GERD Objectives 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 CONTINUITY CLINIC Epidemiology: GER Iceberg Infants Adults Referral Referral 2% 2% Visit MD within the year 10 % 10 % Visit MD within the year Regurgitate > 2 times per day 50 % 50 % Heartburn > 1 times per month CONTINUITY CLINIC Prevalence of Regurgitation in Infancy 70 60 50 % of infants 40 >1 time per day >4 times per day 30 20 10 0 0-3 mos 4-6 mos CONTINUITY CLINIC 7-9 mos 10-12 mos The Antireflux Barrier Esophagus Angle of His LES Crural Diaphragm CONTINUITY CLINIC Stomach CONTINUITY CLINIC Esophageal Capacitance 30 cm; 2x3 cm diam - Shorter esophagus (11 cm; 5 mm diam) - Smaller capacity Adult Infant Gravity CONTINUITY CLINIC Factors Predisposing to GERD Increased gastric volume: Large meals Delayed gastric emptying Duodenogastric reflux Decreased resistance: Inadequate LES tone Inappropriate LES relaxation Inadequate supporting structures Increased pressure: - Tonic (e.g. obesity, slouched posture) - Phasic (e.g. cough, sneeze, strain) CONTINUITY CLINIC Presenting Symptoms Recurrent vomiting in infant Recurrent vomiting and poor weight gain in infant Recurrent vomiting and irritability in infant Recurrent vomiting in older child CONTINUITY CLINIC Heartburn in child or adolescent Dysphagia or feeding refusal Apnea or ALTE Asthma Recurrent pneumonia Upper airway symptoms Chronic cough Warning Signals Suggestive of a Non-GER Diagnosis Recurrent vomiting History and PE Are there warning signs? CONTINUITY CLINIC 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 Signs of Complicated GERD Poor weight gain Excessive crying or irritability Feeding problems Respiratory problems, including: wheezing stridor recurrent pneumonia CONTINUITY CLINIC What approach do you take 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 CONTINUITY CLINIC Upper GI ADVANTAGES LIMITATION CONTINUITY CLINIC Useful for detecting anatomic abnormalities Cannot discriminate between physiologic and nonphysiologic GER episodes Radiographs of Diagnoses that can Mimic GERD Pyloric stenosis CONTINUITY CLINIC Malrotation Upper Endoscopy with Biopsy ADVANTAGES LIMITATIONS CONTINUITY CLINIC Enables visualization and biopsy of esophageal epithelium Determines presence of esophagitis, other complications Discriminates between reflux and non-reflux esophagitis Need for sedation or anesthesia Generally not useful for extraesophageal GERD Examples of Endoscopic Findings Erosive Esophagitis CONTINUITY CLINIC Eosinophilic Esophagitis Esophageal pH Monitoring ADVANTAGES LIMITATIONS CONTINUITY CLINIC 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 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 When would it be USEFUL to obtain esophageal pH monitoring? To establish a relationship between occult GER and chronic symptoms: Upper respiratory sx Chest pain Recurrent pneumonia Apnea/Cyanosis Irritability Intractable asthma CONTINUITY CLINIC To monitor efficacy of medical or surgical therapy: Acid blockers Prokinetic agents Following fundoplication Treatment Options Surgical Tx Medication Lifestyle Changes CONTINUITY CLINIC Conservative Therapy INFANTS OLDER KIDS Normalize feeding volume and frequency Consider thickened formula Consider non-prone positioning during sleep Consider trial of hypoallergenic formula CONTINUITY CLINIC 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 Thickened Formula CONTINUITY CLINIC Unthickened ready-to use infant formula = 20 cal/oz Thickened formula 1 tablespoon rice cereal per ounce = ~34 cal/oz % of Patients Comparison of Drug Therapies For Healing Erosive Esophagitis in Adults 100 90 80 70 60 50 40 30 20 10 0 Placebo Sucralfate Cisapride H2 Blocker PPI Endoscopic Improvement CONTINUITY CLINIC Heartburn relief PPIs in Infants and Children 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 CONTINUITY CLINIC Recommended Oral H2RA Dosages Generic Name Brand Name Typical Peds Dose Ranitidine Zantac 4-10 mg/kg/day divided BID-TID for ages 1 month or older up to 40 mg BID 150 mg BID 150 & 300 mg tablets; 25 mg Efferdose tablet; 15 mg/ml syrup Famotidine Pepcid Pepcid AC 0.5 mg/kg/day divided BID up to 40 mg BID for ages 1-17 years 20 or 40 mg QDBID 10, 20, 40 mg tablets; 40 mg/5 ml liquid; 10 & 20 mg OTC tablets CONTINUITY CLINIC Typical Adult Dose Formulations Oral PPI Dosages for GERD Generic Brand Pediatric Doses Adult Doses Formulations Lansoprazole Prevacid < 30 kg 15 mg QD > 30 kg 30 mg QD for 117 years 15 or 30 mg QD-BID 15 & 30 mg capsules; 15 & 30 mg Solutab Omeprazole Prilosec 20 or 40 mg QD-BID 10, 20 & 40 mg capsules Esomeprazole Nexium 10 or 20 mg QD for 2-16 years 10 or 20 mg QD age 1-11; 20 or 40 mg 20 or 40 mg QD 12-17 yo QD-BID 20 & 40 mg capsules; 10 & 20 mg liquid Pantoprazole Protonix No FDA approval 20 or 40 mg QD-BID 20 & 40 mg tablets; 40 mg oral suspension Rabeprazole Aciphex No FDA approval 20 or 40 mg QD-BID 20 mg tablet CONTINUITY CLINIC Candidate for Antireflux Surgery 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 CONTINUITY CLINIC Principles of Antireflux Surgery Restore intraabdominal segment of esophagus Approximate diaphagmatic crurae CONTINUITY CLINIC Reduce hiatal hernia when present Wrap fundus around LES to reinforce antireflux barrier Summary 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 CONTINUITY CLINIC