1. Pediatric Gastroesophageal Reflux Disease Case Report Loren M. Bellows R1 – Pediatrics

2. Case Presentation: History 7 mo white male cc frequent regurgitation and wheezing x 2 months Wheezing prominent in AM Regurgitation of bilious mixture postprandially Occ arches back while feeding Diet: 24oz Similac Soy q d, rice cereal bid, 2 oz fruit or veg

3. Case Presentation: History Mother Denies: fever, diarrhea, rigors, lethargy PMH: RAD at 4mo, C-section 3w pre-term, poor weight gain Meds: Albuterol syrup for RAD; mother denies improvement of sx FH: no Asthma, CF, allergies SH: no smoke or resp. irritants

4. Case Presentation: Physical Exam Irritable, slightly pale, app. Smaller and younger than age Pulm: Intermittent stridor, no retractions or grunting Spit-up twice while in exam room Remainder: unremarkable

5. Patient Dx and Rx Dx: Gastroesophageal Reflux Disease (GERD) –No Diagnostic Tests at this time Rx: –Nonpharmacologic Dec. volume of feeding, feeding more frequently, thickening formula with rice cereal, keeping infant upright q 30 min postprandially –Pharmacologic Ranitidine (Zantac) 5mg/kg/day orally divided into 2 doses. Continue Albuterol syrup, prn Follow-Up: –No official f/u; mother instructed to call if sx not resolving or worsening.

6. Pediatric GERD Epidemiology Up to 4 of 10 infants under 6mo (Ferri et al, 2006) Becomes less common as GI system matures; 5% of infants spit up regularly after 12mo (Ferri et al, 2006) Most cases are benign, very few (3/1000) cases are significant w/ risk of complications (Ferri et al, 2006)

7. Pediatric GERD Etiology Sx or complications that may result from the passage of gastric materials from the stomach into the esophagus or oropharynx (Gold, 2004) Cause in children: unknown, but may be associated w/ genetic predisposition, premature birth, diet (Ferri et al, 2006)

8. Pediatric GERD Pathophysiology Loss of esophogastric pressure gradient due to: –Delay in neurologic maturation –Insufficient or abnormal LES tone –Spontaneous reductions in sphincter pressure –Changes in abdominal pressure from crying, coughing, defecating (Ferri et al, 2006) Symptom Complex severity depends on: –Frequency and duration of reflux episodes –Cause of acid regurgitation –Susceptibility of esophagus to damage –Aspiration of refluxed gastric contents (Orenstein et al, 2004)

9. Pediatric GERD: Diagnosis Generally Hx and PE sufficient along w/ positive response to Rx (Ferri et al, 2006) Typical Presentation in infants: –Recurrent vomiting –Inability to gain weight –Irritability associated w/ feeding (Gold, 2004) Typical Presentation in children & adolescents –AM nausea or abdominal discomfort –Heartburn, “spit-up” burps that burn, substernal pain –Recurrent vomiting (Gold, 2004) Tests occasionally used: –Upper GI series using Barium Contrast –Nuclear Scintiscan –Esophageal pH monitor Differential Dx –Excessive feeding, Viral Gastroenteritis, food allergies/intolerances, enzyme deficiencies, anatomical abnormalities, colic, viral URI, asthma (Ferri et al, 2006)

10. Pediatric GERD Complications Common –Malnutrition –Failure to thrive –Anemia –Bronchospasm –Recurrent pneumonia –Chronic coughing / wheezing –Sleep apnea Rare –Erosive Esophagitis –Barrett esophagus –Severe Adult GERD Ferri et al, 2006 / Gold, 2004

11. Pediatric GERD Treatment Goals of Rx –Relieve Sx, promote normal growth, heal damage and inflammation, prevent complications Nonpharmacologic –Thickening feeds, decreased volume of feeds, avoidance of carbonated / caffeinated beverages and smoke exposure, elevation of the head during feedings and 30 minutes postprandially Pharmacologic –Antacids: sporadic Sx or w/ diarrhea or constipation –H-2 receptor antagonists if esophagitis suspected –PPI’s suppress acid and aid healing –Metoclopramide Surgical –Fundoplication (RARE)

12. References Orenstein, S, Peters, J, Khan, S, Youssef, N, & Hussain, S. Chapter 204 - Gastroesophageal Reflux Disease (GERD). Behrman: Nelson Textbook of Pediatrics, 2004; http://www.mdconsult.com/das/book/body/72415925- 6/591323078/1175/151.html?SEQNO=1. http://www.mdconsult.com/das/book/body/72415925- 6/591323078/1175/151.html?SEQNO=1 Ferri, F, McIntire, S, Sheehan, D, & Ibia, E. Gastroesophageal reflux in children. 2006;http://www.firstconsult.com/fc_home/members/?urn=c om.firstconsult/1/101/1016309@th_884957::ah_884957.http://www.firstconsult.com/fc_home/members/?urn=c om.firstconsult/1/101/1016309@th_884957::ah_884957 Gold, B. Gastroesophageal reflux disease: Could intervention in childhood reduce the risk of later complications? American Journal of Medicine Supplements, 2004; http://www.mdconsult.com/das/article/body/72415925- 7/jorg=journal&source=MI&sp=15052092&sid=592056777/ N/441810/1.html http://www.mdconsult.com/das/article/body/72415925- 7/jorg=journal&source=MI&sp=15052092&sid=592056777/ N/441810/1.html