1. GERD

2.  The passage of gastric contents into the esophagus (GER) is a normal physiologic process that occurs in healthy infants, children. Most episodes are brief and do not cause symptoms, esophageal injury, or result in other complications. In contrast, gastroesophageal reflux disease (GERD) occurs when the reflux episodes are associated with complications such as esophagitis or poor weight gain.

3. DEFINITIONS  The term "uncomplicated” (GER) is used to describe the normal physiologic process of frequent regurgitation in the absence of pathological consequences. The term, (GERD), is used when the reflux has pathological consequences, such as esophagitis, nutritional compromise, or respiratory complications.

4.  Natural history: Gastroesophageal reflux (GER) is extremely common in healthy infants, in whom gastric fluids may reflux into the esophagus 30 or more times daily. The frequency of reflux decreases with increasing age, such that physiologic regurgitation or vomiting decreases toward the end of the first year of life, and is unusual in children older than 18 months old. Pediatrics 1991; 88:834. Pediatrics 1991; 88:834. Pediatrics 1991; 88:834.

5.  Although the problem usually resolves by the end of infancy, there is a weak association with GERD later in life. As an example, frequent regurgitation during infancy and a history of GERD in the mother (but not the father) both predict the risk of reflux-related symptoms during childhood. Pediatrics 2002; 109:1061. Pediatrics 2002; 109:1061. Pediatrics 2002; 109:1061.

6. Prevalence  The prevalence of various symptoms suggestive of gastroesophageal reflux (GER) was 1.8 to 8.2 percent.  Arch Pediatr Adolesc Med 2000; 154:150. Arch Pediatr Adolesc Med 2000; 154:150. Arch Pediatr Adolesc Med 2000; 154:150.

7. CLINICAL MANIFESTATIONS  The most common symptoms of gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) vary according to age, although overlap may exist:

8.  Infants –Regurgitation is present in 50 to 70 percent of all infants, peaks at age four months, and typically resolves by one year.  A small minority of infants with GER develop other symptoms suggestive of GERD, including feeding refusal, irritability, hematemesis, anemia, respiratory symptoms, and failure to thrive.

9.  Preschool age children with GERD may present with intermittent regurgitation. Less commonly, they may have respiratory complications including persistent wheezing. Decreased food intake or poor weight gain without any other complaints may be a symptom of esophagitis in young children. All of these symptoms are nonspecific and insufficient to make a definitive diagnosis of GERD.

10.  Older children and adolescents – The pattern of GERD in older children and adolescents resembles that seen in adults. The cardinal symptoms are chronic heartburn and/or regurgitation. Complications of GERD, including esophagitis, strictures, Barrett's esophagus, and hoarseness due to reflux laryngitis, also may be seen. Older children may complain of nausea, dysphagia and/or epigastric pain.

11. Surgery Life Style Dietary Management Pharmacotherapy Management Complications Wise Approach GERD 5 Stages Management Life Style

12. Life Style Modification Positions in infants

13. Position in Children Daily activities modification Exercise:? Exercise induced reflux Overweight No snaking close to bed time Exercise:? Exercise induced reflux Overweight No snaking close to bed time

14. Surgery Life Style Dietary Management Pharmacotherapy Management Complications Wise Approach GERD 5 Stages Management Dietary Management

15. Dietetic Management Regurge with normal weight gain and No Signs of GERD 1.Changing feeding schedule: burping, gently massage abdomen and avoid tight diapers 2.Use pacifiers:  saliva and neutralize acid 3.Thickening feeds: precooked corn starch, one grain cereal, carob, gower gum, rice starch?? 4.Using special AR formulas 5.Trying solid foods if weaned 1.Changing feeding schedule: burping, gently massage abdomen and avoid tight diapers 2.Use pacifiers:  saliva and neutralize acid 3.Thickening feeds: precooked corn starch, one grain cereal, carob, gower gum, rice starch?? 4.Using special AR formulas 5.Trying solid foods if weaned

16. Persistent regurge signs of poor weight gain esophagitis or respiratory symptoms Consider cow milk with protein elimination Re-evaluate (upper GI examination) Trial of medication N.B. - Probiotics - Homeotherapy N.B. - Probiotics - Homeotherapy

17. Surgery Life Style Dietary Management Pharmacotherapy Management Complications Wise Approach GERD 5 Stages Management Pharmacotherapy

18. II) Second line drugs - Acid blocking drugs ( neutralise or  stomach acidity ) 1- Histamine H2RA Ranitidine 2- Proton pump inhibitors PPI Omeprazole 1- Histamine H2RA Ranitidine 2- Proton pump inhibitors PPI Omeprazole I) First line drugs - Mylicon - Gaviscon - Mylicon - Gaviscon

19. Prokinetics (drugs that improve intestinal coordination) 1- Cisapride (propalsid) abnormal heart rate 2- Erythromycin side effect is an advantage III)Third line drugs

20. Approaches to Acid-Reducing Therapy  Begin treatment with PPI  Maintain improvement with PPI  Switch to H2RA  Begin treatment with PPI  Maintain improvement with PPI  Switch to H2RA  Begin treatment with H2RA  Inadequate response  PPI  Inadequate response  ↑ PPI dose  Begin treatment with H2RA  Inadequate response  PPI  Inadequate response  ↑ PPI dose Step Down Step Up

21. Tachyphylaxis: tolerance with prolonged use inspite increasing dose Decreased absorption of Fe, Ca, Folic acid, B12 Tachyphylaxis: tolerance with prolonged use inspite increasing dose Decreased absorption of Fe, Ca, Folic acid, B12 Side effects of antacids: Stomach acid is a part of the body immune system Kills pathological bacteria in the gut

22. Surgery Life Style Dietary Management Pharmacotherapy Management Complications Wise Approach GERD 5 Stages Management Management Complications

23. Management of Supraesophageal Complications Chronic sore throat & hoarsness Dental erosions OM & Sinusitis Wheezing Asthma Apnea Bradycardia Chronic cough ALTE

24. ALTE = acute life threatening event apnea, color change, chocking gaging 60% to 70% of infants with ALTE have recurrent regurge and abnormal esophageal pH Relationship between GER and obstructive or mixed apnea most convincing when infant was: Awake, Supine, Fed within past hour ALTE = acute life threatening event apnea, color change, chocking gaging 60% to 70% of infants with ALTE have recurrent regurge and abnormal esophageal pH Relationship between GER and obstructive or mixed apnea most convincing when infant was: Awake, Supine, Fed within past hour GER and ALTE

25. Aspiration Syndromes Aspiration pneumonia & pleural effusion Acid aspiration pneumonitis Interstitial lung disease & pulmonary fibrosis Aspiration pneumonia & pleural effusion Acid aspiration pneumonitis Interstitial lung disease & pulmonary fibrosis

26. GER Asthma Does GER Cause Asthma?

28. Surgery Life Style Dietary Management Pharmacotherapy Management Complications Wise Approach GERD 5 Stages Management Surgery

29. Infants and Children: Failure of medical therapy Dependence on aggressive or prolonged medical therapy Persistent asthma or recurrent pneumonia due to GERD Infants and Children: Failure of medical therapy Dependence on aggressive or prolonged medical therapy Persistent asthma or recurrent pneumonia due to GERD