PEDIATRIC GERD

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PEDIATRIC GERD
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INTRODUCTION

• Gastroesophageal reflux
• Gastroesophageal reflux disease

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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
Infants ()
Age (months)
Nelson et al. Arch Pediatr Adolesc
Med.1997151569
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Prevalence of GERD in infants

• Premature infants (by pH-metry) gt85
• -3-10 apnea, bradycardia,
• exacerbation of BPD
• Infants lt3 months (by Hx) 20-100
• -33 receive medical attention
• -80 resolve with minimal intervention
• and no diagnostic evaluation

bat
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Genetic Predisposition for GERD

• Familial clustering
• Concordance for acid regurgitation
• Proposed genetic links
• Chromosome 13 locus (13q14)
• Chromosome 9 locus

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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.
200132S1
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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

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Presenting Symptoms and Signs of GERD

• Older Children and Adolescents Heartburn
  Chronic cough
• Regurgitation Nausea/epigastric
• Esophagitis pain
• Asthma
• Recurrent Pneumonia
• Hoarseness

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Frequency of presenting symptoms in 76 children
with GERD
Percentage of subjects
63.9
34
29
22
18
16
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Supraesophageal symptoms of GERD in children
Apnea/bradycardia
Chronic cough
Wheezing/asthma
Supra-esophageal manifestations of GERD
Otitis/sinusitis
Chronic sore throat
Hoarseness
Dental
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LESS COMMON SIGNS AND SYMPTOMS IN CHILDREN

• Hematemesis
• Iron deficiency anemia
• Failure to thrive/grow
• Sandifers syndrome
• (pseudo-torticollis, posturing

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Taking a History for a child with Suspected GERD

• History
• Feeding History
• Pattern of vomiting
• Past Medical History
• Psychosocial History
• Family History
• Growth Chart

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Alarm and Signals Suggestive of Non-GERD Diagnoses

• Recurrent vomiting
• History and physical examination
• Are there warning signals?

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Common Nonreflux causes of Vomiting

• Infections
• Sepsis
• Meningitis
• Urinary tract infection
• Otitis media
• Obstruction
• Pyloric stenosis
• Malrotation
• Intussusception

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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

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Common Nonreflux Causes of Vomiting (continuation)

• Metabolic/Endocrine
• Galactosemia
• Fructose intolerance
• Urea cycle defects
• Diabetic ketoacidosis
• Toxic
• Lead poisoning

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Common Nonreflux Causes of vomiting (continuation)

• Neurologic
• Hydrocephalus and shunt
• malfunctioning
• Subdural hematoma
• Intracranial hemorrhage
• Tumors
• Migraine

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Common Nonreflux Causes of Vomiting (continuation)

• Allergic
• Dietary protein intolerance
• Respiratory
• Posttussive emesis
• Pneumonia
• Renal
• Obstructive uropathy
• Renal insufficiency

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Common Nonreflux Causes of Vomiting

• Cardiac
• CHF and disease
• Recreational drugs and alcohol
• consumption
• Pregnancy
• Other
• Overfeeding
• Self-induced emesis

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Diagnostic Approach to GER

• History and Physical examination
• Diagnostic studies
• Contrast Radiographs
• Esophageal ph monitoring
• Endoscopy
• Multichannel intraluminal impedance
• Scintigraphy

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GOALS IN THE TREATMENT OF REFLUX

• Eliminate symptoms quickly
• Heal esophagitis
• Manage or prevent complications
• Maintain remission

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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
• -Problemplacebo effect

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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)

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Empiric Therapy in GERD(continuation)

• Define goals and length of empiric
• trial before initiation of therapy
• Stop treatment if empiric therapy fails

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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

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Management of Mild GERD Symptoms

• Explanation and reassurance
• Diet and lifestyle
• Antacids

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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.200132(suppl2)S1

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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,.200132(suppl 2)S1

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Management of Mild-to-Moderate GERD Symptoms

• Prokinetics
• - Metoclopramide - Cisapride
• H2Receptor Antagonists
• - Cimetidine - Nizatidine
• - Famotidine - Ranitidine
• Proton Pump Inhibitors
• -Omeprazole -Lansoprazole

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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

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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 H2RAs to H2RAs
  for
• healing and
  ph
• control
  
• -Cost and
  managed
• care
  restrictions

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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 gt12 years 150 mg. BID
• Cimetidine gt16 years 800 mgBID or
• 400 mg. QID
• 3

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PPIs Approved for Rx ofPediatric GERD (FDA
Labeling)

• Omeprazole
• Weight Dosing Duration Indicated Ages
• lt20 kg 10mg QD up to 2yrs-16yrs
• 12 wks
• gt20 kg 20mg QD up tp 2yrs-16yrs
• Lansoprazole
• lt30 kg 15 mg QD up to 12mo.-11yrs
• gt30kg 30mg QD 12 wks 12mo-11yrs
• Nonerosive esophagitis-up to 8wks 12-17yrs

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Importance of timing of PPIdose

• Dosing Administer PPI
• QD 30 min. before breakfast
• BID 30 min before breakfast
• and evening meal

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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

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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

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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.2002621503.
Gold b. Pediatric Drugs. 20024673
Rudolph CD., et al. Jpediatr GassstroenterolNutr.2
00132S1
Klinkenberg- KknolEC, et al.Gastroenterology20001
18(4)661. l
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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

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Children at Risk for Long-term Complications of
GERD

• Asthma
• Cystic fibrosis
• Esophageal atresia
• Downs syndrome
• Erosive esophagitis
• Neurologic impairment

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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

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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

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Complications of GERD

• Esophagitis
• Peptic Stricture
• Failure to thrive
• Pulmonary/ENT disease
• Barretts esophagus
• Adenocarcinoma

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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)

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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

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Summary

• Complications of GERD include
• -Asthma
• -Erosive esophagitis
• -Stricture
• -Barretts esophagus
• -Adenocarcinoma

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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

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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

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Summary

• Children less than 18 months old with
• GER rarely develop GERD
• Complications of GERD
• -Asthma Adenocarcinoma
• -Erosive esophagitis
• -Stricture
• -Barretts esophagus

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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

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• 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.