Gastroesophageal Reflux
Childhood
Mary Ann Hudson, RN
OSU College of Nursing
Patient History
• 10 year old male with chief complaint of stomach and throat
pain that worsens at night and with large, rich meals.
• Patient has history of infant reflux and was given liquid Zantac
until one year of age when symptoms of arching and crying
with meals resolved without medication.
• Father has history of gastroesophageal reflux and peptic
ulcer. Father has recently completed a two-week Prilosec
treatment for breakthrough reflux after being treated for h.
pylori.
• Patient lives with father on the weekends along with his twin
sister. During the week, patient lives with twin sister and his
mother. Parents have been divorced for a little over a year.
Custody agreement requires that both parents be present at
medical/health appointments unless it is an emergency. Both
mother, father, and twin sister are in exam during this visit.
• Mother has no significant history of reflux or gastrointestinal
disease. Sister is symptom free. Mother reports patients
symptoms appear following every meal, father disagrees with
this history, patient is not sure.
Patient History
• Patient questioned about supraesophageal
symptoms of GER.
• Patient and parents deny apnea.
• Patient and parents deny asthma or wheezing.
• Patient has a significant history of sinusitis and
Otitis Media.
• Patient and parents deny hoarseness, but endorse
post meal “sounds” like wet burping, excessive
swallowing, and throat clearing.
• Patient and parents endorse dry, constant cough.
• Patient and parents endorse frequent sore throat
complaints. Patient has a significant history of
sore throat visits negative for GABS pharyngitis or
other symptoms.
Significant Visit Observations
related to Barnard Model of Health
Patient Exam
• Patient HEENT, cardiac, pulmonary, M/S,
Neurological, exams are all WNL. Patient is calm,
cooperative, and has a normal body temperature.
• Patient BS are hyperactive in both upper
quadrants. Patient tolerates deep abdominal
palpation in all quadrants except peri-umbilically.
• Today, though patient complains of throat pain, no
erythema, exudate, or injury is noted in the
oropharynx.
• At this time, no labs or studies will be ordered,
though if first-line treatment is unsuccessful, an h.
pylori lab is a reasonable next step given father’s
previous Dx.
Diagnosis and Treatment Plan
Dx:
Gastroesophageal Reflux
Treatment:
Omeprazole 20 mg tablet PO once per day for fourteen (14
days).
Elevate HOB 10-30 degrees.
Eat smaller, more frequent (4-6x/day) meals
Follow-up at end of omeprazole treatment to discuss
symptoms and if further studies or treatment is necessary.
Direct pharmacy to divide prescription so that the four
weekend doses are available to father, and HOB should be
elevated at both households. Avoid large, weekend meals.
Patient is given a small tablet with dates to record number of
times he feels pain or discomfort, or to draw a “smiley face”
if there was no pain. Parents may remind patient, but not fill
in tablet.
GER Journal—Each Table Dated
with extra spot for smile
Symptom
Throat Pain
Tummy Pain
Feeling
uncomfortable or
sick in any way
Yes (number of
times)
No
A little bit
(number of
times)
Gastroesopageal Reflux
Pathophysiology
GER is caused by a failure
of the cardia, or the portion
of the stomach attached to
the esophagus. In a normal
finding, the Angle of His
creates a valve that prevents
bile, enzymes, and stomach
acid from entering the
esophagus where they
cause pain and inflammation
of esophageal tissue.
GER Differentials
• GERD—damage to esophageal tissue as indicated by
a very long duration >3 months (no clinical guidelines),
severe symptoms, previous trial of first-line treatment
• Ulcer—pain timed consistently before or after meals,
Hx of microorganism exposure, sharp UQ or
periumbilical pain.
• IBS/UC—Lower GI symptoms
• Celiac Disease—previous first-line treatment failures,
other systemic symptoms
• Abdominal Mass—palpation, constant or severe
symptoms, first-line treatment failure
• Asthma/UA Disease—primarily respiratory symptoms
• Functional Abdominal Pain—careful social, toileting,
dietary, and medical history
Childhood GER Epidemiology
It is estimated that as many as 2 million
US children may suffer from GER.
Risk factors include an infant history of
reflux, family history of reflux, obesity,
low activity, chronic disease like Down’s
or CF, hiatal hernia, GI tract structural
abnormalities including those that are
repaired, prematurity, and possibly poor
sleep and/or diet.
Rudolph, C., Mazur, L., Liptak, G., Baker, R., Boyle, J., Colletti, R., ,…Werlin, S. (2001).
Guidelines for evaluation and treatment of gastroesophageal reflux in infants and
children: recommendations of the North American Society for Pediatric Gastroenterology
and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 32 Suppl 2, S1-31.
Objective:
Establish clinical guidelines for simple reflux for infants and children
according to systemic review of literature.
Results:
There is no gold standard for the diagnosis of reflux in children, and
a comprehensive history and physical exam are still the best tools.
There is an array of effective first-line treatment for reflux to consider
before child is evaluated for GERD with upper GI studies. Treatment
should be based on history.
Conclusions:
H2 blockers, PPIs, motility regulators all demonstrated effectiveness
in children with GER. Best effectiveness seems to be correlated with
history. Systemic review does not suggest clear guidelines for
treatment failure, though persistent symptoms after first-line
pharmacological treatment do suggest failure. Supportive treatment
like increased HOB, smaller meals, and increased activity are
palliative.
Tighe, MP.; Afzal, NA.; Bevan, A.; Beattie, RM. “Current pharmacological
management of gastro-esophageal reflux in children: an evidence-based
systematic review.” Paediatric Drugs, v. 11 issue 3, 2009, p. 185-202.
Objective:
Evaluate pharmacological management of GER in children
(excludes infants).
Results:
H2 blockers, PPI, and motility regulators all demonstrate
effectiveness. Antacids are equivocal in their effectiveness.
Conclusions:
H2 blockers have the longest clinical history and
demonstrated effectiveness and safety as first-line treatment
for GER. PPIs have emerged as demonstrating a similar,
higher compliance treatment and may be more effective for
reflux due to h. pylori infection. Motility regulators should be
considered after failures of an acid reducer or by history.
Romano, C., et al. “Proton pump inhibitors in pediatrics: evaluation of efficacy
in GERD therapy.” Current Clinical Pharmacology, v. 6 issue 1, 2011, p. 41-7.
Objectives:
To evaluate effectives of PPIs as efffective treatment in
childhood GER.
Results:
PPIs are safe and effective for the treatment of
childhood GER and slightly more effective than H2
blockers in the treatment of GERD.
Conclusions:
PPIs should be considered in a childhood diagnosis of
GER. Shorter treatment and fewer daily doses may be
related to higher compliance. Previously used in
confirmed cases of GERD, PPIs are also effective for
GER.
North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN)
GUIDELINES
Diagnosis:
Complete patient and family history,
complete symptom history, complete
medical (including infant) history, physical
symptoms including UQ or periumbilical
pain, vomiting, oropharnyx pain, weight
loss, heartburn, UR symptoms, recurrent
AOM or U/L RI, and dental erosion. Always
consider surpaesophageal symptoms. For
severe symptoms or pharmacological
failure consider ordering an upper GI film,
an endoscopic study, or a pH probe study.
Treatment:
First Class (H2 Blockers)
• cimetidine (Tagamet)
• ranitidine (Zantac)
• famotidine (Pepcid)
• nizatidine (Axid)
• esomeprazole (Nexium)
• omeprazole (Prilosec)
• lansoprazole (Prevacid)
Third Class (prokinetic agents)
• metoclopramide (Reglan)
• cisapride (Propulsid)
Consider Also:
• Have your child eat more frequent
smaller meals.
• Have your child avoid eating 2 to 3
hours before bed.
• Raise the head of your child's bed 6 to
8 inches
• Have your child avoid carbonated
drinks, chocolate, caffeine, and foods
that are high in fat or contain a lot of
acid (citrus fruits) or spices.
Critique of Care
Patient History:
Patient history focused on symptoms, familial and infant
history, as well as supraesophageal symptoms.
Patient Physical:
Ruled out most likely differentials. Symptom severity or
duration did not rise to the level of ordering studies.
Patient Treatment:
Ranitidine used more often as first-line, but given
Barnard considerations that may impact compliance, as
well as paternal history, omeprazole was an excellent
choice. Supportive care suggested was appropriate for
this child, and journal addressed other Barnard
considerations and may also rule out functional
abdominal pain.
References
Gibbons, TE.; Gold, BD. “The use of proton pump inhibitors in children: a comprehensive
review.” Paediatric Drugs, v. 5 issue 1, 2003, p. 25-40.
Romano, C., et al. “Proton pump inhibitors in pediatrics: evaluation of efficacy in GERD
therapy.” Current Clinical Pharmacology, v. 6 issue 1, 2011, p. 41-7.
Rudolph, C., Mazur, L., Liptak, G., Baker, R., Boyle, J., Colletti, R., Werlin, S. (2001).
Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children:
recommendations of the North American Society for Pediatric Gastroenterology and Nutrition.
Journal of Pediatric Gastroenterology and Nutrition, 32 Suppl 2, S1-31.
Tighe, MP.; Afzal, NA.; Bevan, A.; Beattie, RM. “Current pharmacological management of
gastro-esophageal reflux in children: an evidence-based systematic review.” Paediatric Drugs,
v. 11 issue 3, 2009, p. 185-202.
Gastroesophageal Reflux in Children and Adolescents
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health
NIH Publication No. 06–5418 August 2006, Retrieved 11/5/2011 from
http://digestive.niddk.nih.gov/ddiseases/pubs/gerinchildren/gerinchildren.pdf