Transcript pediatric gerd

PEDIATRIC GERD
INTRODUCTION
Gastroesophageal reflux
Gastroesophageal reflux disease
Mechanism and
Pathophysiology of Reflux
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Transient relaxation of the lower
esophageal sphincter
The short infant esophagus has limited
volume
Predominantly recumbent position of
infants
Delayed emptying
Increased abdominal pressure
Prevalence of Regurgitation in
Healthy Infants
Infants (%)
100
1 time a day
4 times a day
0
0-3
4-6
7-9
Age (months)
10-12
Prevalence of GERD in infants
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Premature infants (by pH-metry) >85%
-3-10%: apnea, bradycardia,
bat
exacerbation of BPD
Infants <3 months (by Hx) 20-100%
-33% receive medical attention
-80% resolve with minimal intervention
and no diagnostic evaluation
Genetic Predisposition for GERD
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Familial clustering
Concordance for acid regurgitation
Proposed genetic links
Chromosome 13 locus (13q14)
Chromosome 9 locus
PRESENTING SYMPTOMS AND
SIGNS OF GERD
INFANTS
-Feeding refusal
-Recurrent vomiting
-Poor weight gain
-Irritability
-Apnea or ALTE
-Arching or head tilting (“pseudo-torticollis”)
PRESENTING SYMPTOMS AND
SIGNS OF GERD
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Preschool
Intermittent vomiting or regurgitation
Less commonly respiratory complications
Decreased food intake without any
other complaints may be a symptom
of esophagitis
Presenting Symptoms and Signs
of GERD
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Older Children and Adolescents
Heartburn
Chronic cough
Regurgitation
Nausea/epigastric
Esophagitis
pain
Asthma
Recurrent Pneumonia
Hoarseness
Frequency of presenting symptoms in
76 children with GERD
Percentage of subjects
70
60
Heartburn or
epigastricpain
Recurrent
abdominal pain
Respiratory
symptoms
Regurgitation
63.9
50
40
30
20
10
0
34
29
22
Retrosternal pain
18
16
Vomiting
Supraesophageal symptoms of
GERD in children
Apnea/bradycardia
Chronic cough
Wheezing/asthma
Supra-esophageal
manifestations
of GERD
Chronic sore
throat
Dental
Otitis/sinusitis
Hoarseness
LESS COMMON SIGNS AND
SYMPTOMS IN CHILDREN
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Hematemesis
Iron deficiency anemia
Failure to thrive/grow
Sandifer’s syndrome
(“pseudo-torticollis,” posturing
Taking a History for a child with
Suspected GERD
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History
Feeding History
Pattern of vomiting
Past Medical History
Psychosocial History
Family History
Growth Chart
Alarm and Signals Suggestive
of Non-GERD Diagnoses
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Recurrent vomiting
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History and physical examination
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Are there warning signals?
Common Nonreflux causes of
Vomiting
Infections
Sepsis
Meningitis
Urinary tract infection
Otitis media
Obstruction
Pyloric stenosis
Malrotation
Intussusception
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
Common Nonreflux Causes of
Vomiting (continuation)
Metabolic/Endocrine
Galactosemia
Fructose intolerance
Urea cycle defects
Diabetic ketoacidosis
Toxic
Lead poisoning
Common Nonreflux Causes of
vomiting (continuation)
Neurologic
Hydrocephalus and shunt
malfunctioning
Subdural hematoma
Intracranial hemorrhage
Tumors
Migraine
Common Nonreflux Causes of
Vomiting (continuation)
Allergic
Dietary protein intolerance
Respiratory
Posttussive emesis
Pneumonia
Renal
Obstructive uropathy
Renal insufficiency
Common Nonreflux Causes of
Vomiting
Cardiac
CHF and disease
Recreational drugs and alcohol
consumption
Pregnancy
Other
Overfeeding
Self-induced emesis
Diagnostic Approach to GER
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History and Physical examination
Diagnostic studies
Contrast Radiographs
Esophageal ph monitoring
Endoscopy
Multichannel intraluminal impedance
Scintigraphy
GOALS IN THE TREATMENT
OF REFLUX
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Eliminate symptoms quickly
Heal esophagitis
Manage or prevent complications
Maintain remission
Expert Recommendations for
Empiric Therapy in GERD
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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
Empiric Therapy in GERD
(continuation)
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Consideration for dose, duration, and
type of medication
-Severity of disease
-Cost and insurance requirements
-Risk of underlying conditions
(eg. Asthma)
Empiric Therapy in GERD
(continuation)
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Define goals and length of empiric
trial before initiation of therapy
Stop treatment if empiric therapy fails
Strategies for the Empiric
Trial: Step-up Therapy
High-dose
PPI
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PPI
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H2Ra
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Lifestyle
Modicifations*
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Important to implement with medications as well
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No studies evaluating these strategies in children
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Management of Mild GERD
Symptoms
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Explanation and reassurance
Diet and lifestyle
Antacids
Lifestyle Management of Mild
GERD Symptoms
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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
Lifestyle Management of Mild
GERD Symptoms
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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
Management of Mild-toModerate GERD Symptoms
Prokinetics
- Metoclopramide - Cisapride
H2Receptor Antagonists
- Cimetidine - Nizatidine
- Famotidine - Ranitidine
Proton Pump Inhibitors
-Omeprazole -Lansoprazole
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
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
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
PPIs Approved for Rx of
Pediatric 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
Importance of timing of
PPIdose
Dosing
QD
BID
Administer PPI
30 min. before breakfast
30 min before breakfast
and evening meal
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
Observed Adverse Events with
PPI
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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
Observed Adverse Events with
PPIs
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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
The Role of Metoclopramide in
the Treatment of GERD
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High incidence of adverse events
Medication crosses the blood brain barrier
Tardive dyskinesia (amy be irreversible)
Lethargy
Irritability
Evidence suggests poor clinical efficacy
Children at Risk for Long-term
Complications of GERD
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Asthma
Cystic fibrosis
Esophageal atresia
Down’s syndrome
Erosive esophagitis
Neurologic impairment
Asthmatic Children without
GERD Symptoms
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Indications for work-up
Radiographic evidence of recurrent
pneumonia
Nocturnal asthma that occurs more
than once weekly
Continuous oral or high-dose inhaled
corticosteroids
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
Complications of GERD
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Esophagitis
Peptic Stricture
Failure to thrive
Pulmonary/ENT disease
Barrett’s esophagus
Adenocarcinoma
Considerations for Testing or
Referral to a GI Specialist
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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)
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
Summary
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Complications of GERD include:
-Asthma
-Erosive esophagitis
-Stricture
-Barrett’s esophagus
-Adenocarcinoma
SUMMARY
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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
SUMMARY
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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
Summary
Children less than 18 months old with
GER rarely develop GERD
 Complications of GERD :
-Asthma
Adenocarcinoma
-Erosive esophagitis
-Stricture
-Barrett’s esophagus
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Summary
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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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Shawn is 9 months old brought for the first
time for check up. He spits up frequently, has
frequent otitis media and congestion. BW
was 3kg. Current wt. Is 6 kg.
Peter is 3 years old complaint of intemittent
periumbilical pain that occurs daily worse
after meals. He vomits 1-2x a week and
refuses to eat s-3 meals/week. He has history
of frequent spitting up during the first 2 years
of like and was treated with ranitidine.