Differentiating GER from GERD: To "D" or not to "D" Jenifer R. Lightdale, MD, MPH Gastroenterology and Nutrition Boston Children’s Hospital Harvard Medical.

Differentiating GER from GERD:To "D" or not to "D"

Jenifer R. Lightdale, MD, MPHGastroenterology and NutritionBoston Children’s HospitalHarvard Medical School

1

Children’s Hospital Boston

Prepared for your next patient.

TM

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Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics.

Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

AAP PCO Webinar Objectives Clarify terms related to reflux disease in children Review options for testing and treating reflux

disorders Discuss guidelines for appropriately managing

children with reflux disease

“As a result of participating in this webinar, attendees will be aware of a guideline based approach for identifying which patients will benefit from treatment for gastroesophgeal reflux disease (GERD), as well as which patients should be reassured their gastroesophgeal reflux (GER) is physiologic and not harmful.”

Practice Change

Jenifer R. Lightdale, MD, MPHo Pediatric Gastroenterologisto Children’s Hospital Boston o Endoscopyo Colic/fussy babieso Quality of care

Lay Reports on GERD in Infants Increased in past decade Describe inconsolable newborns who improved

dramatically on proton pump inhibitors (PPIs)o Discussed “colic” as poorly understood

Have contributed to 750% rise in use of PPIs in infantso 1999-2004

Evokes questions of previous misdiagnosis vs. current overuse

WSJ Provocative Health Reporting: “Even the terminology is confusing…most babies

have reflux [and] it usually doesn’t hurt…”

“GER becomes more-serious GERD if the infant won’t eat and stops gaining weight, vomits blood and is extremely irritable…”

GOOD NEWS! There is a pediatric global definition of GER vs. GERD

o To define reflux disease and its manifestations in infants, toddlers, children, and adolescents

A primary objective of the definition is to clarify terms related to reflux-related symptoms and signs in children

Sherman PM, Hassall E, Fagundes-Neto U, et al. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol. 2009;104(5):1278–1295

More Good News! There are Pediatric Gastroesophageal Reflux Clinical

Practice Guidelines o Endorsed by the North American and European Societies

for Pediatric Gastroenterology, Hepatology, and Nutritiono Basis of a 2013 Clinical Report from the American

Academy of Pediatrics (AAP) Intended to be used in daily practice of all

practitioners when evaluating and managing children with reflux disease

Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557. Lightdale JR, Gremse DA. Section on Gastroenterology, Hepatology and Nutrition. Gastroenterology Reflux: Management Guidance for the Pediatriatrician. Pediatrics. 2013: 131(5): e1684-1695.

Global consensus especially useful because physiologic GER is now recognized to be relatively common in babies and kids…

(Mean upper limit of normal)Infants(N=509)

Children(N=48)

Adults(N=432)

# daily reflux episodes 73 25 45

# reflux episodes lasting > 5 min 9.7 6.8 3.2

Reflux index (% of time pH < 4)* *over approx 24 hours 11.7% 5.4% 6%

Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(supplement 2):S1–S31

Clarification via Global Consensus GERD is defined to be present when reflux of gastric contents

causes either troublesome symptoms or complications

Troublesome symptoms or complications of reflux

• Recurrent vomiting andpoor weight gain in infant

• Recurrent vomiting andirritability in infant

• Recurrent vomiting inolder child

• Heartburn in child/adolescent

• Esophagitis

• Dysphagia or feeding refusal

• Apnea or ALTE• Asthma• Recurrent pneumonia• Upper airway symptoms • Unusual arching or

seizure-like movements (Sandifer syndrome)

Example of Sandifer Syndrome

Photos courtesy of Harland Winter, MD.Werlin SL, D'Souza BJ, Hogan WJ, et al. Sandifer syndrome: an unappreciated clinical entity. Dev Med Child Neurol. 1980;22(3):374–378

What about complications of GERD?

e.g. Is there a danger to not recognizing and treating it?

Complications of Reflux

Normal mid- anddistal esophagus

Erosive esophagitis:grade 2 and grade 4

Z-line

Erosions

Esophageal stricturesecondary to GERD:radiography andendoscopy

Barrett’s esophagus:endoscopy and histology

Normal

Barrett’s

Barrett’sNormal

Stricture

Complications of Reflux

Endoscopic Biopsies Useful to evaluate for a variety conditions, but are

not required for diagnosis of GERD Possible findings on biopsy:

o Gastroesophageal refluxo Food allergy or intoleranceo Primary eosinophilic esophagitiso Drug inducedo Infection

• Candida• Herpes simplex• Cytomegalovirus

Pathologic esophagitis

NormalEH, epithelial height; PL, papillary layer; BL, basal layerNormal: PL ~ 40% of epithelial height; BL ~ 15%GERD: PL ~ 90% of epithelial height; BL ~ 30%

PLPL

BLBL

EH

EH

Esophagitis

Peptic esophagitis Eosinophilic esophagitisNormal esophagus

Eosinophilic Esophagitis

Clinical Cases• 5 month old who effortlessly spits-up 6–10x/day, but

seems comfortable and is growing well

• 4 month old who is losing weight is reported to vomit 2–3x/day, and seems increasingly fussy with feeds

• 15 year old who presents complaining of heartburn

So What is GER??? And What is GERD??? Understanding the difference

o May help to avoid overclassifying patients with GERD vs. physiologic GER

o May avoid overtesting o May avoid overtreatmento May help identify when to refer patients to specialists

GER Gastroesophageal Reflux

o The passage of gastric contents into the esophaguso Occurs with/without regurgitation and vomiting

GER is a normal physiologic process o Several times/day in healthy infants, children, and adults

Most Episodes of GER

Last < 3 minutes Occur in the postprandial period Cause few or no symptoms GER can cause vomiting

o A coordinated autonomic and voluntary motor response with forceful expulsion of gastric contents

Regurgitation (“spitting up”) is the most visible symptom of GERo Occurs daily in 50% of infants < 3 months of ageo Resolves spontaneously in most by 12–14 months

Prevalence of Regurgitation in Infancy

0

10

20

30

40

50

60

70

0-3 4-6 7-9 10-12

Age (months)% of

Infants

1 time a day

4 times a day

Adapted from Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997;151(6):569–572

n=948

Physiology of GER GER occurs during transient relaxations of the lower

esophageal sphincter (LES)o Relaxation of the LES that is unaccompanied by

swallowing permits gastric contents into the esophagus

LES is not a “true” sphinctero Comprised of crural support, an intra abdominal segment, ‑

and the “angle of His”

Composition of the LES

• Healthy adult – LES 3cm in length, at level of diaphragm

• Neonate – LES 1.5cm in length, above the diaphragm

Adult

Esophageal Capacity

• Shorter esophagus• Smaller capacity

GravityInfant

WHEN DOES GER “become” GERD Aberrance in normal physiology

o Insufficient clearance and buffering of refluxateo Decreased rate of gastric emptyingo Abnormalities in efficacy of epithelial repairo Decreased neural protective reflexes

Development of erosive esophagitis causes esophageal shorteningo May result in hiatal herniation

Esophagitis can cause shortening of the stomach, leading to hiatal hernia.

© Copyright 2003 New England Minimally Invasive Surgeons

Genetics of Reflux Cluster studies suggest inheritability of GER/GERD

and their complicationso Hiatal herniao Erosive esophagitiso Barrett’s esophaguso Esophageal adenocarcinoma

Swedish Twin Registry o Increased concordance in monozygotic vs. dizygotic

Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

High Risk Populations Several pediatric patient populations appear to be at

higher risk of GERDo Neurologically impairedo Obese infants, children, and adolescentso Certain genetic syndromeso Esophageal atresiao Chronic lung diseases o History of prematurity


Testing for Reflux Disorders No one test can be used to diagnose reflux, and

instead must be matched to a clinical question Reflux tests are useful

o To document the presence of GER(D)o To detect complications o To establish a causal relationship between GER and

symptomso To evaluate therapy o To exclude other conditions


Diagnostic Approach• Depends on symptoms and signs

• History and physical examination

• Upper gastrointestinal (GI) series

• Esophageal pH monitoring

• Esophagogastroduodenoscopy and biopsy

• Empirical medical therapy

Upper GI Radiography

• Cannot discriminate between physiologic and nonphysiologic GER episodes

Limitation

• Useful for detecting anatomic abnormalities

Advantage

Pyloric stenosis Malrotation

Esophagogastroduodenoscopy (EGD)

• Need for sedation or anesthesia• Endoscopic grading systems not yet

validated for pediatrics• Poor correlation between endoscopic

appearance and histopathology• Generally not useful for extra-esophageal

GERD

Limitations

• Enables visualization and biopsy of esophageal epithelium

• Determines presence of esophagitis, other complications

• Discriminates between reflux and non-reflux esophagitis

Advantages

Esophageal pH Monitoring

• Cannot detect nonacidic reflux• Cannot detect GER complications

associated with “normal” range of GER• Not useful in detecting association

between GER and apnea unless combined with other techniques

Limitations

• Detects episodes of reflux• Determines temporal association

between acid GER and symptoms

Advantages

Multiple Intraluminal Electrical Impedance Measurement

Advantages• Detects nonacidic GER episodes• Detects brief (< 15 s) acidic GER episodes• Useful for studying respiratory symptoms

and GER in infants

Limitations• Normal values in pediatric age groups not

yet defined• Analysis of tracings time-consuming• Portable device unavailable for outpatient

studies

pH channel

pH 4

Impedancechannels

Z 1

Z 4

Pediatric Catheter

Infant Catheter

pH Sensors

Impedance Sensors

Non-AcidReflux

History and Physical Exam Symptoms and signs associated with GER are non-

specifico i.e. Not all children with GER have heartburn or irritabilityo Conversely, heartburn and irritability can be caused by

conditions other than GER

Major roles of History/Physical Exam when evaluating GERDo To exclude other worrisome disorders that present with

vomitingo To recognize complications of GERD

Symptoms and Signs of GER/GERD

Symptoms• Recurrent regurgitation

with/without vomiting• Weight loss or poor weight gain• Irritability in infants• Heartburn or chest pain• Hematemesis• Dysphagia, Odynophagia, Feeding

refusal• Apnea spells • Wheezing• Stridor• Cough• Hoarseness• Dystonic neck posturing (Sandifer

syndrome)

Signs• Esophagitis• Esophageal stricture• Barrett Esophagus• Laryngeal/pharyngeal inflammation• Recurrent pneumonia• Anemia• Dental erosion

Indications for Further Evaluation in Infants With Vomiting • Bilious vomiting• GI bleeding

– Hematemesis– Hematochezia

• Consistently forceful vomiting

• Onset of vomiting after 6 months of life

• Severe failure to thrive• Diarrhea• Constipation• Fever

• Lethargy • Hepatosplenomegaly• Bulging fontanelle• Macro/microcephaly• Seizures• Abdominal tenderness or

distension• Documented or suspected

genetic/metabolic syndrome• Associated chronic disease

Differential Diagnosis of Vomiting in Infants and Children – GI

Gastrointestinal obstruction• Pyloric stenosis• Malrotation with

intermittent volvulus• Intestinal duplication• Hirschsprung disease• Antral/duodenal web• Foreign body• Incarcerated hernia

Other GI disorders• Achalasia• Gastroparesis• Gastroenteritis• Peptic ulcer• Eosinophilic

esophagitis/gastroenteritis• Food allergy• Inflammatory bowel disease• Pancreatitis• Appendicitis

Differential Diagnosis of Vomiting in Infants and Children – Non-GINeurologic• Hydrocephalus• Subdural

hematoma• Intracranial

hemorrhage• Intracranial mass• Infant migraine Infectious• Sepsis• Meningitis• Urinary tract

infection • Pneumonia• Otitis media• Hepatitis

Metabolic/endocrine• Galactosemia• Hereditary fructose

intolerance• Urea cycle defects• Amino and organic

acidemias• Congenital adrenal

hyperplasia

Renal• Obstructive uropathy• Renal insufficiency

Toxic• Lead• Iron• Vitamin A and D• Medications: ipecac,

digoxin, theophylline, etc.

Cardiac• Congestive heart failure• Vascular ring

Psychiatric• Munchausen syndrome

by proxy• Child neglect or abuse• Self induced vomiting

Important to Obtain a Feeding and Vomiting HistoryFeeding and dietary history• Amount/frequency

(overfeeding)• Preparation of formula• Recent changes in feeding

type or technique• Position during feeding• Burping• Behavior during feeding:

choking, gagging, cough, arching, discomfort, refusal

Pattern of vomiting• Frequency/amount• Pain• Forceful or not• Blood or bile• Associated fever, lethargy,

diarrhea

Other Histories in the Infant/Child With Suspected GERDPast medical history• Prematurity• Growth and development • Past surgery and

hospitalizations• Newborn screen results• Recurrent illnesses

(croup, pneumonia, asthma)

• Symptoms of hoarseness, fussiness, hiccups

• Apnea• Previous weight and

height gain

Medications• Current vs. Recent• Prescription• Non-prescription

Family psycho-social history

• Sources of stress• Maternal or paternal

drug use• Post partum depression

Family medical history• Significant illnesses• Family history of GI

disorders• Family history of

atopy

Growth chart• Height• Weight• Head circumference

History/Physical Examination Severity of reflux or esophagitis found on diagnostic

testing does not directly correlate with symptom severity

In infants and toddlers, there is no symptom or group

of symptoms that can reliably diagnose GERD or predict treatment response

In older children and adolescents, history and

physical examination are generally sufficient to reliably diagnose GERD and initiate management


For Infants For Older Children

Conservative Therapy for GER

• Avoid large meals

• Do not lie down immediately after eating

• Lose weight, if obese

• Avoid caffeine, chocolate, and spicy foods that provoke symptoms

• Eliminate exposure to tobacco smoke

• Normalize feeding volumeand frequency

• Consider thickened formula

• Consider non-prone positioning during sleep

• Consider trial of hypoallergenic formula

Treating physiologic GER in infants Once the diagnosis of GER is established

o Parental education, reassurance, and anticipatory guidance are recommended

o Dietary changes and thickening of formula can be considered

In general no other intervention is necessary

If symptoms worsen or do not resolve by 12 to 18 months of age or “warning signs” develop, referral to a pediatric gastroenterologist is recommended


Treatment of GER in infants Evidence supports

o 2–4 week trial of an extensive protein hydrolysate in formula fed infants with vomiting

o Thickening of formula which may decrease visible reflux (regurgitation)

o Supine position for sleeping

If no improvement, referral to a pediatric gastroenterologist may be appropriate


Effect of Thickening Milk Formula Feedings With Rice Cereal

0.0

0.5

1.0

Adapted from Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr. 1987;110(2):181–186

Caloric Density(cal/cc)

Emesis(episodes/90 min)

Sleep Time(min asleep/90 min)

Crying Time(min crying/90 min)

Unthickened Thickened

p=.015 p=.026 p=.042

0

1

2

3

4

5

0

10

20

30

40

50

0

5

10

15

20

25

n=20

Thickened formula

Unthickened formula

0

200

400

600

800

44.555.566.5pH

Vis

cosi

ty (

cps)

Pre-thickened Formulas Change Viscosity With Acidification

Unthickenedformula

Enfamil AR

Formula + rice cereal

Reprinted with permission from Mead Johnson Nutrition

Positioning and GER

Sitting

Supine

Prone

60°

Adapted from Ramenofsky ML, Leape LL. Continuous upper esophageal pH monitoring in infants and children with gastroesophageal reflux, pneumonia, and apneic spells. J Pediatr Surg. 1981;16(3):374–378

Effect of Sleep Position on GER in Infants and Sudden Infant Death Syndrome (SIDS) Mortality

Reflux Index1

(% time pH <4)

Supine 15.3 0.05* 2.3 1.0

Left side 7.7 0.05* 1.1 3.5†

Right side 12.0 0.05* 1.8 3.5†

Prone 6.7 4.4 1.0 13.9

*Mortality rate for all non-prone positions combined†Combined odds ratio 1 Tobin JM, McCloud P, Cameron DJ. Posture and gastro-oesophageal reflux: a case for left lateral positioning. Arch Dis Child. 1997;76(3):254–3582 Skadberg BT, Morild I, Markestad T. Abandoning prone sleeping: Effect on the risk of sudden infant death syndrome. J Pediatr. 1998;132(2):340–3433 Oyen N, Markestad T, Skaerven R, et al. Combined effects of sleeping position and prenatal risk factors in sudden infant death syndrome: the Nordic Epidemiological SIDS Study. Pediatrics. 1997;100(4):613–621

SIDS Mortality2

(per 1000 live births)Reflux IndexOdds Ratio

SIDS MortalityOdds Ratio3

Positioning Therapy for GERD

• Non-prone positioning during sleep is recommended– Supine positioning confers lowest risk

for SIDS and is preferred

• Prone positioning may be considered in cases where risk of death from GER complications outweighs potential increased risk of SIDS

• If prone positioning is recommended, discuss rationale with parents

• Avoid soft bedding, pillows, loose sheets near infant

• Left side positioning during sleep may be beneficial

• Elevate head of bed

• Avoid lying down immediately after eating

For Infants For Older Children

American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3 Pt 1):650–656; Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(supplement 2):S1–S31

Treatment of GERD in Older Children A left sided sleeping position with elevation of the

head of the bed may decrease symptoms and GER

In adults, obesity and late night eating are associated with increased refluxo To date, no evidence to support specific dietary

restrictions to decrease symptoms of GER in pediatric populations

Appropriate to trial acid suppression

Goals of Pharmacotherapy • Control symptoms

• Promote healing

• Prevent complications

• Improve health-related quality of life

• Avoid adverse effects of treatment

Medical Treatment of GERD Both Histamine-2 receptor antagonists (H2RAs) and

PPIs o Produce relief of symptoms and mucosal healing of GERD o Are superior to buffering agents, alginates, and sucralfate

PPIs are superior to H2RAs in relieving symptoms and healing esophagitis.

Potential side effects of each currently available prokinetic agent outweigh the potential benefitso No evidence for routine use of metoclopramide,

erythromycin, bethanechol, or domperidone for GERDVandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroesophageal Nutr. 2009;49(4):548–557

Inhibition of Acid Secretion in Gastric Parietal Cell

Copyright 1996 by Excerpta Medica Inc.Adapted from Sanders SW. Pathogenesis and treatment of acid peptic disorders: comparison of proton pump inhibitors with other antiulcer agents. Clin Ther. 1996;18(1):2–34

Effect of H2RAs on Healing of Esophagitis

Cucchiara S, Gobio-Casali L, Balli F, et al. Cimetidine treatment of reflux esophagitis in children: an Italian multicentric study. J Pediatr Gastroenterol Nutr. 1989;8(2):150–156

N = 32 children with esophagitis treated with cimetidine 30-40 mg/kg/d or placebo for 12 weeks

Cimetidine

Placebo 20%

Significant symptom improvement with cimetidine, not placebo

Simeone D, Caria MC, Miele E, et al. Treatment of childhood peptic esophagitis: a double-blind placebo-controlled trial of nizatidine. J Pediatr Gastroenterol Nutr. 1997;25(1):51–55

N = 26 children with esophagitis treated with nizatidine 10 mg/kg/d or placebo for 8 weeks

Nizatidine

Placebo

Esophagitis Healing

Esophagitis Healing

15%

71%

69%

“Vomiting” reduced in both treatment arms; significant improvement in other GERD symptoms only with nizatidine

Proton Pump Inhibition

Copyright 1996 by Excerpta Medica Inc.Adapted from Sanders SW. Pathogenesis and treatment of acid peptic disorders: comparison of proton pump inhibitors with other antiulcer agents. Clin Ther. 1996;18(1):2–34

PPIs in Adults With GERD • Most potent inhibitors of acid secretion• Both pharmacolic and numerous randomized

controlled trials– Superior to H2RAs in relieving reflux symptoms and

healing esophagitis– Effective in patients unresponsive to high-dose H2RA– Superior to H2RAs in maintaining remission of

esophagitis

• Demonstrated safety in patients treated for 1.4 to 11.2 years (N=230 patients)

PPIs in Infants and Children With GERD • Pharmacologic studies with omeprazole and

lansoprazole

• No randomized placebo-controlled trials have demonstrated improvement of GERD in children

Case Series of Esophagitis Patients Treated With Omeprazole

Authors N Results

Gunasekaran, et al, 1993 15 children < 3.3 mg/kg/day x 12.2 mo (mean)

Symptoms and endoscopic assessment improved in all

De Giacomo, et al, 1997 10 children20 or 40 mg QD x 3 mo

Clinical, endoscopic, and pH improvements in all; no changein biopsy findings

Alliet, et al, 1998 12 infants0.5 mg/kg/day x 6 wk

Endoscopic and histologic improvement or resolution in all

Strauss, et al, 1999 18 children0.3-1.4 mg/kg/day x 8–12 wk

13/17 asymptomatic

Hassall, et al, 2000 57 children0.7-3.5 mg/kg/day x 3 mo

Esophagitis healed in 54/57; symptomatic improvement in 93%

Effect of Omeprazole on Esophagitis

Hassall E, Israel D, Shepherd R, et al. Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter study of efficacy, safety, tolerability and dose requirements. International Pediatric Omeprazole Study Group. J Pediatr. 2000;137(6):800–807

N = 65 children with erosive esophagitis

% of Patients

100

80

60

40

20

0Healed with

< 3.5 mg/kg/day

95%

72%

44%

Healed with< 1.4 mg/kg/day

Healed with0.7 mg/kg/day

Optimal Timing of PPI Dose

Single PPI dose:

Administer half-hourbefore breakfast

If second PPI dose:

Administer half-hourbefore evening meal

Available Prokinetic Agents Are Unproven or Ineffective• Cisapride: withdrawn• Bethanechol: only 1 randomized controlled trial (RCT)• Erythromycin: no RCT• Domperidone: available in Canada, no RCT• Metoclopramide:

– Esophageal pH improvement in 1 of 6 RCT– Clinical improvement in 1 of 4 RCT– High incidence (~30% prevalence) of adverse events


Increasing Concern about Safety of ProkineticsProkinetic Adverse Events

Bethanechol Malaise, abdominal cramps, colicky, pain, nausea and belching, diarrhea, urinary urgency; contraindicated in

hyperthyroidism, bronchial asthma, and otherconditions

Domperidone Hyperprolactinemia, dry mouth, rash, headache,diarrhea, nervousness

Erythromycin Abdominal pain, nausea, vomiting, diarrhea, pyloricstenosis

Metoclopramide Restlessness, drowsiness, fatigue and lassitude(10%); insomnia, headache, confusion, dizziness,mental depression; extrapyramidal reactions includingparkinsonian-like symptoms, tardive dyskinesia, andmotor restlessness; galactorrhea, gynecomastia,cardiovascular effects, nausea, diarrhea

Prescribing Information for Reglan® and Urecholine®; Curry JI, Lander TD, Stringer MD. Erythromycin as a prokinetic agent in infants and children. Aliment Pharmacol Ther 2001;15(5):595–603; Ramirez B, Richter JE. Review article: promotility drugs in the treatment of gastro-oesophageal reflux disease Aliment Pharmacol Ther. 1993;7(1):5–20

Treatment of GERD in Older Children Lifestyle changes with a 4-week PPI trial are

recommended.

If symptoms resolve, continue PPI for 3 months

If symptoms persist or recur after treatment, child should be referred to a pediatric gastroenterologist

Conclusions It is important to clarify whether a pediatric patient

has physiologic GER or pathologic GERD There are guidelines for appropriate testing and

treating of children with reflux disease…o Also useful for deciding when to refer to subspecialists

Recommended Approach to the Infant With Recurrent Regurgitation and Vomiting


Recommended Approach to the Infant With Recurrent Regurgitation and Weight Loss


Recommended Approach to the Older Child or Adolescent With Heartburn


THANK YOU!

Acknowledgements• AAP• EQIPP Staff and Co-Faculty• NASPGHAN• NASPGHAN Foundation

(CDHNF)

ReferencesLightdale JR, Gremse DA. Section on Gastroenterology, Hepatology and Nutrition. Gastroenterology Reflux: Management Guidance for the Pediatriatrician. Pediatrics. 2013;131(5):e1684–1695

Sherman PM, Hassall E, Fagundes-Neto U, Gold BD, Kato S, Koletzko S, Orenstein S, Rudolph C, Vakil N, Vandenplas Y. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol. 2009;104(5):1278–1295

Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr. 2008;152:310–314

Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 2000;154:150–154

Vandenplas Y, Rudolph C, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenz T. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). J Ped Gastr Nutr. 2009;49:548–557

TM

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Differentiating GER from GERD: To "D" or not to "D" Jenifer R. Lightdale, MD, MPH Gastroenterology and Nutrition Boston Children’s Hospital Harvard Medical.

Documents

reflux disease slide

reflux disorders

irritable slide

gastroesophgeal reflux

refluxrelated symptoms

practice change slide

current overuse slide

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