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

Epidemiology: GER Iceberg Infants Referral Visit MD within the year Regurgitate > 2 times per day Adults Referral Visit MD within the year Heartburn > 1 times per month 2% 2% 10 % 10 % 50 % 50 %

Prevalence of Regurgitation in Infancy % of infants

The Antireflux Barrier Esophagus Angle of His LES Stomach Crural Diaphragm

Esophageal Capacitance 30 cm; 2x3 cm diam - Shorter esophagus (11 cm; 5 mm diam) - Smaller capacity Adult Infant Gravity

Factors Predisposing to GERD Decreased resistance: Inadequate LES tone Inappropriate LES relaxation Inadequate supporting structures Increased gastric volume: Large meals Delayed gastric emptying Duodenogastric reflux Increased pressure: - Tonic (e.g. obesity, slouched posture) - Phasic (e.g. cough, sneeze, strain)

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 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 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 Recurrent vomiting History and PE Are there warning signs?

Signs of Complicated GERD Poor weight gain Excessive crying or irritability Feeding problems Respiratory problems, including: wheezing stridor recurrent pneumonia

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

Upper GI ADVANTAGES LIMITATION Useful for detecting anatomic abnormalities LIMITATION Cannot discriminate between physiologic and nonphysiologic GER episodes

Radiographs of Diagnoses that can Mimic GERD Malrotation Pyloric stenosis

Upper Endoscopy with Biopsy ADVANTAGES Enables visualization and biopsy of esophageal epithelium Determines presence of esophagitis, other complications Discriminates between reflux and non-reflux esophagitis LIMITATIONS Need for sedation or anesthesia Generally not useful for extraesophageal GERD

Examples of Endoscopic Findings Erosive Esophagitis Eosinophilic Esophagitis

Esophageal pH Monitoring ADVANTAGES 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

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 To monitor efficacy of medical or surgical therapy: Acid blockers Prokinetic agents Following fundoplication

Treatment Options Surgical Tx Medication Lifestyle Changes

Conservative Therapy INFANTS OLDER KIDS 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

Thickened Formula Unthickened ready-to use infant formula = 20 cal/oz Thickened formula 1 tablespoon rice cereal per ounce = ~34 cal/oz

Comparison of Drug Therapies For Healing Erosive Esophagitis in Adults % of Patients

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

Recommended Oral H2RA Dosages Generic Name Brand Name Typical Peds Dose Typical Adult Dose Formulations 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 QD-BID 10, 20, 40 mg tablets; 40 mg/5 ml liquid; 10 & 20 mg OTC tablets

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 1- 17 years 15 or 30 mg QD-BID 15 & 30 mg capsules; 15 & 30 mg Solutab Omeprazole Prilosec 10 or 20 mg QD for 2-16 years 20 or 40 mg QD-BID 10, 20 & 40 mg capsules Esomeprazole Nexium 10 or 20 mg QD age 1-11; 20 or 40 mg QD 12-17 yo 20 & 40 mg capsules; 10 & 20 mg liquid Pantoprazole Protonix No FDA approval 20 & 40 mg tablets; 40 mg oral suspension Rabeprazole Aciphex 20 mg tablet

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

Principles of Antireflux Surgery Restore intraabdominal segment of esophagus Approximate diaphagmatic crurae 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