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Diagnosis and Treatment of Gastroesophageal Reflux in Infants and ChildrenMAJ Drew Baird, MDMAJ Dausen Harker, MDCPT Aaron Karmes, DO
Family Medicine Residency ProgramDarnall Army Medical CenterFort Hood, Texas
Learning Objectives
• Know the definitions and presentation of – Regurgitation (spitting up)– Gastroesphogeal reflux (GER)– Gastroesophageal reflux disease (GERD)
• Understand the differential diagnosis and warning signs/symptoms in children with reflux
• Be familiar with diagnostic tests in evaluating reflux• Be able to educate parents/patients on lifestyle
changes to treat reflux• Know pharmacologic treatments of pediatric reflux
Outline: A Case-based Approach
• Definitions• Epidemiology and mechanisms• Risk factors• Clinical presentation and evaluation
• Differential diagnosis• Warning signs and symptoms• Diagnostic testing
• Treatments• When to refer
Case 1
Case 2
Case 3
Case 1
• 8yo M c/o intermittent nighttime vomiting preceded by epigastric pain, provoked by certain foods
• What further questions should you ask?
Definitions
• GER = passive movement of stomach contents into esophagus– Regurgitation (spitting up) = passive movement of
stomach contents into/out of mouth– Vomiting = forceful movement of stomach contents …
• GERD = GER that causes bothersome symptoms and/or medical complications→Reflux esophagitis→Barrett’s esophagus→Esophageal adenocarcinoma
Vandenplas, et al. J Pediatr Gastroenterol Nutr. 2009;49:498-547.
The problem
• Transient lower esophageal sphincter relaxation
Typical Symptoms (GER/GERD)
• Infants– Regurgitation, vomiting– Postprandial irritability, back arching
• Children/adolescents– Heartburn, abdominal pain– Regurgitation– Dysphagia/odynophagia
“Bothersome” Symptoms (GERD)
• Weight loss, failure to thrive• Infants– Postprandial irritability, prolonged feeding, feeding refusal– Sandifer syndrome– ALTE
• Children/adolescents– Bothersome symptoms
• Extra-esophageal signs/symptoms– Cough– Recurrent pneumonia, otitis media, sinusitis
Epidemiology: GER in infancy
• It’s common!– Half of 0-3mo infants spit up at least 1x/day– 2/3 of 4mo infants spit up at least 1x/day
• >40% spit up most feedings
• It gets better!
1.Nelson, et al. Arch Pediatr Adolesc Med. 1997;151:569-572.
2.Martin, et al. Pediatrics 2002. 109:1061-1067.
Epidemiology: GERD
• Less common than GER• Bimodal incidence during childhood• Overall childhood prevalence 3.3% (adults, 5%)
Ruigomez, et al. Scand J Gastroenterol, 2010;45:139-146.
Risk Factors for GERDCondition Odds ratio (95% confidence interval)Hiatal hernia 7.4 (2.7-20.3)Neurodevelopmental disorders 3.4 (2.5-4.7)Cystic fibrosis 3.3 (0.6-18.1)Epilepsy 2.1 (1.3-3.3)Congenital esophageal disorders 1.7 (1.4-2.1)Asthma 1.3 (1.0-1.6) for ages 1-11yo
1.1 (0.9-1.3) for adolescentsPrematurity Not definedLung transplant Not definedObesity Proposed risk factor, not defined
1. Ruigomez, et al. Scand J Gastroenterol. 2010;45:139-146.2. Marchland, et al. J Pediatr Gastroenterol Nutr. 2006 Jul;43(1):123-135.3. Gauer, et al. Am Fam Physician. 2014 Aug 15;90(4):244-251.4. Dhillon, et al. Acta Paediatr. 2004;93:88-93.5. Benden, et al. Pediatr Pulmonol. 2005 Jul;40(1):68-71.
Case 1 - concluded
• 8yo M c/o intermittent nighttime vomiting x 5 days preceded by epigastric pain, provoked by certain foods– ROS: admits to regurgitating food occasionally, which
doesn’t bother him– PMH: - GERD treated with ranitidine as an infant
- Asthma (hasn’t used inhaler in years)– Growth & development: normal– Physical exam: normal
• Diagnosed with GER, but with close follow-up
Case 2
• 26 day old male presented with non-bilious projectile vomiting after every feeding
– Weighed less than birth weight
– Dehydrated with a scaphoid abdomen
– Small, round, olive-like mass palpated in right upper quadrant
• What is your differential diagnosis?
Evaluation of reflux-related symptoms
• GER and GERD are clinical diagnoses– Further diagnostic testing generally unnecessary and not
superior to the H&P• History
– Symptoms (regurgitation, vomiting, heartburn, etc.)• Relationship to food• Extra-esophageal symptoms• Warning signs and symptoms
– Presence of risk factors– Past medical history– Family History
• Physical Exam – mainly used to rule out other diagnoses
Van der Pol, et al. J Pediatr 2013;162:983-987.
Evaluation of reflux-related symptoms
• Differential diagnosis – it’s huge!
• Key DDx distinguishers– Age at presentation– Acute vs. subacute/chronic presentation– Infant vs. child/adolescent– Common vs. uncommon DDx– Warning signs/symptoms
Warning signs and symptoms
• Weight loss, failure to thrive• Fever• Bilious vomiting– Or, persistent, forceful vomiting
• Abdominal tenderness, distension, mass• GI bleeding (or iron deficiency anemia)• ALTE• Persistent diarrhea, constipation
Diagnostic testing
• Not usually needed for most GER/GERD cases
• Diagnostic testing reserved for– Warning signs/symptoms– Atypical (extra-esophageal) symptoms– Suspicion for alternate diagnosis– Medical complications of GERD– Failure of initial GERD therapies
Diagnostic testing
• Barium contrast radiography• Endoscopy with biopsy• Esophageal pH monitoring• Multiple intraluminal impedance
with pH monitoring• Esophageal manometry• Nuclear scintography• Ultrasound• Questionnaires
Case 2 - concluded
• 26 day old male presented with non-bilious projectile vomiting after every feeding– Weight loss– Olive-like mass in abdomen
• Urgent ultrasound ordered
Pyloric muscle canal: 169mmPyloric muscle thickness: 3.55mm
Case 3
• 14mo F presents with spitting up/vomiting and irritability after eating solids– Now refusing solid foods,
only wants breast milk– Stool is yellow, mustardy color– PMH: - born FT via SVD @ 40 wks, IUTD
- GERD dx at 4mo, treated with ranitidine, resolved by 6mo
– ROS: chronic cough, being treated with albuterol
Case 3
• 14mo F presents with spitting up/vomiting and irritability after eating solids– Now refusing solid foods,
only wants breast milk– Stool is yellow, mustardy color– PMH: - born FT via SVD @ 40 wks, IUTD
- GERD dx at 4mo, treated with ranitidine, resolved by 6mo
– ROS: chronic cough, being treated with albuterol
• What treatment(s) would you advise?
Treatment Algorithm
GER GERD Warning signs and symptoms
• Reassurance• Educate on lifestyle
interventions, consider adopting
• Focused workup• Imaging as appropriate• Consider subspecialty
referral
Adopt lifestyle and dietary interventions for 2-4 weeks and reassess
If no improvement,• 4-8 week trial of H2RA
or PPI and reassess
If symptoms improve,• Continue for 8-12
weeks and reassess
If no improvement,• Consider alternate diagnosis,
imaging as appropriate• Consider pediatric GI referral
Lifestyle Interventions: Infants
• Reassurance! • Reduced feeding volumes• Consider removing immunogenic foods from
mom’s diet (breastfeeding infants)• Change resting body position (in awake infant)– Flat prone– Left-side down– Prone sleeping (after 1 year of age)
1. Vandenplas, et al. J Pediatr Gastroenterol Nutr. 2009;49:498-547.2. Lightdale, et al. Pediatrics. 2013;131(5):e1684-e1695.
Lifestyle Interventions: InfantsRice cereals (thickening agents) Amino acid formulas
Antiregurgitant formulas
Lifestyle Interventions: Infants
• Infant sleep positioners?
Lifestyle Interventions: Children
• Dietary changes – Trigger avoidance– Smaller, more frequent meals
• Weight loss in obese children• Chew sugarless gum after meals• Avoid late-evening meals• Avoid laying down after meals• Smoking cessation
Medications for GERD
• Acid suppressants– Histamine-2 receptors
antagonists (H2RAs)– Proton pump inhibitors
(PPIs)– Antacids
• Not recommended in children < 12yo
• Gut motility agents– Erythromycin (off-label)– Metoclopramide (off-label)
• Antispasmodics (off-label)
Evidence for medications in infantsSymptom improvement
Reflux index reduced
Histology and endoscopy
H2RAs Very low quality Very low quality Low quality
Cimetidine + + +
Famotidine - - -
Nizatidine + + +
Ranitidine - + +
PPIs Very low quality Low quality Very low quality
Esomeprazole - + -
Lansoprazole - - -
Omeprazole + + +
Rabeprazole - - -
Tighe, et al. Cochrane Database of Systematic Reviews 2014.
Evidence for medications in childrenSymptom improvement
Reflux index reduced
Histology and endoscopy
H2RAs Low quality Low quality Low quality
Cimetidine + + +
Famotidine - - -
Nizatidine - + +
Ranitidine + + +
PPIs Moderate quality Low quality Moderate quality
Esomeprazole + - +
Lansoprazole + + +
Omeprazole + + +
Rabeprazole - - -
Tighe, et al. Cochrane Database of Systematic Reviews 2014.
When to Refer
• Pediatric Gastroenterology– Failure of medical therapy– Serious medical complications– Other diagnoses need exploring
• Surgery indicated for– Failure of medical therapy– Serious medical complications– Intolerance of medical therapy
Case 3 - continued
• 14mo F presents with spitting up/vomiting and irritability after eating solids– Refusing solid foods– PMH: GERD dx at 4mo,
treated and resolved by 6mo– ROS: chronic cough, being treated with albuterol
• Started on liquid ranitidine, f/u in 1 month
• Oh, by the way, her older sister had a late presentation of intestinal malrotation at 2 ½ yo requiring surgery– Ordered barium contrast study
Take Home Points
• GER is common, especially in infancy– GERD is less common
• GER & GERD are distinct, clinical diagnoses– Warning signs/symptoms deserve evaluation
• Reassurance and lifestyle interventions are first line treatments for GER & GERD
• H2RAs and PPIs are effective for GERD treatment based on limited evidence
Questions?
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