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PEDIATRIC GERD

PEDIATRIC GERD. INTRODUCTION. Gastroesophageal reflux Gastroesophageal reflux disease. Mechanism and Pathophysiology of Reflux. Transient relaxation of the lower esophageal sphincter The short infant esophagus has limited volume Predominantly recumbent position of infants

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PEDIATRIC GERD

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  1. PEDIATRIC GERD

  2. INTRODUCTION Gastroesophageal reflux Gastroesophageal reflux disease

  3. Mechanism and Pathophysiology of Reflux • Transient relaxation of the lower esophageal sphincter • The short infant esophagus has limited volume • Predominantly recumbent position of infants • Delayed emptying • Increased abdominal pressure

  4. Prevalence of Regurgitation in Healthy Infants Infants (%) Age (months) Nelson et al. Arch Pediatr Adolesc Med.1997;151:569

  5. Prevalence of GERD in infants • Premature infants (by pH-metry) >85% -3-10%: apnea, bradycardia, exacerbation of BPD • Infants <3 months (by Hx) 20-100% -33% receive medical attention -80% resolve with minimal intervention and no diagnostic evaluation bat

  6. Genetic Predisposition for GERD • Familial clustering • Concordance for acid regurgitation • Proposed genetic links Chromosome 13 locus (13q14) Chromosome 9 locus

  7. PRESENTING SYMPTOMS AND SIGNS OF GERD INFANTS -Feeding refusal -Recurrent vomiting -Poor weight gain -Irritability -Apnea or ALTE -Arching or head tilting (“pseudo-torticollis”) Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1

  8. PRESENTING SYMPTOMS AND SIGNS OF GERD • Preschool Intermittent vomiting or regurgitation Less commonly respiratory complica- tions Decreased food intake without any other complaints may be a symptom of esophagitis

  9. Presenting Symptoms and Signs of GERD • Older Children and Adolescents Heartburn Chronic cough Regurgitation Nausea/epigastric Esophagitis pain Asthma Recurrent Pneumonia Hoarseness

  10. Frequency of presenting symptoms in 76 children with GERD Percentage of subjects 63.9 34 29 22 18 16

  11. Supraesophageal symptoms of GERD in children Apnea/bradycardia Chronic cough Wheezing/asthma Supra-esophageal manifestations of GERD Otitis/sinusitis Chronic sore throat Hoarseness Dental

  12. LESS COMMON SIGNS AND SYMPTOMS IN CHILDREN • Hematemesis • Iron deficiency anemia • Failure to thrive/grow • Sandifer’s syndrome • (“pseudo-torticollis,” posturing

  13. Taking a History for a child with Suspected GERD • History Feeding History Pattern of vomiting Past Medical History Psychosocial History Family History Growth Chart

  14. Alarm and Signals Suggestive of Non-GERD Diagnoses • Recurrent vomiting • History and physical examination • Are there warning signals?

  15. Common Nonreflux causes of Vomiting Infections Sepsis Meningitis Urinary tract infection Otitis media Obstruction Pyloric stenosis Malrotation Intussusception

  16. Common Nonreflux causes of vomiting (continuation) Gastrointestinal Eosinophilic esophagitis Peptic ulcer disease Achalasia Pill esophagitis Gastroparesis Crohn disease Gastroenteritis Gall bladder disease Pancreatitis Celiac disease

  17. Common Nonreflux Causes of Vomiting (continuation) Metabolic/Endocrine Galactosemia Fructose intolerance Urea cycle defects Diabetic ketoacidosis Toxic Lead poisoning

  18. Common Nonreflux Causes of vomiting (continuation) Neurologic Hydrocephalus and shunt malfunctioning Subdural hematoma Intracranial hemorrhage Tumors Migraine

  19. Common Nonreflux Causes of Vomiting (continuation) Allergic Dietary protein intolerance Respiratory Posttussive emesis Pneumonia Renal Obstructive uropathy Renal insufficiency

  20. Common Nonreflux Causes of Vomiting Cardiac CHF and disease Recreational drugs and alcohol consumption Pregnancy Other Overfeeding Self-induced emesis

  21. Diagnostic Approach to GER • History and Physical examination • Diagnostic studies Contrast Radiographs Esophageal ph monitoring Endoscopy Multichannel intraluminal impedance Scintigraphy

  22. GOALS IN THE TREATMENT OF REFLUX • Eliminate symptoms quickly • Heal esophagitis • Manage or prevent complications • Maintain remission

  23. Expert Recommendations forEmpiric Therapy in GERD • Empiric therapy can be used as a “test” to determine if GERD is causing a specific symptom -No gold standard test for GERD -Avoids invasive testing -Can have GERD despite normal diagnostic tesitng -Problem:placebo effect

  24. Empiric Therapy in GERD (continuation) • Consideration for dose, duration, and type of medication -Severity of disease -Cost and insurance requirements -Risk of underlying conditions (eg. Asthma)

  25. Empiric Therapy in GERD(continuation) • Define goals and length of empiric trial before initiation of therapy • Stop treatment if empiric therapy fails

  26. Strategies for the Empiric Trial: Step-up Therapy • High-dose • PPI • PPI • H2Ra • Lifestyle • Modicifations* • Important to implement with medications as well • No studies evaluating these strategies in children

  27. Management of Mild GERD Symptoms • Explanation and reassurance • Diet and lifestyle • Antacids

  28. Lifestyle Management of Mild GERD Symptoms Infants • Normalize feeding volume and frequency • Consider thickened formula • Positioning -Upright after meals -Avoid car seats at home • Consider 2-4 week trial of hypoallergenic formula Rudolph CD, et al.Jpediatr Gastroenterol Nutr.2001:32(suppl2):S1

  29. Lifestyle Management of Mild GERD Symptoms • Older Children and Adolescents • Avoid large meals (especially prior to exercising • Do not eat or drink 2 hours prior to bedtime • If obese, weight loss program • Limit food and drink that provoke GERD • Symptoms • Rudolph CD, et al. Jpediatr Gastroenterol Nutr,.2001:32(suppl 2):S1

  30. Management of Mild-to-Moderate GERD Symptoms Prokinetics - Metoclopramide - Cisapride H2Receptor Antagonists - Cimetidine - Nizatidine - Famotidine - Ranitidine Proton Pump Inhibitors -Omeprazole -Lansoprazole

  31. Acid Suppression Options for GERD in Children Therapy Medications Considerations Histamine2 Cimetidine -Available for receptor Famotidine infants,children antagonists Nizatidine and adolescents (H2RAs) Ranitidine -Less potent acid suppression compared with PPIs -Tolerance is an issue

  32. Acid suppression Options for GERD in Children Therapy Medications Considerations Proton Esomeprazole -Available for Pump Lansoprazole children and Inhibitors Omeprazole adolescents (PPIs) -Superior efficacy to H2RA’s to H2RAs for healing and ph control -Cost and managed care restrictions

  33. FDA Labeling for Rx H2RA Therapy for Pediatric GERD Indicated Ages Dosing Ranitidine 1 month to 5-10 mg/kg/day 16 years divided BID Famotidine 1 year to 1 mg/kg/day 16 years divided BID up to 40 mg. BID Nizatidine >12 years 150 mg. BID Cimetidine >16 years 800 mgBID or 400 mg. QID 3

  34. PPIs Approved for Rx ofPediatric GERD (FDA Labeling) Omeprazole Weight Dosing Duration Indicated Ages <20 kg 10mg QD up to 2yrs-16yrs 12 wks >20 kg 20mg QD up tp 2yrs-16yrs Lansoprazole <30 kg 15 mg QD up to 12mo.-11yrs >30kg 30mg QD 12 wks 12mo-11yrs Nonerosive esophagitis-up to 8wks 12-17yrs

  35. Importance of timing of PPIdose Dosing Administer PPI QD 30 min. before breakfast BID 30 min before breakfast and evening meal

  36. H2RAs and Tachyphylaxis H2RAs develop loss of efficacy in antisecretory potency -Might occur as early as second dose of H2RA increasing to 29 days of dosing Tolerance phenomenon is not overcome by an increase in dosage

  37. Observed Adverse Events with PPI • PPI Adverse Events • Lansoprazole Headache (3%) Constipation (5%) Diarrhea,abdominal pain nausea • Omeprazole Headache (2.4% Rash(1.1%) Diarrhea(1.9%) Abdominal pain, nausea constipation

  38. Observed Adverse Events with PPIs • No reported long-term side effects with PPIs • Adverse events reported with PPIs are similar to those reported with placebo Scott LJ et al.Drugs.2002;62:1503. Gold b. Pediatric Drugs. 2002;4:673 Rudolph CD., et al. Jpediatr GassstroenterolNutr.2001;32:S1 Klinkenberg- KknolEC, et al.Gastroenterology2000;118(4):661. l

  39. The Role of Metoclopramide in the Treatment of GERD • High incidence of adverse events • Medication crosses the blood brain barrier Tardive dyskinesia (amy be irrever- sible) Lethargy Irritability • Evidence suggests poor clinical efficacy

  40. Children at Risk for Long-term Complications of GERD • Asthma • Cystic fibrosis • Esophageal atresia • Down’s syndrome • Erosive esophagitis • Neurologic impairment

  41. Asthmatic Children withoutGERD Symptoms • Indications for work-up Radiographic evidence of recurrent pneumonia Nocturnal asthma that occurs more than once weekly Continuous oral or high-dose inhaled corticosteroids

  42. Asthmatic Children without GERD Symptoms Indications for work-up (continuation) More than 2 courses of oral corticosteroid required per year Exacerbation of asthma whenever medications are decreased

  43. Complications of GERD • Esophagitis • Peptic Stricture • Failure to thrive • Pulmonary/ENT disease • Barrett’s esophagus • Adenocarcinoma

  44. Considerations for Testing or Referral to a GI Specialist • No response to PPI therapy • Patient is unable to be weaned from medical therapy or has significant side effects • Signs of complications or severe disease -Alarm signs or sxs present(eg.blood loss,Significant growth problems and -Life threatening issues (eg.respiratory)

  45. SUMMARY Pediatric reflux is a common condition in children Children less than 18 months old with GER rarely develop GERD GERD in children presents as a variety of symptoms

  46. Summary • Complications of GERD include: -Asthma -Erosive esophagitis -Stricture -Barrett’s esophagus -Adenocarcinoma

  47. SUMMARY • Early detection and intervention may prevent life-long complications • An empiric trial of acid suppression can be diagnostic and therapeutic • PPI therapy is the most effective for GERD symptom relief and esophageal healing

  48. SUMMARY • Children with cystic fibrosis, esophageal atresia, or neurologic impairment may be at greater risk of complications of GERD • Safe and effective treatments exist for long-term suppression of acid

  49. Summary • Children less than 18 months old with GER rarely develop GERD • Complications of GERD : -Asthma Adenocarcinoma -Erosive esophagitis -Stricture -Barrett’s esophagus

  50. Summary • Children with cystic fibrosis, esophageal atresia,or neurologic impairment may be at greater risk for complications of GERD • Safe and effective treatments are available for long term acid suppression and should be used

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