Paediatric Consultant with interest in Gastro/Oncology: The Old and the New Dr Mark Tighe Paediatric Consultant with interest in Gastro/Oncology: Poole Hospital No funding to declare

Aims: An update GORD including NICE guidelines CMPA including pan-Dorset guidelines “The views expressed in this talk are those of Mark Tighe and not necessarily those of NICE.”

NICE Definitions Gastro-oesophageal reflux (GOR) = Passage of gastric contents into the oesophagus. ‘Common physiological event: can happen at any age and is often asymptomatic. More common after feeds or meals. “Overt regurgitation”—the visible regurgitation of feeds.’ GOR +severe symptoms (such as marked distress), complications or failure to thrive = Gastro-oesophageal reflux disease. GI complications= Oesophagitis Haematemesis, (Oesophageal strictures Barrett’s oesophagitis). Extra-intestinal= Chronic respiratory disease Chronic otitis media Sinusitis ALTE/Apnoea Secondary anaemia

Natural history Infant GOR is very common; In 40% of infants less than 3 months old. Normally starts before 8 weeks of age Improves with age (functional) Oesophagus lengthens More upright Increased tone of lower oesophageal sphincter. More solid diet. only 5-10% of children have symptoms after the age of 1y.

GOR in older children Symptoms similar to adults (e.g.) Recurrent epigastric pain Heartburn. Less likely to improve spontaneously= GORD Oesophageal strictures from GORD in childhood reported. Likely to respond to treatment Evidence-based associations: -Recurrent aspiration pneumonia -Frequent otitis media (>3 episodes in 6 m) -Dental erosion with neurodisability (e.g. cerebral palsy). [Based on moderate-low quality evidence from observational studies.]

Differential diagnoses In infants: Overfeeding (>180ml/kg/day in formula-fed infants) Surgical: e.g. pyloric stenosis/malrotation Cow’s milk protein intolerance Central causes of vomiting e.g. raised ICP Inborn error of metabolism: e.g. renal tubular acidosis In older children Rumination Functional dyspepsia

Predisposing conditions Neurological impairment (e.g. cerebral palsy) Repaired oesophageal atresia (OA) Congenital diaphragmatic hernia Chronic lung/cardiac disease. Prematurity

Diagnosis of GOR(D) Symptoms alone, Investigations if in doubt Avoiding the need for expensive +/- harmful Ix. Investigations if in doubt Do not routinely investigate if the only symptom is Unexplained feeding difficulties (such as refusing to feed, gagging, or choking) Distressed behaviour Faltering growth Chronic cough Hoarseness Single episode of pneumonia. [Based on high to low quality evidence]

Investigations: 24hr pH probe Endoscopy/biopsy Barium swallow Gastric emptying scan IgE/RAST Milk? USS?

• Do not offer an upper GI contrast to diagnose /assess severity of GORD. [Based on the opinion of the GDG.] • Perform an urgent upper GI contrast for infants with unexplained bile stained vomiting (40% have a surgical pathology). [Based on the opinion of the GDG.] • Consider an upper GI contrast for children and young people with bile stained vomiting (persistent or recurrent). • Offer an upper GI contrast for children and young people with a history of GORD with dysphagia.

Endoscopy -Haematemesis/Melaena -Dysphagia • Refer infants, children, and young people for endoscopy if: -Haematemesis/Melaena -Dysphagia -No improvement in regurgitation >1 year -Persistent faltering growth associated with overt regurgitation -Unexplained distress in children&young people with communication difficulties -Retrosternal, epigastric, or upper abdominal pain that needs ongoing medical treatment or refractory to medical treatment -Feeding aversion and a history of regurgitation -Unexplained iron deficiency anaemia -A referral for fundoplication -Back arching or features of Sandifer’s syndrome. [Based on high-low quality evidence from observational studies and opinion of the GDG.]

Oesophageal pH/impedance monitoring Consider in infants, children, and young people with: -Suspected recurrent aspiration pneumonia -Unexplained apnoeas -Unexplained non-epileptic seizure-like events -Unexplained upper airway inflammation -Dental erosion associated with a neurodisability -Frequent otitis media -Evaluation for fundoplication -A suspected diagnosis of Sandifer’s syndrome. [Based on high-low quality evidence from observational studies and opinion of the GDG.] • Consider an oesophageal pH study without impedance monitoring in infants, children, and young people, to ascertain effective acid suppression. [Based on the experience and opinion of the GDG.]

Figure 1: Example of normal 24 hour pH-probe: reflux index 2%

Figure 2: Example of mild acid reflux on 24 hour pH-probe: reflux index 8.9% -

Figure 3: Example of severe acid reflux on 24 hour pH-probe: reflux index 48%

Treatment of GOR Alleviate symptoms Promote normal growth Prevent complications.

Conservative options Medical treatment Reassurance of parents Altering infant’s positioning Medical treatment Altering the feed’s consistency e.g. (Gaviscon Infant/Enfamil AR/ SMA Staydown). Altering the gastric pH Ranitidine/Omeprazole Altering the motility of the gut. Domperidone

For infants…. Breastfed infants with frequent regurgitation AND marked distress: Ensure that a person with appropriate expertise performs a breastfeeding assessment If regurgitation continues, consider trial with alginate for 1-2 weeks. If successful continue, with regular trials off…

For bottle-fed infants In formula fed infants with frequent regurgitation + marked distress : Review the feeding history + Reduce feed volumes if excessive Then offer a trial of smaller more frequent feeds, Offer a trial of pre-thickened formula (prescribed) No head-to-head trials, may be economically cheaper If unsuccessful, stop the thickened formula and offer trial of alginate for 1-2 weeks. If successful, continue with regular trials off.

Review if: Persistently projectile Bile stained (green or yellow-green) vomiting Haematemesis (blood in vomit) New signs of marked distress (box), feeding difficulties, or faltering growth No improvement beyond the first year of life. [Based on moderate and low quality evidence from observational studies and on the experience and opinion of the GDG]

Do not offer proton pump inhibitors (PPIs) or H2 antihistamines [H2RA] to treat overt regurgitation only. [Based on moderate and low quality evidence from RCTs.] Consider a 4 week trial of H2RA or PPI for pre-verbal children or children with neurodisability with overt regurgitation AND one or more: Unexplained feed difficulties (refusing feeds/gagging/choking) Distressed behaviour Faltering growth. [Based on the experience and opinion of the GDG.]

For Children and young people Consider 4 week trial of a PPI for persistent heartburn, retrosternal/epigastric pain. [Based on moderate-low quality evidence from RCTs & the opinion of the GDG] • Assess the response to PPI/H2 RA at 4 weeks and consider referral +/- endoscopy if the symptoms have not resolved or recur after stopping Rx. [NB rebound] [Based on the experience and opinion of the GDG.] • When choosing between PPIs and H2 antihistamines take into account: -Availability/cost of age appropriate preparations -Preference of the parent, child, or young person (as appropriate) Offer PPI or H2RA to children &young people with endoscopy confirmed reflux oesophagitis and consider repeat endoscopy as necessary to guide treatment. [Based on moderate-low quality RCT evidence from RCTs + the opinion of the GDG.] • Do not offer metoclopramide, domperidone, or erythromycin to treat GOR(D) without seeking specialist advice and considering potential to cause adverse events (MHRA alert). [Based on moderate-very low quality evidence from RCTs and opinion of the GDG.]

Other interventions Consider fundoplication in infants, children, and young people with severe, intractable GORD if: Failed medical treatment or Feeding regimens to manage GORD are impractical— e.g. long term, continuous, thickened enteral tube feeding. [Based on moderate and low quality evidence from observational studies and RCTs and opinion of the GDG.]

Cow’s Milk Protein Allergy (CMPA)

Background Leading cause of food allergy in infants and young children <3 years old Often confused with lactose intolerance, and regurgitation/reflux, colic, and constipation Aim to set the background for Dorset-wide pathway By the end of today: Understand CMPA Help identify accurately those children with CMPA And those that don’t have CMPA! And to help spread the word, and use this regularly!

CMPA Sensitivity to the protein in cow’s milk. N.B. Normal babies often have gut dysmotility Reflux=>Colic=>Constipation/loose stools Often better by 1-2years CMPA: Symptoms can range: mild=> dramatic Can be non-IgE or IgE mediated. IgE mediated: can have positive skin prick tests +blood tests Non-IgE: Unlikely to have positive tests Can still be symptomatic

Lactose intolerance Lactose: sugar in milk/dairy Common +transient e.g. after gastroenteritis. Rarely persists. Varies with ethnic groups: commoner in Asian/Afro-Caribbean families. 1 in 50 Northern Europeans. Symptoms include: Bloating flatulence (wind) diarrhoea Won’t cause blood in stools/rash/ vomiting Children risk missing nutrients if diagnosed incorrectly. If lactose-free trialled: lactose should be reintroduced gradually in 6 weeks.

“It’s all in the history…..” History of allergic problems? □ Yes □ No   Family history of allergic problems? □ Yes □ No   Age of onset and relation to change in diet? Breast to bottle? Weaning? Introduction of cow’s milk?  What foods are causing concern?  □ Cow’s milk □ Peanuts □ Fish □ Soya □ Eggs □ Tree nuts □ Wheat □ Shellfish What quantity will trigger a reaction?   What symptoms are triggered? Skin: Gastrointestinal: Respiratory System:   Cardiovascular:   What is the time course between exposure and the onset of symptoms? □ < 2 hours □ > 2 hours

Signs and Symptoms of possible food allergy   Signs and Symptoms of possible food allergy Non – IgE-mediated Slower onset – >2 hours IgE-mediated Rapid onset –minutes to 2 hrs The Skin Pruritus Erythema Atopic eczema Acute urticaria (localised or generalised) Acute angioedema (most commonly in the lips and face, and around the eyes

Signs and Symptoms of possible food allergy Non – IgE-mediated Slower onset – >2 hours IgE-mediated Rapid onset –minutes to 2 hrs   The gastrointestinal system Gastro-oesophageal reflux Loose/frequent stools Blood +/- mucus in stools Abdominal pain/colic Food refusal/aversion Constipation Perianal redness Pallor and tiredness Faltering growth & 1/more G.I. symptoms above (+/- atopic eczema)  Angioedema of the lips, tongue/palate Oral pruritus Nausea Colicky abdominal pain Vomiting Diarrhoea

Signs and Symptoms of possible food allergy Non – IgE-mediated IgE-mediated Rapid onset – within minutes to 2 hours   The respiratory system Upper respiratory tract symptoms – nasal itching, sneezing, rhinorrhoea or congestion (+/- conjunctivitis) Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath Signs and symptoms of anaphylaxis or other systemic allergic reactions

Red flags for referral to secondary care Bloody stools: (especially breast fed babies) Anaphylaxis/Angioedema/ Rapid onset Wheeze “Vast majority of non-IgE mediated food allergy can be managed within primary care.” Consider GP discussion/referral Significant IgE-mediated allergy (atopy/wheeze/Urticaria) Faltering growth Gastrooesophageal reflux disease/resistant constipation

How to classify CMPA Non-IgE mediated CMPA? Slower onset >2 hrs One or more of the following: Skin symptoms Gastro symptoms Respiratory symptoms IgE-mediated CMPA? Rapid onset (minutes-2hrs) One or more of the following: Urticaria Wheeze Anaphylaxis Refer to Paediatrician For Urgent advice or Rapid Access Clinic Telephone – Poole Hospital NHS Foundation Trust 01202 665511 Bleep 0155 Allergy focused History If exclusive breast feeding Check feeding technique Strict maternal milk-free Diet for 2-4 wks Milk-free weaning from 6 m If formula feeding EHF* for 2-4 wks Milk-free weaning from 6m If mixed breast and formula Strict maternal milk-free diet Plus EHF for 2-4 weeks Milk free weaning from 6m Improvement No improvement Eliminate soya as well for 2-4 weeks If exclusive breast feeding Re-introduce cow’s milk into maternal diet If symptoms return, this confirms ∆ CMPA Restart maternal milk-free diet Milk free weaning from 6m If formula feeding or mixed feeding Re-introduce cow’s milk formula If symptoms return , this confirms ∆ CMPA Continue with EHF Milk free weaning from 6 months Still no improvement CMPA unlikely Return to normal diet Refer to Paediatrician EHF=Extensively Hydrolysed Formula

Reintroducing Cows Milk At around 12 months old or 6 months after diagnosis Re-introduce cow’s milk into maternal diet if breastfeeding Milk reintroduction in the infant’s diet No Improvement Improvement Return to normal diet Return to milk free diet Repeat reintroduction of cow’s milk in 6 months Refer for Skin Prick Testing if active eczema

Any questions?

Summary This is only useful if you use it! CMPA vs lactose intolerance vs normal babies How to spot those at risk, and when to refer How to manage CMPA