Pediatric Gastroesophageal Reflux: Diagnosis and Management

Laurie Conklin, M.D. Gastroenterology and Nutrition

Definitions
GER Passage of gastric contents into the esophagus

GERD

Symptoms or complications that may occur when gastric contents reflux into the esophagus or oropharynx Regurgitation Passage of refluxed gastric contents into oropharynx Vomiting Expulsion of refluxed gastric contents from the mouth

Prevalence of Regurgitation in Infancy

70 60 50

% of Infants

40 30 20 10 0 0-3 4 to 6 7 to 9 10 to 12 1 X/day 4 X/day

Age in months
Adapted from Nelson et al, Arch 3 PediatrAdolescMed1997;151:569

Prevalence of GER symptoms in children

566 parents of children ages 3-9 yrs 615 children ages 10-17 yrs 2200 adults ages 25-74 yrs

20 18 16 14 12 10 8 6 4 2 0

Heartburn

Epigastric pain Regurgitation

Nelson et al, Arch Pediatr Adolesc Med 2000;154:150 and Locke et al, Gastro 1997;112:1448 Slide adapted from CDHNF/NASPGHAN slideset

Heartburn and/or Acid Regurgitation

At- Risk Populations for GERD

Individuals with:
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Neurological impairment Obesity Some genetic syndromes Esophageal atresia Chronic lung disease Repaired achalasia Hiatal hernia

Presenting Signs and Symptoms of GERD

Recurrent vomiting in an infant Recurrent vomiting and poor weight gain in an infant Recurrent vomiting and irritability in infant Recurrent vomiting in an older child

Heartburn in a child/adolescent Esophagitis Dysphagia or feeding refusal Apnea or ALTE Asthma Recurrent pneumonia Upper airway symptoms

Diagnostic approach depends on signs and symptoms

History and physical examination Upper GI series Esophageal pH monitoring Upper endoscopy with biopsies Empirical medical therapy

Upper GI Series
Advantages: Evaluation of the anatomy Limitations: Cannot discriminate between physiologic and non-physiologic GER episodes

Esophageal pH probe monitoring

Advantages:
Detects episodes of acid reflux Possible to correlate reflux with symptoms Can assess efficacy of acid blockade in non-responsive patients

Disadvantages:
Cant detect alkaline reflux Not useful in detecting association between GER and apnea
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Upper endoscopy or EGD

Advantages:
Enables visualizes of epithelium and enables biopsies to be taken Discriminates between reflux and other conditions (eosinophilic esophagitis)

Disadvantages:
Need for anesthesia Poor correlation between visual appearance and biopsy findings Not usually useful for extraesophageal manifestations of GERD

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Nuclear Scintigraphy (Milk Scan)

Advantages:
May have a role in diagnosis of pulmonary aspiration in patients with refractory respiratory symptoms

Disadvantages:
Standards for interpretation are poorly established. Gastric emptying studies alone do not confirm a diagnosis of reflux

Nuclear Scintigraphy is not recommended for routine evaluation of patients with suspected GERD
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Multichannel Intraluminal Impedance

Advantages:
Detects non acidic GER episodes May be useful for studying respiratory symptoms and GER in infants

Disadvantages:
Normal values in pediatric age groups not yet welldefined Analysis of tracings is time consuming

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Empiric Therapy vs. Diagnostic Work-up??

Diagnosis is often made clinically Tests are useful to:
Document the presence of pathologic reflux Establish a causal relationship between reflux and symptoms To evaluate therapy To exclude other conditions

No one test can address all of these questions

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Presenting signs and symptoms of GERD

Recurrent vomiting in an infant Recurrent vomiting and poor weight gain in an infant Recurrent vomiting and irritability in an infant Recurrent vomiting in an older child Heartburn in a child/adolescent Esophagitis Dysphagia or feeding refusal Apnea or ALTE Asthma Recurrent pneumonias Upper airway symptoms

Adapted from Rudolph et al, J PediatrGastroenterolNutr2001;32:S1

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History in Child with Suspected GERD

Feeding History Amount and frequency (overfeeding) Formula (preparation errors) Positioning/ burping Psychosocial History Stress Pattern of Vomiting Frequency and amount Forceful Painful Family History GI problems Metabolic or allergic history Past Medical History Growth and development Prematurity Surgery Growth Chart Weight, height, head circumference

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Adapted from Rudolph et al, J PediatrGastroenterolNutr2001;32:S1 Orenstein et al, ClinPediatr1993;32:472

Warning Signs Suggestive of a Non-GERD diagnosis

Bilious or forceful vomiting Hematemesis or hematochezia Recurrent Vomiting Vomiting or diarrhea Abdominal tenderness or distension History and Physical Exam Onset of vomiting after 6 months of life Fever, lethargy, hepatosplenomegaly Macrocephaly, microcephaly, seizures

WARNING SIGNS
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Adapted from Rudolph et al, J PediatrGastroenterolNutr2001;32:S1

Signs of Complicated GERD

Poor weight gain Excessive crying or irritability Feeding problems Respiratory problems
Wheezing Stridor Recurrent pneumonia

Warning Signals? No Signs of Complicated GERD?

Adapted from Rudolph et al, J PediatrGastroenterolNutr2001;32:S1

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Conservative Management of Infants with Recurrent Vomiting

History and physical exam sufficient Parental education
Warning signs Reassurance

No warning signs!

No pharmacotherapy recommended Can thicken formula or try a hypoallergenic formula If symptoms persist >18 months of age, refer to a pediatric gastroenterologist

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Rudolph et al, J PediatrGastroenterolNutr2001;32:S1

Infant with recurrent vomiting and poor weight gain

If warning signs are present: If inadequate calories offered: If adequate calories offered: Consider other diagnoses Referral to GI Educate and follow up closely Consider other causes of vomiting

Rudolph et al, J 19 PediatrGastroenterolNutr2001;32:S1

Effect of Sleep Position on GER in Infants and SIDS Mortality

Reflux Index1 (% time pH<4) SIDS Reflux Index Mortality2 Odds Ratio (per 1000 live births) SIDS Mortality Odds Ratio3

Supine Left side Right side Prone

1Tobin 2

15.3 7.7 12.0 6.7

0.05* 0.05* 0.05* 4.4

2.3 1.1 1.8 1.0

1.0 3.5 3.5 13.9

et al. Arch DisChild1997;76:254 Skadberget al, J Pediatr1998;132:340 3 Oyenet al, Pediatrics1997;100:613

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*Mortality rate for all non-prone positions combined Combined odds ratio

Adapted from NASPGHAN slideset

Positioning Therapy for GERD

For Infants
Non-prone positioning during sleep is recommended Supine positioning confers lowest risk for SIDS Prone positioning can be considered in cases where risk of GERD is deemed lifethreatening Avoid soft bedding, pillows, loose sheets

For Older Children

Left side positioning during sleep may be beneficial Elevate the head of the bed Avoid lying down immediately after eating

American Academy of Pediatrics, Task Force on Infant Sleep Position on SIDS, 21 Pediatrics2000;105:650 and Rudolph et al, J PediatrGastoenterolNutr2001;32:S1

Management of Heartburn or Chest Pain

H2RA or PPI for 2-4 weeks Lifestyle Changes: Weight loss if obese Avoid fried/fast food, spicy food, caffeine No eating before bed or exercise

No change Symptoms recur EGD with biopsies

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Improvement Rx for 2-3 months

Management of Infants/Children with Reflux Esophagitis

Initial Treatment: Lifestyle Changes H2RA blocker or PPI Optimize medical management: Increase dose of PPI or give BID Repeat endoscopy Consider a prokinetic Consider pH probe on therapy
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Respiratory symptoms of GERD

Wheezing Chronic cough Stridor and hoarseness Recurrent pneumonia Apnea

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Asthma: When to Treat GERD

Persistent Asthma AND GER symptoms:
Vigorous acid suppression for 3 months, monitoring for symptoms

Persistent Asthma and NO GER symptoms:

Consider esophageal pH monitoring or empiric treatment trial in children with: Recurrent pneumonia Nocturnal asthma >1x weekly Corticosteroid dependency
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Management of GER-associated ALTE

pH probe monitoring is only helpful if performed with measurement of chest wall movement and respirations Therapeutic options include:
Thickened feedings Acid suppression

Fundoplication is only considered in the most severe cases

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GERD-related pneumonia
Incidence of GER-related recurrent aspiration in otherwise healthy infants and children is RARE Before considering GER, need to think about other causes like neuromuscular disease or esophageal/ laryngeal abnormalities Combination of tests can be helpful:

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pH probe Bronchoscopy with pulmonary lavage Swallowing assessment (VSS, FEES) Nuclear scintigraphy

Medications Used to Treat GERD

Antacids Histamine-2 Receptor Antagonists Proton Pump Inhibitors Prokinetic Agents Mucosal surface agent

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Inhibition of Acid Secretion in the Parietal Cell

H+

K+ PPI

Histamine-2 29 receptor

Prostaglandin receptor

Acetylcholine Gastrin receptor receptor

Histamine-2 Receptor Antagonists

Peak plasma concentration occurs 2.5 hours after dosing Can be used for GERD symptoms and esophagitis Tachyphlaxis can develop with chronic use

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Proton Pump Inhibitors

Superior efficacy to H2-receptor antagonists Effect does not diminish with chronic use Should be taken once per day before breakfast

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Effect of Lansoprazole on GERD Symptoms

p<0.01
100 90 80 Median % 70 of days 60 with GERD symptoms 50 40 30 20 10 0
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100% 79%

N=66 children with GERD sxs treated with Lansoprazole 15-30 mg QD-BID for 8-12 weeks

20%

Tolia, et al. JPediatr Gastroenterol Nutr (2002) 35; Suppl 4

Baseline

Week 2

Week 12

Effect of Lansoprazole on Esophagitis

100 90 80 % Patients 70 With Esophagitis60 50 40 30 20 10 0

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100%

N= 28 children with grade 2 erosive esophagitis treated with lansoprazole 15-30 mg QD-BID For 8-12 weeks

22%

0%

Baseline

Week 8

Week 12

Tolia, et al. JPediatr Gastroenterol Nutr (2002) 35; Suppl 4

Outcomes of Antireflux Surgery in Children

Success rate (complete relief of symptoms) Mortality related to surgery Overall complication rate Dumping syndrome Gas bloat syndrome Small bowel obstruction Wrap failure Re-operation rate 57-92% 0-5% 2 - 45% N/A 2 8% 1 11% 1 13% 3 19%

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NA = Not estimated; one report suggested <30%. Rudolph et al, J PediatrGastroenterolNutr2001;32:S1

Summary
GER is common in healthy infants and usually resolves by 12-18 months of age Approach to diagnosis and treatment depends on symptoms and signs (and severity) Currently available tests do NOT conclusively demonstrate a relationship between GER and specific symptoms A thorough history and clinical judgement are imperative for optimal evaluation and management
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