1. GERD

2. 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

3. 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 %

4. Prevalence of Regurgitation in Infancy
% of infants

5. The Antireflux Barrier
Esophagus
Angle of His
LES
Stomach
Crural Diaphragm

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

8. 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)

9. 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

10. 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?

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

12. 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

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

14. Radiographs of Diagnoses that can Mimic GERD
Malrotation
Pyloric stenosis

15. 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

16. Examples of Endoscopic Findings
Erosive Esophagitis
Eosinophilic Esophagitis

17. 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

18. 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

19. Treatment Options
Surgical Tx
Medication
Lifestyle Changes

20. 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

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

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

23. 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

24. 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

25. 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 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 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

26. 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

27. 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

28. 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