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Practice Change
As a result of participating in this webinar,
attendees will be aware of a guideline based
approach for identifying which patients will
benefit from treatment for gastroesophgeal
reflux disease (GERD), as well as which
patients should be reassured their
gastroesophgeal reflux (GER) is physiologic
and not harmful.
GOOD NEWS!
There is a pediatric global definition of
GER vs. GERD
o To define reflux disease and its manifestations
in infants, toddlers, children, and adolescents
Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint
recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr.
2009;49(4):548557. Lightdale JR, Gremse DA. Section on Gastroenterology, Hepatology and Nutrition. Gastroenterology
Reflux: Management Guidance for the Pediatriatrician. Pediatrics. 2013: 131(5): e1684-1695.
Infants
(N=50
9)
Childre
n
(N=48)
Adults
(N=43
2)
73
25
45
9.7
6.8
3.2
11.7%
5.4%
6%
Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and
children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr
Gastroenterol Nutr. 2001;32(supplement 2):S1S31
Troublesome symptoms or
complications of reflux
Recurrent vomiting
and
poor weight gain in
infant
Recurrent vomiting
and
irritability in infant
Recurrent vomiting in
older child
Heartburn in
child/adolescent
Esophagitis
Dysphagia or feeding
refusal
Apnea or ALTE
Asthma
Recurrent pneumonia
Upper airway
symptoms
Unusual arching or
seizure-like
movements (Sandifer
syndrome)
Complications of Reflux
Normal midand
distal
esophagus
Z-line
Erosive esophagitis:
grade 2 and grade 4
Erosions
Complications of Reflux
Esophageal stricture
secondary to GERD:
radiography and
endoscopy
Stricture
Barretts
esophagus:
endoscopy and
histology
Barretts
Normal
Barretts
Normal
Endoscopic Biopsies
Useful to evaluate for a variety conditions,
but are not required for diagnosis of GERD
Possible findings on biopsy:
o
o
o
o
o
Gastroesophageal reflux
Food allergy or intolerance
Primary eosinophilic esophagitis
Drug induced
Infection
Candida
Herpes simplex
Cytomegalovirus
Pathologic esophagitis
EH
EH
PL
PL
BL
BL
Normal
Esophagitis
EH, epithelial height; PL, papillary layer; BL, basal layer
Normal: PL ~ 40% of epithelial height; BL ~ 15%
GERD: PL ~ 90% of epithelial height; BL ~ 30%
Normal esophagus
Peptic esophagitis
Eosinophilic esophagitis
Eosinophilic
Esophagitis
Clinical Cases
5 month old who effortlessly spits-up 6
10x/day, but seems comfortable and is
growing well
4 month old who is losing weight is
reported to vomit 23x/day, and seems
increasingly fussy with feeds
15 year old who presents complaining of
heartburn
GER
Gastroesophageal Reflux
o The passage of gastric contents into the
esophagus
o Occurs with/without regurgitation and vomiting
% of
Infant
s
Age (months)
n=948
0-3
4-6
7-9
10-12
Adapted from Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms of gastroesophageal reflux
during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr
Adolesc Med. 1997;151(6):569572
Physiology of GER
GER occurs during transient relaxations of
the lower esophageal sphincter (LES)
o Relaxation of the LES that is unaccompanied
by swallowing permits gastric contents into the
esophagus
Esophageal Capacity
Shorter esophagus
Smaller capacity
Gravit
y
Adu
lt
Infa
nt
Genetics of Reflux
Cluster studies suggest inheritability of
GER/GERD and their complications
o
o
o
o
Hiatal hernia
Erosive esophagitis
Barretts esophagus
Esophageal adenocarcinoma
Neurologically impaired
Obese infants, children, and adolescents
Certain genetic syndromes
Esophageal atresia
Chronic lung diseases
History of prematurity
Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint
recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and
the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr.
2009;49(4):548557
Diagnostic Approach
Depends on symptoms and signs
History and physical examination
Upper gastrointestinal (GI) series
Esophageal pH monitoring
Esophagogastroduodenoscopy and biopsy
Empirical medical therapy
Upper GI Radiography
Advantage
Useful for detecting
anatomic abnormalities
Limitation
Cannot discriminate
between physiologic and
nonphysiologic GER
episodes
Pyloric stenosis
Malrotation
Esophagogastroduodenoscopy
(EGD)
Advantages
Esophageal pH Monitoring
Advantages
Limitations
Z1
Impedance
channels
Limitations
Z4
Impedance
Sensors
Pediatric
Catheter
pH
Sensors
Infant
Catheter
Non-Acid
Reflux
Signs
Esophagitis
Esophageal stricture
Barrett Esophagus
Laryngeal/pharyngeal
inflammation
Recurrent pneumonia
Anemia
Dental erosion
Consistently forceful
vomiting
Onset of vomiting after
6 months of life
Severe failure to thrive
Diarrhea
Constipation
Fever
Lethargy
Hepatosplenomegaly
Bulging fontanelle
Macro/microcephaly
Seizures
Abdominal tenderness
or distension
Documented or
suspected
genetic/metabolic
syndrome
Associated chronic
disease
Gastrointestinal
obstruction
Pyloric stenosis
Malrotation with
intermittent volvulus
Intestinal duplication
Hirschsprung disease
Antral/duodenal web
Foreign body
Incarcerated hernia
Other GI disorders
Achalasia
Gastroparesis
Gastroenteritis
Peptic ulcer
Eosinophilic
esophagitis/gastroenter
itis
Food allergy
Inflammatory bowel
disease
Pancreatitis
Appendicitis
Metabolic/endocrine
Galactosemia
Hereditary
fructose
intolerance
Urea cycle defects
Amino and organic
acidemias
Congenital adrenal
hyperplasia
Renal
Obstructive
uropathy
Renal insufficiency
Toxic
Lead
Iron
Vitamin A and D
Medications: ipecac,
digoxin,
theophylline, etc.
Cardiac
Congestive heart
failure
Vascular ring
Psychiatric
Munchausen
syndrome
by proxy
Child neglect or
Important to Obtain a
Feeding and Vomiting History
Feeding and dietary
history
Amount/frequency
(overfeeding)
Preparation of formula
Recent changes in feeding
type or technique
Position during feeding
Burping
Behavior during feeding:
choking, gagging, cough,
arching, discomfort, refusal
Pattern of vomiting
Frequency/amount
Pain
Forceful or not
Blood or bile
Associated fever,
lethargy, diarrhea
Medications
Current vs. Recent
Prescription
Non-prescription
Family psychosocial history
Sources of stress
Maternal or paternal
drug use
Post partum
depression
Family medical
history
Significant
illnesses
Family history of
GI disorders
Family history of
atopy
Growth chart
Height
Weight
Head
circumference
History/Physical Examination
Severity of reflux or esophagitis found on
diagnostic testing does not directly
correlate with symptom severity
In infants and toddlers, there is no
symptom or group of symptoms that can
reliably diagnose GERD or predict
treatment response
In older children and adolescents, history
and physical examination are generally
sufficient to reliably diagnose GERD and
initiate management
Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint
recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and
the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal
Nutr. 2009;49(4):548557
Normalize feeding
volume
and frequency
Consider thickened
formula
Consider non-prone
positioning during sleep
Consider trial of
hypoallergenic formula
Eliminate exposure to
tobacco smoke
recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr.
2009;49(4):548557
Caloric Density
(cal/cc)
n=20
Emesis
(episodes/90 min)
p=.026
Sleep Time
(min asleep/90 min)
p=.042
Crying Time
(min crying/90 min)
Adapted from Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr.
1987;110(2):181186
Thickened formula
Unthickened formula
Formula +
rice cereal
Enfamil AR
Unthickened
formula
60
Sitting
Supine
Adapted from Ramenofsky ML, Leape LL. Continuous upper esophageal pH monitoring in
infants and children with gastroesophageal reflux, pneumonia, and apneic spells. J
Pediatr Surg. 1981;16(3):374378
Prone
Supine
Reflux
Index1
(% time pH
15.3
<4)
Left side
Right side
Prone
0.05*
2.3
1.0
7.7
0.05*
1.1
3.5
12.0
0.05*
1.8
3.5
6.7
4.4
1.0
13.9
If prone positioning is
recommended, discuss
rationale with parents
Avoid
soft bedding,
pillows,
loose
American Academy
of Pediatrics, Task
Force on Infant
Sleep Position and Sudden Infant Death Syndrome. Changing concepts
of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3 Pt
sheets near infant
1):650656; Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in
infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr
Gastroenterol Nutr. 2001;32(supplement 2):S1S31
Goals of Pharmacotherapy
Control symptoms
Promote healing
Prevent complications
Improve health-related quality of life
Avoid adverse effects of treatment
Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint
recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr.
2009;49(4):548557
Cimetidine
Placebo
71%
Esophagitis Healing
20%
Significant symptom improvement with cimetidine, not placebo
Cucchiara S, Gobio-Casali L, Balli F, et al. Cimetidine treatment of reflux esophagitis in children: an Italian multicentric study. J
Pediatr Gastroenterol Nutr. 1989;8(2):150156
N = 26 children with esophagitis treated with nizatidine 10 mg/kg/d or placebo for 8 weeks
69%
Nizatidine
Placebo
Esophagitis Healing
15%
Vomiting reduced in both treatment arms; significant improvement in other
GERD symptoms only with nizatidine
Simeone D, Caria MC, Miele E, et al. Treatment of childhood peptic esophagitis: a double-blind placebo-controlled trial of
nizatidine. J Pediatr Gastroenterol Nutr. 1997;25(1):5155
Results
Gunasekaran, et
al, 1993
15 children
< 3.3 mg/kg/day x 12.2 mo
(mean)
De Giacomo, et al,
1997
10 children
20 or 40 mg QD x 3 mo
12 infants
0.5 mg/kg/day x 6 wk
Strauss, et al,
1999
18 children
0.3-1.4 mg/kg/day x 812
wk
13/17 asymptomatic
Hassall, et al,
2000
57 children
0.7-3.5 mg/kg/day x 3 mo
95%
72%
N = 65
children
with erosive
esophagitis
44%
Healed with
0.7 mg/kg/day
Healed with
< 1.4 mg/kg/day
Healed with
< 3.5 mg/kg/day
Hassall E, Israel D, Shepherd R, et al. Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter
study of efficacy, safety, tolerability and dose requirements. International Pediatric Omeprazole Study Group. J Pediatr.
2000;137(6):800807
in
hyperthyroidism, bronchial asthma, and other
conditions
Domperidone
Erythromycin
Metoclopramide
including
parkinsonian-like symptoms, tardive dyskinesia, and
motor restlessness; galactorrhea, gynecomastia,
Prescribing Information for Reglan and Urecholine; Curry JI, Lander TD, Stringer MD. Erythromycin as a
cardiovascular
effects,
nausea, diarrhea
prokinetic agent in infants and children.
Aliment Pharmacol Ther
2001;15(5):595603;
Ramirez B, Richter JE.
Review article: promotility drugs in the treatment of gastro-oesophageal reflux disease Aliment Pharmacol
Ther. 1993;7(1):520
Conclusions
It is important to clarify whether a
pediatric patient has physiologic GER or
pathologic GERD
There are guidelines for appropriate
testing and treating of children with reflux
disease
o Also useful for deciding when to refer to
subspecialists
Recommended
Approach to the
Infant With
Recurrent
Regurgitation and
Vomiting
Recommended
Approach to the
Infant With
Recurrent
Regurgitation and
Weight Loss
Recommended
Approach to the
Older Child or
Adolescent With
Heartburn
THANK YOU!
Acknowledgements
AAP
EQIPP Staff and CoFaculty
NASPGHAN
NASPGHAN
Foundation (CDHNF)
References
Lightdale JR, Gremse DA. Section on Gastroenterology, Hepatology and
Nutrition. Gastroenterology Reflux: Management Guidance for the
Pediatriatrician. Pediatrics. 2013;131(5):e16841695
Sherman PM, Hassall E, Fagundes-Neto U, Gold BD, Kato S, Koletzko S,
Orenstein S, Rudolph C, Vakil N, Vandenplas Y. A global, evidence-based
consensus on the definition of gastroesophageal reflux disease in the pediatric
population. Am J Gastroenterol. 2009;104(5):12781295
Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the
primary care setting for symptoms suggesting infant gastroesophageal reflux. J
Pediatr. 2008;152:310314
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of
gastroesophageal reflux during childhood: a pediatric practice-based survey.
Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 2000;154:150
154
Vandenplas Y, Rudolph C, Di Lorenzo C, Hassall E, Liptak G, Mazur L,
Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenz T. Pediatric
Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations
of the North American Society of Pediatric Gastroenterology Hepatology and
Nutrition (NASPGHAN) and the European Society of Pediatric Gastroenterology
TM