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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