GERD IN CHILDREN

1. Issues in diagnosis
management of
GERD in children
PRESENTED BY:
Virendra Gupta
GUIDED BY:
Dr. B. S. Sharma Sir

2. Definitions
GER
Passage of gastric contents into the
esophagus with or without
regurgitation or vomiting.
NASPGHAN GUIDELINES 2009;49:498-547 .
Retrograde movement of gastric
contents across the lower esophageal
sphincter (LES) into the esophagus.
Nelson textbook of pediatric_19
th
e-
Regurgitation (spitting-up)
-
Effortless movement of stomach
contents into the esophagus and
mouth.
Nelson textbook of pediatric_19
th
e-

3. Definitions
GERD
Presence of troublesome
symptoms and/or complications
of persistent GER.
NASPGHAN GUIDELINES 2009;49:498-547
or
GER becomes pathological
when it causes troublesome
symptoms and physical
complications, hence the term
gastro esophageal reflux disease
(GERD).
Nelson textbook of pediatric_19
th
e-

5. GERD-EPIDEMIOLOGY
•GERD – One of the commonest gastrointestinal
diagnoses in pediatric practice in the West
•Prevalence of an abnormal quantity of GER in
infants- 8%
Vandenplas et al ,Pediatrics 1991;88:834-840

6. GERD-EPIDEMIOLOGY
•10 % of babies from a well baby clinic(62 / 602
babies) had symptoms of GER
De S et al Trop Gastroenterol. 2001 ; 22(2):99-102
•GER - 35% of cases with respiratory symptoms
(recurrent bronchopneumonia, reactive airway
disease and chronic cough)
Jain A et al, J Trop Ped.2002;48:39-42

7. Prevalence of GERD in
Asthmatic Children
•A significant no. of childhood asthmatic
patients experience GERD
•25-75% have abnormal intra esophageal pH
•Only 50% have esophageal symptoms of GERD


Pediatr Drugs.2005;7:177-186
J Pediatr Gastroenterol Nutr 2001; 32: S1

8. CONDITIONS WITH HIGHER
PREVALENCE
•Cerebral palsy
•Mentally challenged
•TEF
•Obesity

9. GER- NATURAL COURSE
Infant reflux
•1st few months of life- Becomes evident
•4 month of life- Peaks
•12 month of life- Resolves in up to 88%
•24 month of life- Resolves nearly all
older children
•Tend to be chronic, waxing and waning
•50% completely resolves
•50% resembles adult patterns of GER

10. PREVALENCE OF GER IN INFANCY
0
10
20
30
40
50
60
70
%

o
f

i
n
f
a
n
t
s
0-3 months4-6 months7-9 months10-12 months
Age (months)
> 1 time a day
Arch Pediatr Adolescent Med 1997:151-159
GER is common in infants and most of them outgrow it by 1 year of age

11. AETIOLOGY OF GERD
•Genetic predisposition
•Environmental factors
–Food habit
–Eating fast
–Obesity
–Stress
–Exposure to tobacco smoke
•Nerologically impaired children

12. ESOPHAGUS
•Exposed to a variety of
potentially noxious substances.
•Major challenge to the integrity
of esophageal function is GER

13. ESOPHAGEAL DEFENSES: THREE TIERS
•Anti reflux barrier - Lower esophageal
sphincter, The diaphragmatic pinchcock and
Angle of His
•Esophageal clearance - Limit the duration of
contact between luminal contents and
esophageal epithelium
•Esophageal mucosal resistance - Comes into
play when reflux contact time is prolonged

14. LES
•High pressure zone-Length
3-6 cm & Pressure of about
20 mmHg
•Pressure < than 6 mmHg
favors GER
•20% of all reflux episodes
occur in relation to a
decreased basal low resting
LES pressure
(Cadiot et al Gut 1997)

15. INTRA-ABDOMINAL ESOPHAGUS
•Rt & Lt crus of diaphragm
produces a pinch cock
action to constrict
esophagus at the hiatus
•Length of the intra
abdominal esophagus-
>2cm

16. ANGLE OF HIS
•An acute angle between
the greater curvature of the
stomach and the esophagus

•If the angle is obtuse as in
hiatal hernia this favors
GER episodes.

17. PATHOPHYSIOLOGY OF GERD
•Transient LES relaxation
•Reduced esophageal body
peristalsis

19. Gastric
distension
Vagally mediated
abnormal
neural control of LES
Increase in GER
Haital hernia
obtuse angle of His
Low basal LES tone
Defective LES motility
Increased TLESRs
Overfeeding
overweight
increased abdominal pressure
Impaired pH neutralization
Delayed acid clearance
Poor mucosal resistanceGERD

21. symptoms
Neonates/Infants
Regurgitation-
especially postprandially
Signs Of Esophagitis-
(irritability, arching, choking,
gagging, feeding aversion)
failure to thrive
Poor weight gain
Older Children/Adolescents
Early morning nausea
Abdominal discomfort
Burps that burn
Sub sternal pain
Heartburn
Recurrent vomiting
•Sandifer syndrome-
neck contortions
(arching, turning of
head)

22. Non GI Manifestations of GERD
Extra-esophageal symptoms
Otorhinolaryngeal
• Chronic otitis media
• Hoarseness
• Globus sensation
• Persistent cough
• Sore throat
Pulmonary
• Asthma
• Recurrent pneumonias
• Chronic Cough
• Apnoea

23. Non GI Manifestations of GERD
Extra-esophageal symptoms
•Excessive coughing,
•Irritability
•Sleep disturbances
•Poor appetite
•Acute life threatening events
(ALTE)
•Bradycardia
•Abnormal posturing / arching
(Sandifer’s
syndorme)
•Dental erosions / waterbrash

25. COMPLICATIONS
•Erosive esophagitis
•Stricture
•Barrett esophagus
•Adenocarcinoma
•Weight loss
•Failure to thrive
•Progressive pulmonary
fibrosis
•Adenoidal enlargement
•Otitis media

26. Asthma & GERD
Coexistence seems to be more frequent than
would be expected for a chance occurrence.
Asthma
GERD
Asthma + GERD
Does GERD cause Asthma ? Does asthma cause GERD?

27. Does Asthma Trigger GERD?
Proposed Mechanisms
Coughing
Increase
Intraabdominal
Pressure
Increasing
Pressure Gradient
Across The LES
Asthma
Medications
Lower LES
Pressure
GERD

28. Does GERD Trigger Asthma?
Am J Med 2001; 111: 37S
Reflux Theory
Direct contact between
gastric refluxate and
lung tissues
Inflammation of the
airway
Bronchial
smooth muscle
reactivity

29. Does GERD Trigger Asthma?
Moser et al, Gastroenterology 1991; 101: 1512
Tuchman et al, Gastroenterology 1984; 87: 872
Reflex Theory
Esophagus and bronchial tree have
identical embryological derivation
Share common innervation (via
vagus nerve) and common reflexes
Stimulation of receptors in distal
esophagus by refluxate
Leads to vagal reflux
Producing bronchial constriction
and/or cough

30. GER& ASTHMA
•Medical therapy does not consistently
improve pulmonary function, asthma
symptoms or need of asthma medication
•Approach to GER related asthma should be
individualized
•Selected subgroup of asthmatics benefit from
anti reflux therapy
Cochrane Systematic Review

31. Naspghan’s Recommendations
Asthma exacerbations despite compliance with asthma
therapy
Frequent episodes of nocturnal asthma or nocturnal
cough
Two or more courses of systemic corticosteroids per year
despite maintenance asthma medication use.
Work up and /or initiation of empiric therapy for GERD
in the child with asthma should be considered in the
following situations:-
All patients with severe refractory asthma should undergo
oesophgeal pH monitoring to evaluate the presence of GERD.
Severe refractory asthma

32. When to suspect GERD associated
Asthma?
•Associated typical symptoms
of GERD
•Nocturnal cough
•Difficult to control asthma

33. GER & Chronic cough
•GERD is currently considered the third leading
cause of chronic cough affecting an estimated
20 % of patients
•Most patients do not have heartburn or
regurgitation
•Anti reflux therapy combined with lifestyle
changes have reported cough resolution in 70-
100% of patients

34. DIAGNOSIS

35. •GERD is diagnosed on basis of
history & clinical features
•An empiric trial of PPI therapy is a
widely used diagnostic test

36. GERD symptoms questionnaire
•Developed for infants and young children
•Individual symptom score calculated as the product
of symptom frequency and severity score
•Useful in distinguishing symptomatic GERD from
healthy children
Deal L et al JPGN 2005

37. INVESTIGATIONS FOR GERD
Goal Investigation
1-Documenting reflux
2-Documenting tissue
damage
3-Establishing GER as
etiology of episodic
symptoms
4-Documenting
Anatomical deficiency

1-24 hr pH monitoring
-Scintiscan
2-Endoscopy, Occult blood

in stool
3-pH monitoring
4-Barium study

38. DIFFERENTIALS
Esophageal motility disorders
Eosinophilic esophagitis
Crohn's disease

39. •Most quantitative and sensitive method
•Cumbersome & not easily available
•Used to correlate symptoms with reflux
episode
•Probe inserted acc to length calculated
by strobel’s formula {5+ 0.252x length in
cm}
•All medications discontinued 72hrs
before test
•Reflux episode: ph <4
•Reflux index : % of time when esophageal
ph is <4
•Mild- 5- 10%
•Moderate -10-20%
•Severe >20%
•Now wireless capsules are available
24 HOUR ESOPHAGEAL PH MONITORING

40. INDICATIONS FOR ESOPHAGEAL PH MONITORING
1.For assessing efficacy of
acid suppression during
treatment
2.Evaluating apneic episodes
in conjunction with a
pneumogram and perhaps
impedance
3.Evaluating atypical GERD
presentations such as
chronic cough, stridor,
and asthma

41. Performed in children with
vomiting and dysphagia
Evaluate for-
Achalasia
Esophageal Strictures
Stenosis
Hiatal Hernia
Gastric Outlet
Intestinal Obstruction
It has poor sensitivity and
specificity in the diagnosis of
GERD
CONTRAST RADIOGRAPHIC STUDY
(USUALLY BARIUM)

42. •In most of patients normal so
not useful for GERD
•To identify complications
like ulcers, strictures,
barrett’s esophagus
•Biopsies can be obtained for
early diagnosis of barrett’s &
cancers
•Biopsies can differentiate
other causes of esophagitis
like eosinophilic esophagitis
ENDOSCOPY

43. •Both for diagnosing GERD and for understanding
esophageal function
•Cumbersome test
•Multiple sensors and a distal ph sensor
•Document acidic reflux, weakly acidic reflux, and
weakly alkaline reflux
•An important tool in respiratory symptoms
•Determination of nonacid reflux
MULTICHANNEL INTRALUMINAL
IMPEDANCE (MII)

44. Evaluates for-
•Visible airway signs a/w extra esophageal
GERD
Posterior laryngeal inflammation
Vocal cord nodules
•Diagnosis of silent aspiration
•Evaluation for dysmotility
LARYNGOTRACHEOBRONCHOSCOPY

45. •Using of high-dose proton pump inhibitor (PPI)
•useful in adolescent and adults
•Diagnosis most of time clinical
•Response to treatment is considered as confirmed diagnosis
Pitfalls
•Does not include diagnostic tests
•Gastritis & peptic ulcers presents & responds similarly
•20% may have placebo effects
EMPIRICAL ANTIREFLUX THERAPY
(THERAPEUTIC TRIAL)

46. •Helpful in diagnosing delayed
gastric emptying
•Low radiation hazard
•Useful when fundoplication is

considered
NUCLEAR SCINITISCAN

47. ESOPHAGEAL MOTILITY TESTING
•RESEARCH TOOL
•USEFUL TO EVALUATE NON RESPONDERS
ESOPHAGEAL IMPEDENCE
USEFUL FOR NON ACID REFLUX AS DETECT LIQUID IN ESOPHAGEAL
LUMEN

48. GERD Investigations
•To establish a cause and effect relationship between
reflux and symptoms such as irritability, heart burn ,
coughing, choking etc.
•To exclude exacerbating causes such as gastric
emptying delay, anatomical abnormalities
•To document damage due to reflux and to exclude
associated conditions-esophageal strictures,
Barret,s esophagus etc.

49. Management of GERD

50. Treatment Goals of GERD

51. TREATMENT
•POSITIONING
•DIETARY MEASURES
•PHARMACOTHERAPY
•SURGERY

52. POSITIONING
•Head end elevation about 30
degree
•Left lateral positioning
•Prone positioning
•<1yr not recommended, can
be done in awake state as
during sleep risk of SIDS
outweigh the benefits
•Don’t use soft bed during
prone positioning

53. DIETARY MODIFICATIONS
•Small feed with increase in frequency
•Increase proportion of solids or semisolids
•Avoid spicy foods, tea, coffee, cola & late evening
meals alcohol & tobacco
•Avoid acid containing foods like citrus juices,
carbonated beverages, and tomato juices
•Chewing gum is useful as it increases production of
bicarbonate containing saliva & increases rate of
swallowing and promote acid clearance

54. PHARMACOTHERAPY
ACID REDUCING AGENTS
•H2 receptor antagonists
•Proton pump inhibitors
•Antacids
PROKINETICS
•Metaclopromide
•Bethanechol
•Erythromycin
•Baclofen
•Cisapride

55. Proton pump
Histamine
H+
K+
H+
K+,Cl- K+,Cl-
HCl
K+
H2 receptors
antagonists
Proton pump
inhibitors
Antacids
Mode of Action
Thus PPIs block the final step in gastric acid secretion.

56. ANTACIDS
•Good for symptomatic relief as are short acting
•Best to take app. 1 hr after meal or before symptoms of
reflux
•Calcium containing antacids should be avoided as promote
gastrin secretion
•Use antacids containing both aluminum & magnesium

57. HISTAMINE ANTAGONISTS
•Selective inhibition of histamine receptors on gastric parietal cells
•Best taken 30 minutes before meals as blood levels peaks when
stomach is producing acid actively
•Effects last for 6 hrs
•Used for uncomplicated GERD
•Tachyphylaxis or diminution of response after long term used
•CIMETIDINE 40mg/kg /day TID
•RANITIDINE 1-2 mg/kg /day BD
•FAMOTIDINE1 mg/kg day BID
•NIZATIDINE 10 mg/kg /day BID

58. PROTON PUMP INHIBITOR
•Shuts off acid production more completely and for
longer period of time
•Especially useful for complications or inadequate
response by histamine receptor antagonists
•Available as capsules containing enteric coated granules
that can be emptied in soft foods or liquids
•Should be taken30 minutes before meals for maximal
effect
•No PPI is approved for use in infants
•OMEPRAZOLE 0.3-3.5mg/kg /day BD
•LANSOPRAZOLE<10KG 7.5 MG OD, 10-30 KG 15 MGOD >30KG 30MG
OD[0.73-1.66mg/kg/day]
•PANTOPRAZOLE[0.5 -1 mg /kg/day]
•ESOMEPRAZOLE 1.0 mg/kg QD

59. PRO MOTILITY DRUGS
•Increase pressure in LES & strengthen peristalsis of esophagus ,
speeds up gastric emptying
•None affects the frequency of TLESRs
•Most effective when 30 min before meals
•Reserved for non responders or to enhance other treatments of
GERD
•METOCLOPROMIDE 0.4-0.8 mg/kg / day QID[5,10 MG,5MG/5ML] (dopamine-2 and 5-HT
3
antagonist)
•BETHANECHOL (cholinergic agonist)
•ERYTHROMYCIN (motilin receptor agonist)
•BACLOFEN (centrally acting γ-aminobutyric acid (GABA) agonist )
•CISAPRIDE 0.8 mg/ kg/day QID[1MG/ML,10 MG, 20MG](serotonergic agent)
•MOSAPRIDE 0.5-0.8 mg/kg/day QID

60. FOAM BARRIERS
•Composed of an antacid and a foaming agent
•Forms physical barrier to reflux
•Best taken after meals
•Available as magaldrate with alginate

61. SURGERY
•FUNDOPLICATION IS DONE
•USUALLY WHEN MEDICAL THERAPY FAILS
•DONE BY LAPAROSCOPY OR LAPAROTOMY
•COMPLICATION IS STICKING OF FOOD

62. ENDOSCOPIC TREATMENT
•SUTURING OF LES
•APPLICATION OF RADIOFREQUENCY WAVES
•INJECTION OF MATERIAL INTO WALLS

63. REASONABLE APPROACHES

65. Take Home Message
•A common childhood problem
•More common in select pediatric populations
•Diagnosis is essentially clinical , based on high
index of suspicion
•Trial of therapy is justified in patient with high
degree of suspicion
•Investigations required in individualized cases