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PEDIATRIC GERD INTRODUCTION Gastroesophageal reflux Gastroesophageal 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 Infants (%) 100 1 time a day 4 times a day 0 0-3 4-6 7-9 Age (months) 10-12 Prevalence of GERD in infants Premature infants (by pH-metry) >85% -3-10%: apnea, bradycardia, bat exacerbation of BPD Infants <3 months (by Hx) 20-100% -33% receive medical attention -80% resolve with minimal intervention and no diagnostic evaluation 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”) PRESENTING SYMPTOMS AND SIGNS OF GERD Preschool Intermittent vomiting or regurgitation Less commonly respiratory complications 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 Percentage of subjects 70 60 Heartburn or epigastricpain Recurrent abdominal pain Respiratory symptoms Regurgitation 63.9 50 40 30 20 10 0 34 29 22 Retrosternal pain 18 16 Vomiting Supraesophageal symptoms of GERD in children Apnea/bradycardia Chronic cough Wheezing/asthma Supra-esophageal manifestations of GERD Chronic sore throat Dental Otitis/sinusitis Hoarseness 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 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 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 formula Rudolph 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-toModerate GERD Symptoms Prokinetics - Metoclopramide - Cisapride H2Receptor Antagonists - Cimetidine - Nizatidine - Famotidine - Ranitidine Proton Pump Inhibitors -Omeprazole -Lansoprazole 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 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 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 >12 years 150 mg. BID Cimetidine >16 years 800 mgBID or 400 mg. QID 3 PPIs Approved for Rx of Pediatric 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-16yrs Lansoprazole <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 QD BID Administer PPI 30 min. before breakfast 30 min before breakfast and evening meal 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 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:S1 Klinkenberg- 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 irreversible) 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 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 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.
