1. GASTROESOPGHEAL REFULX DISEASE IN CHILDREN
Dr Shrish Bhatnagar

2. Dedication
JNMC
SGPGIMS
Dr S K BHATNAGAR

3. DEFINATION
Gastroesophageal reflux or GER means Involuntary passage of gastric contents into the esophagus and is often Physiological but gastroesophageal reflux disease or GERD means symptoms or complications associated with pathological GER

4. PREVALENCE
Infants
55%
15%
10%
>12 months

5. Prevalence of GERD
GERD is defined to be present when reflux of gastric contents causes either troublesome symptoms or complications.
In a study from USA involving pyrosis or heartburn was reported in 1.8% of the 3-9 years age group and 3.5% in the 10 to 17 years age group compared to 22% in adults (>18 years).
Hence, the prevalence of GERD slowly increases with age during childhood and becomes quite frequent among young adults.

6. Presenting symptoms

7. History

8. Case Snippet 1 Newborn presents with bilious vomiting on day 3
Clinically: dehydrated
Bilious vomiting usually suggests a small intestinal obstruction and we would normally expect a distended abdomen but
Abdomen: soft and sunken!

9. X ray – single air bubble

10. Why no abdominal distension in small intestinal obstruction ?
Higher the obstruction - more the vomiting; lesser the pain and distension
Lower the obstruction - more the distension and pain; lesser the vomiting

11. USG ABDOMEN
1. Pylorospasm 2. SMA SMV relationship axis on transverse images - reversal sign should make us strongly suspect malrotation 3. The “whirlpool” sign - SMV wrapping around SMA is rare

12. Barium Upper GI series – malrotation with midgut volvulus

13. Timely surgery before bowel gangrene

14. If not operated in time …
Small bowel gangrene sets in and extensive bowel resection may render the child TPN dependent for life!

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

16. Esophageal Capacity Shorter esophagus Smaller capacity Gravity Infant
Adult

17. NO ROLE OF EMPERICAL H2RA/PPI
Case –I/2
NO ROLE OF EMPERICAL H2RA/PPI
Further Evaluation

18. Case -2 Further Evaluation LONG DURATION Drugs for 2-3 weeks Drugs for
Taper Drugs for 2-3 months
LONG DURATION
Further Evaluation

19. Conditions predisposing to Severe GERD

20. Testing for Reflux Disorders
No one test can be used to diagnose reflux, and instead must be matched to a clinical question
Reflux tests are useful
To document the presence of GER(D)
To detect complications
To establish a causal relationship between GER and symptoms
To evaluate therapy
To exclude other conditions
BARIUM STUDIES OBSOLETE

21. UGI Endoscopy Advantages Limitations
Enables visualization and biopsy of esophageal epithelium
Determines presence of esophagitis, other complications
Discriminates between reflux and non-reflux esophagitis
Limitations
Endoscopic grading systems not yet validated for pediatrics
Poor correlation between endoscopic appearance and histopathology
Generally not useful for extra-esophageal GERD

22. Case snippet 2
8 month old with non bilious vomiting since 3 months of age.
Vomits both liquids as well as solids
Thought to have GERD
Advised more solids, domperidone and PPI
No response!
USG abdomen: normal
Barium swallow: showed evidence of gastroesophageal reflux disease but no hiatus hernia

23. Case progress Vomiting continued! Mild FTT Serum IgA tTG negative
Pediatric Gastroenterological consult

24. Eosinophilic esophagitis

25. Management
Eosinophilic esophagitis is a difficult disease to treat - often needing a trained pediatric gastroenterologist and allergy specialist
In small children – complete elimination of
M ilk
E gg
W heat
S oy
Older children - steroid sprays to be swallowed

26. Esophageal pH Monitoring
Advantages
Detects episodes of reflux
Determines temporal association between acid GER and symptoms
RI is the precentage of time esophgeal pH is <4
RI>10% in infants and >5% in children is diagnostic
Limitations
Cannot detect nonacidic reflux
Cannot detect GER complications associated with “normal” range of GER
To be introduced in August 2014

27. Multichannel Intraluminal –Impedance (MII) 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
High per test cost.
pH channel
pH 4 Z 1
Impedance channels Z 4

28. Management- Life style Changes
For Infants
For Older Children
Normalize feeding volume and frequency
Consider thickened formula
Consider non-prone positioning during sleep
Consider trial of hypoallergenic formula
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

29. Effects of Thickening of milk feeds with rice cereal
Unthickened
Thickened
n=20
p=.015
p=.026
p=.042
Caloric Density
(cal/cc)
Emesis (episodes/90 min)
Sleep Time (min asleep/90 min)
Crying Time (min crying/90 min)
Adapted from Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr. 1987;110(2):181–186

30. Effect of positioning and GERD
60°
Sitting
Supine

31. Case snippet 3
1.5 yr old toddler brought by mum for complaints of non bilious vomiting last 2-3 months
Vomiting usually occurs during and soon after feeds
What is your diagnosis?

32. Is this GERD or forced feeding?
GERD symptoms usually peak around 3- 6months of age or even earlier. More with liquids > solids
Vomiting - more of a passive regurgitation
Irritability - suggests esophagitis/ CMPA
Extraesophageal symptoms - nocturnal cough, Sandifer syndrome - more common in devp delay
Picky eating starts after 1 yr of age. Food refusal. Picky eaters. Sensory oral aversions. Delve deeper into the history - meal times are warzone between mum and kid
But sometimes they co exist!

33. Treatment of GERD in Older Children
A left sided sleeping position with elevation of the head of the bed may decrease symptoms and GER
In adults, obesity and late night eating are associated with increased reflux
To date, no evidence to support specific dietary restrictions to decrease symptoms of GER in pediatric populations
Appropriate to trial acid suppression

34. Pharmacological Therapy
Children with GERD need potent acid suppression therapy for at least 12 weeks.
Antacids can be used for symptomatic relief for a brief period but prolonged therapy is contraindicated in children due to side effects
Aluminum toxicity (osteopenia, rickets, microcytic anemia, and neurotoxicity) in aluminum containing antacids and sucralfate
Risk of milk alkali syndrome (hypercalcemia, alkalosis, and renal failure with calcium containing antacids.

35. Histamine-2 Receptor Antagonists in Pediatric with GERD (H2-RAs)
Ranitidine, and Famotidine are safe and effective. Ranitidine comes in 75mg/5ml syrup, dose 4-10mg/kg/day, divided BID-TID. Famotidine - dose1-1.2mg/kg/day, divided BID-TID

36. Histamine-2 Receptor Antagonists in Pediatric with GERD (H2-RAs)
Oral dose for peptic ulcer: 2mg/kg to 4mg/kg, twice daily to a maximum of 300mg per day.;
Maintenance of Healing of Duodenal and Gastric Ulcers: 2-4mg/kg once daily to a maximum of 150mg.day.
Treatment of GERD and Erosive Esophagitis : 5- 10mg/kg/day usually given as 2 divided doses .

37. Proton Pump Inhibitors
They are also called Na-K-ATPase inhibitors as they inhibit acid secretion
PPIs should be taken 30 minutes before breakfast
Once daily dosing is adequate and children
2-2.5mg/ kg/day for omeprazole and
1.4 mg/kg/day for lansoprazole
The advantages of PPIs are
more effective in relieving symptoms and healing esophagitis
prolonged action (requires once daily dose),
no tachyphylaxis on prolonged use, and
relatively safe drug on long term use.

38. Duration of Medical Therapy
GERD needs profound acid suppression for a longer duration of time.
Drug therapy is recommended for at least 12 weeks and then to taper over 2 to 3 months as rebound hyperacidity is known after sudden stoppage of drugs
In a diagnosed case of GERD, if there is no symptomatic improvement in 4 weeks then the dose of drugs needs to be increased.
In erosive esophagitis, repeat endoscopy to document healing is indicated at the end of 12 weeks course
In a long term follow-up study in children, it has been shown that prolonged drugs therapy (median 3 years and up to 12 years) is safe

39. Bronchial asthma and GERD
The clinical association of bronchial asthma and GERD is very strong but causal relationship has not yet been established.
It is not yet clear” Is it asthma that causes GERD or is it GERD that causes asthma?”
Persistent asthma with symptomatic GERD: can be treated with PPI with a clear explanation given to the patient that symptoms might improve
Intermittent asthma : there is no clinical relation with GERD
Difficult to control asthma : (chronic symptoms,continued requirement of steriods) : may derive some benefit from medical therapy . However It is recommended to perform pH study before considering a trial of long-term PPI therapy

40. GERD in neurologically impaired children
Prevalence of GERD in neurologically impaired children is much higher and the prevalence is almost 50%.
Severity and complications of GERD is also much more in this subset of patients.
It has been shown that the prevalence of erosive esophagitis is 30% to 70% compared to just 5% in normal children .
This group of children needs prolonged medication and more often surgery

41. Conclusions
GER is common in infants but GERD is not so common in early childhood.
Most infants have physiological reflux and resolve by 18 months of age.
There is no gold standard diagnostic test.
Empirical H2RA/ PPI therapy for 4 weeks is justified in older children and adolescents with classical symptoms.
Medical therapy with H2 RA/ PPI is very effective and safe and should be continued for long duration
Surgical therapy carries significant morbidity and often fails in those who need it most

42. THANK YOU