Pediatric Gastroesophageal Reflux
Transcript of Pediatric Gastroesophageal Reflux
Objectives
● Learn pathophysiology of reflux in pediatric patients
● Understand factors that improve or worsen reflux
● Expand on differential diagnosis and mimickers
● Determine which diagnostic modalities help with diagnosis
● Current treatment recommendations
GER in Pediatrics
● Spitting up - effortless passage of
gastric contents into pharynx or mouth
● Vomiting - forceful expulsion
● Rumination - voluntary, habitual, and
effortless regurgitation of recently
ingested food then either expulsed or
re-swallowed
Gastroesophageal Reflux
Disease (GERD)
● GER complications present○ Significant irritability
○ Feeding difficulties
○ Poor weight gain
● Risk factors
○ Hiatal hernia
○ Neuromuscular disease
○ Prematurity
○ Hx esophageal atresia,
achalasia, or esophageal
dysmotility
Gastroesophageal Reflux (GER)
● “Spitting up”,
“Regurgitation”
● Passage of stomach
contents up into esophagus
GER in Infants
● Normal physiologic process (at least 1/d)
● < 3 months ~50%
● Worst at 4 months old ~67%
● At 7 mo 20%, at 12 mo ~5% or less
Confounding factors:
● Starting infant foods
● More time upright and sitting
● Decreased number of lower esophageal (LES) relaxations
GER in Infants
Pathophysiology
● Transient lower esophageal sphincter relaxations (TLESR)
○ Postprandial period → gastric distension → inc intragastric pressure
● Large volume feeds and delayed gastric emptying worsen distension
GER in Infants
Anti-Reflux Barrier:
● Diaphragmatic crural
support
● Intra-abdominal
segment of
esophagus
● Angle of His
Sliding hiatal hernia
compromises barrier
GERD in Infants
● Effortless regurgitation
and spitting up most
common presentation
● “Happy spitters”
● GERD less common
● Rare extraintestinal signs
GERD in Infants
Sandifer Syndrome
● Dystonic spasmodic movement with
head, neck, and back posturing
● ?? Shared innervation of diaphragm
and head/neck muscles causing
reflex contraction
● ?? Symptomatic relief due to
improved esophageal motility
● Uncommon
GERD in Infants
Brief Resolved Unexplained Events (BRUEs)
● Data to support association with BRUEs are limited
● ~15% of 527 apneic episodes were temporally linked with reflux
○ Prospective study - pneumogram + impedance pH study
● There can be temporal relation from history and observation
○ Close proximity to feed, infant was awake, obstructive apnea
● ?? Exaggeration of normal protective reflexes
GERD in Children
● Reflux/heartburn in ~2% of 3-
9 yo, 5-8% in 10-17 yo
● Association between GER
and asthma
● PNA not often from
aspiration of refluxed
content, but possible abn
swallow
● Constipation → cologastric
brake causing delayed gastric
emptying
GERD in Children: Warning Signs
● Concerning signs warrant evaluation● Reassurance for uncomplicated reflux● Referral to peds GI if symptoms persist
beyond 12 - 18 mo
Non-reflux causes of vomiting
Infections● Sepsis● Meningitis● Gastroenteritis● UTI● Otitis Media
Anatomic/Obstructive● Foreign body● Pyloric stenosis● Malrotation● Intussusception● SMA syndrome
Psych/Behavioral
Cardiac● CHF
Neurologic● Increased ICP● Migraine
Respiratory● Posttussive emesis● Pneumonia
Renal● Obstructive● Renal insufficiency
Onc● Lymphoma
Drugs and alcohol
Pregnancy
GI● Esophagitis
○ EOE○ Pill○ Infectious
● Achalasia● Gastritis
○ PUD○ H. pylori
● Gastroparesis● Cholelithiasis● Hepatitis● Pancreatitis● Celiac● Crohn disease● Eosinophilic GI
disease
Diagnosis and Evaluation
History
● Inquire about the nature of vomiting○ Bile or Blood?○ Forceful or projectile?○ Systemic symptoms - irritable fever, lethargy?
● Feeding history○ Volume and frequency○ Type of formula and how prepared○ Positioning during and after feeds
● Dysphagia symptoms○ Eating slowly○ Cutting food into small pieces, avoiding particular foods
Diagnosis and Evaluation
History
● PMH○ Prematurity○ Neurologic problems○ Growth or developmental concerns○ Past surgeries or hospitalizations○ Allergies
● ROS○ Respiratory or ENT symptoms
● Fam Hx○ GI diseases including GERD○ Atopic disease
Physical Exam
● General appearance● Weight and length● Pulmonary and cardiac ● Abd -- distention, tenderness,
bowel sounds, HSM● Neurologic assessment
Diagnosis and Evaluation
Upper GI Study
● Poor sensitivity, specificity, and PPV
● Evaluate anatomy○ Hiatal hernia○ Malrotation○ Stenosis○ Esophageal web or stricture○ Annular pancreas○ Tracheoesophageal fistula○ Vascular rings○ Achalasia○ Gastric outlet obstruction
Diagnosis and Evaluation
Esophageal Manometry
● Assessing esophageal peristalsis and upper esophageal sphincter and LES pressures
● Useful for esophageal motility disorder
● Not used to dx GERD
Diagnosis and Evaluation
Scintigraphy
● “Gastric emptying scan”● Uses formula/food labeled with
99technetium● May ID esophageal reflux and
aspiration, but poor sensitivity and specificity for GERD compared to pH monitoring
Diagnosis and Evaluation
24-hr impedance pH study
● Frequency of reflux episodes● Acid vs non-acid reflux● Extent (to proximal esophagus)● Correlation with symptoms
GER - drop in impedance progression distally to proximally as liquid advances from stomach to esophagus
pH probe to determine pH < 4.0, number of episodes, duration, symptom index
Diagnosis and Evaluation
Endoscopy with Biopsy
● Direct visual inspection and histologic examination
● Evaluate for diseases that mimic reflux and may be recommended for refractory or recurring GERD
Treatment and Management
Lifestyle Modifications (Infants)
● Smaller more frequent feeds● Inc caloric density with dec vol● Frequent burping● Keeping upright after feeds● Avoiding vigorous handling● Elevating HOB when sleeping● Avoid tobacco smoke exposure
** Inc SIDs while prone** Car seat inc intraabdominal pressure
Treatment and Management
Thickeners
● Decreased number of regurgitation and vomiting episodes
● pH monitoring showed no change in reflux index (episodes of acid reflux per hour → 0.6/d)
● Rice cereal inc caloric density○ Requires faster flow nipple
● Avoid xanthum gum-based thickeners in < 1 yo due to association with NEC
Treatment and Management
Formula Change
● Higher whey? Whey empties faster from stomach than casein
● If suspect cow-milk protein allergy, can trial casein hydrosylate or AA formula for 2 wk
Treatment and Management
Lifestyle Modification (Older Children)
● Elevated HOB● Avoid caffeine, chocolate, peppermint, and spicy foods● Fat can slow gastric emptying● Eat smaller portions● Avoid tobacco and alcohol (dec LES pressure)
Treatment and Management
Histamine-2 Receptor Antagonists (H2RAs)● Dec acid secretion by inhibiting H2
receptor on gastric parietal cell● Onset in 30 mins, peak 2.5 hrs● First-line therapy → famotidine (Pepcid)● Tachyphylaxis with chronic use
Proton Pump Inhibitors (PPI)● Suppress acid production by inhibiting the
H+/K+ ATPase on gastric parietal cell● Onset 1-2 hr, peak in several days● High rates of healing erosive/ulcerative
esophagitis● AE: HA, n/d, abd pain
If symptoms improve, wean after 4-8 weeks
Treatment and Management
Prokinetic Agents● Improve GER by stimulating more rapid
emptying of the stomach● AE (Metoclopramide): dystonic reactions,
lethargy, irritability, gynecomastia, permanent tardive dyskinesia
● AE (Erythromycin): prolonged QT interval
** Current guidelines do not recommend the use of prokinetic agents for GERD
Treatment and Management
Surface Agents● Sucralfate (sucrose, sulfate, aluminum)
when exposed to acidic pH, forms a gel that binds to eroded mucosa
● AE: Al3+ toxicity or gastric bezoar
Antacids● Acts within minutes to buffer gastric acid● Should be used after meals● AE: elevated Al3+ can cause osteopenia,
rickets, microcytic anemia, neurotoxicity
Treatment and Management
Fundoplication● Inc the LES pressure and inc the
intraabdominal length of the esophagus● Post-op complications
○ Gas-bloat syndrome○ Dysphagia/Retching○ Dumping syndrome
● 10% complications, 10% need revision● 75% restart anti-reflux medications● Consider for severe refractory or life-
threatening complications of GERD
Questions
A 2-month-old boy is brought to the clinic by his parents because of persistent vomiting for the past 2 weeks. The mother thinks that the child might be vomiting green occasionally. The child has not had significant weight gain since the last time you saw him at 2 weeks of age. On physical examination, he is less than the 5th percentile for weight. You are concerned that the child may have some underlying anatomic condition. Which of the following is the most appropriate next step in diagnosis in this patient?
A. 24-hour impedance pH study test.B. Surgery consultation.C. Ultrasonography of the abdomen.D. Upper gastrointestinal series.E. Radiography of the abdomen.
Questions
A 2-month-old boy is brought to the clinic by his parents because of persistent vomiting for the past 2 weeks. The mother thinks that the child might be vomiting green occasionally. The child has not had significant weight gain since the last time you saw him at 2 weeks of age. On physical examination, he is less than the 5th percentile for weight. You are concerned that the child may have some underlying anatomic condition. Which of the following is the most appropriate next step in diagnosis in this patient?
A. 24-hour impedance pH study test.B. Surgery consultation.C. Ultrasonography of the abdomen.D. Upper gastrointestinal series.E. Radiography of the abdomen.
Questions
You are seeing a 3-month-old boy in your clinic. The mother reports that he has been
“vomiting with every feed” and she is concerned that he is “not keeping down anything.” He
is taking a regular cow milk–based formula. On physical examination, he is an alert, active
infant with stable and normal vital signs. The infant is growing well and has been at the 75th
percentile for height and weight on the growth curve. The remainder of the physical
examination findings is unremarkable. Which of the following is the most appropriate next
step in management for this patient?
A. Follow-up in 1 week for weight check.
B. Prescribe acid suppressants.
C. Pyloric ultrasonography.
D. Reflux precautions.
E. Switch to an elemental formula.
Questions
You are seeing a 3-month-old boy in your clinic. The mother reports that he has been
“vomiting with every feed” and she is concerned that he is “not keeping down anything.” He
is taking a regular cow milk–based formula. On physical examination, he is an alert, active
infant with stable and normal vital signs. The infant is growing well and has been at the 75th
percentile for height and weight on the growth curve. The remainder of the physical
examination findings is unremarkable. Which of the following is the most appropriate next
step in management for this patient?
A. Follow-up in 1 week for weight check.
B. Prescribe acid suppressants.
C. Pyloric ultrasonography.
D. Reflux precautions.
E. Switch to an elemental formula.
Summary
● Physiologic reflux should resolve by 12 mo
● Red flags or persistence beyond 12 mo old warrants workup
● UGI should not be ordered as dx test for reflux
● Impedance + pH probe can dx acid vs non-acid reflux
● H2RA or PPI are generally effective medications
● Fundoplication reserved for refractory symptoms, but risk of complications
References
Adamiak, T. and Plati, K. Pediatric Esophageal Disorders: Diagnosis and
Treatment of Reflux and Eosinophilic Esophagitis. Pediatrics in Review. 2018;
39; 392. http://pedsinreview.aappublications.org/content/39/8/392
Sullivan, J. and Sundaram, S. Gastroesophageal Reflux. Pediatrics in Review.
2012; 33; 243. http://pedsinreview.aappublications.org/content/33/6/243