GERDGERD

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ObjectivesObjectives

Discuss the prevalence and significance of GERD in the pediatric population

Discuss the diagnostic evaluation of the child with suspected GERD

Review the management of GERD

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Epidemiology: GER Epidemiology: GER IcebergIceberg

InfantsReferral

Visit MD within the

year

Regurgitate > 2 times per day

AdultsReferral

Visit MD within the year

Heartburn > 1 times per

month

2%

2%

10 %

10 %

50 %

50 %

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Prevalence of Regurgitation Prevalence of Regurgitation in Infancyin Infancy

0

10

20

30

40

50

60

70

0-3 mos 4-6 mos 7-9 mos 10-12 mos

>1 time per day

>4 times per day

% of infants

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The Antireflux BarrierThe Antireflux Barrier

Esophagus

LES

Crural Diaphragm

Angle of His

Stomach

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Esophageal CapacitanceEsophageal Capacitance

- Shorter esophagus (11 cm; 5 mm diam)- Smaller capacity

30 cm; 2x3 cm diam

Gravity

InfantAdult

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Factors Predisposing to Factors Predisposing to GERDGERDDecreased resistance:

Inadequate LES toneInappropriate LES relaxationInadequate supporting structures

Increased pressure:- Tonic (e.g. obesity, slouched posture)- Phasic (e.g. cough, sneeze, strain)

Increased gastric volume:Large mealsDelayed gastric emptyingDuodenogastric reflux

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Presenting SymptomsPresenting Symptoms

Recurrent vomiting Recurrent vomiting in infantin infant

Recurrent vomiting Recurrent vomiting and poor weight and poor weight gain in infantgain in infant

Recurrent vomiting Recurrent vomiting and irritability in and irritability in infantinfant

Recurrent vomiting Recurrent vomiting in older childin older child

Heartburn in child or Heartburn in child or adolescentadolescent

Dysphagia or feeding Dysphagia or feeding refusalrefusal

Apnea or ALTEApnea or ALTE AsthmaAsthma Recurrent pneumoniaRecurrent pneumonia Upper airway Upper airway

symptomssymptoms Chronic coughChronic cough

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Warning Signals Suggestive of

a Non-GER Diagnosis Bilious or forceful

vomiting Hematemesis or

hematochezia Vomiting or diarrhea Abdominal

tenderness or distention

Onset of vomiting after 6 months of life

Fever, lethargy, hepatosplenomegaly

Macrocephaly, microcephaly, seizures

Are there warning signs?

History and PE

Recurrent vomiting

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Signs of Complicated Signs of Complicated GERDGERD

Poor weight gain Excessive crying or irritability Feeding problems Respiratory problems, including:

wheezing stridor recurrent pneumonia

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What approach do you take What approach do you take in suspected GERD?in suspected GERD?

History and physical examination Upper GI series Upper endoscopy and biopsy Esophageal pH or impedance

monitoring Empirical medical therapy* Most common 1st steps listed by

pediatricians

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Upper GIUpper GI

ADVANTAGESADVANTAGES Useful for detecting Useful for detecting

anatomic anatomic abnormalitiesabnormalities

LIMITATIONLIMITATION Cannot discriminate Cannot discriminate

between physiologic between physiologic and nonphysiologic and nonphysiologic GER episodesGER episodes

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Radiographs of Diagnoses Radiographs of Diagnoses thatthat

can Mimic GERD can Mimic GERD

Pyloric stenosis Malrotation

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Upper Endoscopy with Upper Endoscopy with BiopsyBiopsy

ADVANTAGESADVANTAGES Enables visualization and Enables visualization and

biopsy of esophageal biopsy of esophageal epitheliumepithelium

Determines presence of Determines presence of esophagitis, other esophagitis, other complicationscomplications

Discriminates between Discriminates between reflux and non-reflux reflux and non-reflux esophagitisesophagitis

LIMITATIONSLIMITATIONS Need for sedation or

anesthesia Generally not useful

for extraesophageal GERD

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Examples of Endoscopic Examples of Endoscopic FindingsFindings

Erosive EsophagitisEosinophilic Esophagitis

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Esophageal pH Esophageal pH MonitoringMonitoring

ADVANTAGESADVANTAGES Detects episodes of reflux Determines temporal

association between acid GER and symptoms

Determines effectiveness of esophageal clearance mechanisms

Assesses adequacy of H2RA or PPI dosage in unresponsive patients

LIMITATIONS 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

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When would it be USEFUL When would it be USEFUL toto

obtain esophageal pH obtain esophageal pH monitoring?monitoring?To establish a To establish a

relationship between relationship between occult GER and occult GER and chronic symptoms:chronic symptoms:

Upper respiratory sxUpper respiratory sx Chest painChest pain Recurrent pneumoniaRecurrent pneumonia Apnea/CyanosisApnea/Cyanosis IrritabilityIrritability Intractable asthmaIntractable asthma

To monitor efficacy of To monitor efficacy of medical or surgical medical or surgical therapy:therapy:

Acid blockersAcid blockers Prokinetic agentsProkinetic agents Following Following

fundoplicationfundoplication

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Treatment OptionsTreatment Options

Surgical Tx

Medication

Lifestyle Changes

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Conservative TherapyConservative Therapy

INFANTS

Normalize feeding volume and frequency

Consider thickened formula

Consider non-prone positioning during sleep

Consider trial of hypoallergenic formula

OLDER KIDS

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

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Thickened FormulaThickened Formula

Unthickened ready-to use infant formula = 20 cal/oz

Thickened formula 1 tablespoon rice cereal per ounce = ~34 cal/oz

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Comparison of Drug Therapies Comparison of Drug Therapies For Healing Erosive For Healing Erosive

Esophagitis in AdultsEsophagitis in Adults

0

10

20

30

40

50

60

70

80

90

100

EndoscopicImprovement

Heartburn relief

Placebo

Sucralfate

Cisapride

H2 Blocker

PPI

% o

f P

ati

en

ts

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PPIs in Infants andPPIs in Infants andChildren With GERDChildren With GERD

Pharmacologic studies with omeprazole and lansoprazole showing benefit

No randomized placebo-controlled trials

Multiple case series of children refractory to H2RA showing benefit

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Recommended Oral H2RA Recommended Oral H2RA DosagesDosages

Generic Generic NameName

Brand Brand NameName

Typical Peds Typical Peds DoseDose

Typical Typical Adult Adult DoseDose

FormulationsFormulations

RanitidinRanitidinee

ZantacZantac 4-10 mg/kg/day 4-10 mg/kg/day divided BID-TID divided BID-TID for ages 1 for ages 1 month or older month or older up to 40 mg up to 40 mg BIDBID

150 150 mg mg BIDBID

150 & 300 150 & 300 mg tablets; mg tablets; 25 mg 25 mg Efferdose Efferdose tablet; 15 tablet; 15 mg/ml syrupmg/ml syrup

FamotidiFamotidinene

PepcidPepcid

Pepcid Pepcid ACAC

0.5 mg/kg/day 0.5 mg/kg/day divided BID up divided BID up to 40 mg BID to 40 mg BID for ages 1-17 for ages 1-17 yearsyears

20 or 20 or 40 mg 40 mg QD-QD-BIDBID

10, 20, 40 mg 10, 20, 40 mg tablets; 40 tablets; 40 mg/5 ml mg/5 ml liquid; 10 & liquid; 10 & 20 mg OTC 20 mg OTC tabletstablets

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Oral PPI Dosages for GERDGenericGeneric BrandBrand Pediatric DosesPediatric Doses Adult Adult

DosesDosesFormulationsFormulations

LansoprazLansoprazoleole

PrevacPrevacidid

< 30 kg 15 mg QD< 30 kg 15 mg QD

> 30 kg 30 mg QD > 30 kg 30 mg QD for 1- 17 yearsfor 1- 17 years

15 or 30 15 or 30 mg QD-mg QD-BIDBID

15 & 30 mg 15 & 30 mg capsules; 15 capsules; 15 & 30 mg & 30 mg SolutabSolutab

OmeprazolOmeprazolee

PrilosPrilosecec

10 or 20 mg QD for 10 or 20 mg QD for 2-16 years 2-16 years

20 or 40 20 or 40 mg QD-mg QD-BIDBID

10, 20 & 40 10, 20 & 40 mg capsulesmg capsules

EsomepraEsomeprazolezole

NexiuNexiumm

10 or 20 mg QD age 10 or 20 mg QD age 1-11; 20 or 40 mg 1-11; 20 or 40 mg QD 12-17 yoQD 12-17 yo

20 or 40 20 or 40 mg QD-mg QD-BIDBID

20 & 40 mg 20 & 40 mg capsules; 10 capsules; 10 & 20 mg & 20 mg liquidliquid

PantoprazPantoprazoleole

ProtonProtonixix

No FDA approvalNo FDA approval 20 or 40 20 or 40 mg QD-mg QD-BIDBID

20 & 40 mg 20 & 40 mg tablets; 40 mg tablets; 40 mg oral oral suspensionsuspension

RabeprazoRabeprazolele

AciphAciphexex

No FDA approvalNo FDA approval 20 or 40 20 or 40 mg QD-mg QD-BIDBID

20 mg tablet20 mg tablet

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Candidate for AntirefluxSurgery in Childhood

Fails medical therapy due to GERD

Is dependent on aggressive or prolonged medical therapy

Has persistent asthma or recurrent pneumonia due to GERD

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Principles of Antireflux Surgery

Restore intraabdominalsegmentof esophagusApproximatediaphagmaticcrurae

Reducehiatal herniawhenpresentWrap fundusaround LES toreinforceantireflux barrier

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SummarySummary

GER is common in healthy infants Pediatric GERD can present with variable

symptoms Currently available tests often do not

conclusively demonstrate a relationship between GER and specific symptoms

Good history and clinical judgment are important for optimal evaluation and management

Antisecretory agents are the most effective pharmacological therapy