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.