51. Shawn is 9 months old brought for the first time for check up
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.