Mary Abigail Garcia, MD
Susan Chang, (MD in 2008)
Robert Karp, MD
Department of Pediatrics
SUNY-Downstate Medical Center
Pre-Test:
Q1. T or F: Most infants with GERD suffer inadequate growth.
Q2. Best answer. Which of the following answer choices is true of GERD?
A) reported in about 50% of healthy infants
B) is a functional/physiologic process with no underlying abnormalities
C) prevalence peaks at 4-6 months of age
D) is usually a self-limited process
E) all of the above
Q3. T or F. Wheezing can be a sign of Gastroesophageal Reflux Disease (GERD).
Q4. T or F. All children with recurrent vomiting should be sent referred to a pediatric gastroenterologist.
Q5. The first step in a diagnostic work-up for a patient suspected of having GERD is?
A) Barium Swallow
B) Esophageal pH monitoring
C) Diet History
D) Complete history and physical
Q6. The first step in treatment of GERD in infants is?
A) omeprazole
B) cimetidine
C) thickened feedings
D) change in formula to soy based formula
Q7. T or F. GERD presents the same way in infants, children, and adolescents.
Objectives:
On completion of this module, physicians and residents will be able to:
1. Appreciate the pathophysiology of gastroesophageal reflux (GER)
2. Distinguish GER from gastroesophageal reflux disease (GERD)
3. Identify the nutritional consequences of GER and GERD
4. Develop a diagnostic approach to a child suspected of having GER or GERD
5. Apply treatment methods to children with GER and GERD, and
6. Know when to refer a child to a Pediatric Gastrointestinal specialist for further treatment.
Facilitator Preparation:
The facilitator should review the following:
1. Orenstein SR. Gastroesophageal reflux. Pediatric Rev 1999; 20:S120-4
2. Jung AD. Gastroesophageal Reflux in Infants and Children. American Family Physician 2001; 64 (11):1853-1860.
3. Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, Gerson WT, Werlin SL; North American Society for Pediatric Gastroenterology and Nutrition. 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 Suppl 2:S1-31.
Introduction:
Gastroesophageal reflux (GER) is a movement of gastric contents from the stomach back through the lower esophageal sphincter into the esophagus. This is a normal, physiologic process in infants that should resolve by 12 months of age (Nelson SP et al., 1998). However, it can become pathological and defined as Gastroesophageal reflux disease (GERD) when reflux is recurrent and there is poor weight gain, weight loss, and symptoms of esophagitis. In 1935, Winkelstein first described peptic esophagitis in adults, but it wasn't until 1950 that GERD was first described in children (Koufman JA, 2002). Nutritional consequences of GERD include failure to thrive and malnutrition because of not having sufficient calories and/or nutrients for proper growth. Any child with suspected GERD should have a complete history and physical (including diet history) and a referral to a pediatric gastroenterologist as needed for diagnostic studies (barium swallow, esophageal pH monitoring, endoscopy and biopsy, and/or scintigraphy). Treatment for GERD includes changes in diet, lifestyle changes, medications, and sugery."If symptoms worsen or do not improve by 18 to 24 months of age, re-evaluation for complications of GER is recommended. Generally this includes an upper GI series and consultation with a pediatric gastroenterologist," says Rudolph (Rudolph CD et al., 2001).
Case 1:
Shirley J, a 6-week-old baby girl, was brought by her mother to the resident pediatric clinic for follow-up visit. Shirley has been on formula and breast milk since birth. She weighed 3,245 grams at birth and she has gained appropriately to 4,420 grams, but the mother is complaining that Shirley spits up some of her milk after feeding. She regularly burps her after feeds but she continues to spit up. However, Shirley does not vomit and does not have diarrhea or any type of rash. Her developmental milestones are appropriate for her age. On physical examination, she is at the 75-90%ile in weight, length and head circumference and she is following her own growth curve. The rest of the physical examination is within normal limits.
Q1. Why is the child thought to be gaining appropriately?
A1. The weight gain of about 30 grams a day is just fine. Percentiles, taken alone, can be deceiving in a six week old. It is more important that she regains birth weight within the first two weeks of life and gains 25 to 30 grams a day during the first three months. After that, she should maintain her own growth curve. Note that she gained to 4420 grams. Shirley would have been failing to grow if birth weight had been 3,800 grams even with a higher weight for age percentile. Do not use percentiles! Rather check on weight gain per day since birth.
TEACHING CAPTION: Weight gain has to be adjusted for age and gender, weight gain velocity and measures of length. See Growth Curves: http://www.cdc.gov/growthcharts/ There are additional standards available from the World Health Organization for growth of breast fed infants http://www.who.int/childgrowth/en/. These infants experience a gain of about 25 grams a day. See modules in Part III (S1,2, and 3) and module on Breast-feeding. [Source: Lifshitz, F., et al., 1996.]
Q2. What are your concerns for the child?
A2. There are several possibilities. She may be simply spitting up because of improper feeding technique. Another concern is gastroesophageal reflux (GER) that is a common problem in the pediatric age group, especially during infancy. One must distinguish GER from gastroesophageal disease or GERD, a less common but more severe condition. "Gastroesophageal reflux disease (GERD) occurs when gastric contents reflux into the esophagus or oropharynx and produce symptoms," says Rudolph (Rudolph CD et al., 2001). A careful assessment must be made to insure that the child is neurologically intact and does not have anatomic abnormalities, which are two other possibilities.
Q3: What is the definition of Gastroesophageal reflux (GER)?
A3. Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus and is a normal physiologic process in healthy infants, children, and adult. Transient relaxation of the lower esophageal sphincter (LES) or inadequate sphincter tone leads to changes in the abdominal pressure causing brief and asymptomatic episodes of reflux. "The strength of the lower esophageal sphincter, the primary antireflux barrier, is normal in the vast majority of children with GER," says Rudolph (Rudolph CD et al., 2001). The LES is the primary anti-reflux barrier and is normal in the majority of children with GER.
Q4. What is the difference between regurgitation and vomiting?
A4. Regurgitation is the passage of refluxed gastric contents into the oropharynx while vomiting occurs when the refluxed material is expelled from the mouth. Both of these can occur in children with GER.
Case 2:
Anthony is an 8-month-old baby boy, born full term with no complications via normal vaginal spontaneous delivery. He was born at 3315 grams and is currently 7031 grams. He is both breast-fed and on iron fortified formula. During his well-child visit at 6 months old, his mother complained that Anthony was "fussy" about feedings and was spitting up more than usual "about half of anything he drank" for the past 2 months. After a careful history and physical, the pediatrician also noted poor weight gain and recommended thickened feedings with one tablespoon of dry rice cereal per 1 oz of formula and to enlarge the opening of the nipple on his bottles with a criss cross cut. At 8 months, Anthony still has poor weight gain, and has developed a dry cough with 2 episodes of vomiting with blood. His pediatrician recommended a change of formula from a cow's milk based formula to a casein hydrolysate formula and has referred Anthony to a pediatric gastroenterologist for further evaluation of GERD.
Q5: What clinical manifestations distinguish Shirley, with GER, and Anthony, with GERD?
A5: Shirley has GER because she has reflux with no effects on wait gain and does not have any other signs or symptoms suggestive of GERD. Meanwhile, Anthony exhibits GERD.
Gastroesophageal reflux disease (GERD) is the passage of gastric contents into the esophagus or oropharynx that causes symptoms and/or anatomic pathological findings. GERD is complex and symptoms vary in children. Symptoms include poor weight gain, persistent irritability or pain, hematemesis (vomiting blood), apnea, wheezing, aspiration or recurrent pneumonia, chronic cough, and/or stridor (Jung AD., 2001).
GERD is a complex, multifactorial condition that involves gastric acidity and emptying, frequency of reflux, mucosal barrier and clearing mechanisms of the esophagus, visceral hypersensitivity and airway responsiveness.
Sources: Werlin SL, et al., 1980; Kawahara H, et al., 1997.
TEACHING CAPTION: "GER is a normal physiologic process, whereas GERD is a pathological process that can manifest with mostly gastrointestinal and respiratory symptoms."
Q6. What would you do for Anthony?
A6. The first step in management would be an evaluation of feeding technique, then a trial of thickened feedings (1 tablespoon dry cereal per 1 oz formula) with enlarged nipple opening. If those fail to improve weight gain or reduce symptoms, then try a switch in formula to a soy or casein hydrolysate based formula. Next, an evaluation by a pediatric gastroenterologist is warranted. Anthony may be sent for several diagnostic tests: 1) a barium study to check for anatomical abnormalities 2) a scintigraphy to check for gastric emptying or aspiration 3) pH probe with pneumocardiography 4) esophageal biopsy 5) endoscopy (Orenstein, 1999).
Source: Rudolph CD et al., 2001.
Case 2 continued…
Anthony showed no improvement with a change in formula. He was evaluated by the pediatric gastroenterologist. Anthony underwent a barium swallow that did not demonstrate any anatomical defects. He underwent an endoscopy that showed erosion at the distal esophagus near the LES and was diagnosed with GERD. He was prescribe omeprazole 1 mg/kg/24 hr PO ÷ QD-BID.4
Q7. Do symptoms of GERD vary with age?
A7. The most common symptoms of GERD vary according to age, although overlap exists. Children of all ages can present with irritability, problems with feeding, anemia/hematemesis, recurrent pneumonia, wheezing, or obstructive apnea. The classic symptom in infants is regurgitation with weight loss or poor weight gain. In children (2-3 years old), regurgitation and substernal pain becomes the more common presenting symptom (Sondheimer JM et al.,1988).
Q8. What are the most common symptoms among infants with GERD?
A8. Most common manifestation is vomiting. It is present in 50 to 70% of infants, peaks at around age 4 months, and typically resolves by one year (Orenstein, 1997). A small minority develops GERD with symptoms, such as anorexia, dysphagia, arching of the back during feedings, irritability, hematemesis, anemia or failure to thrive. Associations with apparent life-threatening events and chronic respiratory events, including reactive airways disease, recurrent stridor, chronic cough, and recurrent pneumonia, have also been reported (Nelson SP et al., 1998).
Q9. What are the nutritional consequences of GERD in infancy?
A9. Mostly failure to thrive (FTT).
Q10. At what age would you expect children with physiological GER to stop regurgitating?
A10. By 12 months of age (Orenstein, 1999).
Case 2 Continued…
At 18 months of age, his symptoms seemed to have resolved and he was taken off of omeprazole treatment. Anthony is now 3 years old and attends preschool. He has had intermittent episodes of vomiting over the past year, which resolves with a short course of omeprazole. For the past month, he has been refusing food, occasional vomiting, and complaining of a pain in his chest, but has no problems breathing. A 2-week course of omeprazole did not relieved his symptoms. He returns to the pediatrician's office and his given a referral for re-evaluation by the gastroenterologist.
Q11. How does GERD present in a preschool age child?
A11. Intermittent vomiting may be present in this age group although respiratory complications as in infants may also be the presentation but less likely. Decreased food intake may be seen in those with esophagitis. In developmentally delayed children, stereotypical, repetitive stretching and arching movements caused by esophageal pain have been described (Sandifer syndrome). "Arching in infants may represent a response to the discomfort of esophagitis, or perhaps such arching actually helps esophageal clearance. Similarly, the posturing of Sandifer syndrome, with the neck hyperextended or markedly flexed to one side, has been shown recently to improve esophageal clearance of refluxate and resolves when the reflux is treated," says Gorrotxategi (Gorrotxategi P, et al., 1995).
Q12. What are the consequences and what are the treatment options in this age group?
A12. GERD can lead to decreased desire to eat because of pain and vomiting. Children can become malnourished, have dental erosions and not gain weight properly. Children can be treated with lifestyle changes such as eliminating acidic foods, spicy foods, carbonated beverages such as soda, caffeine, peppermint, fatty meals, and eating close to bedtime. In addition, antacids, histamine-1 receptor blockers, or proton pump inhibitors can reduce symptoms of GERD. "A useful strategy is to use H2-receptor blockade for children in whom esophagitis has been demonstrated and to use antacids as supplemental therapy for symptoms of pain, for children in whom their constipating (aluminum) or stool-softening (magnesium) features are desirable, or as short-term empiric therapy in children in whom esophagitis has not been documented," says Orenstein (Orenstein, 1999). In the case of Anthony, he seems to have GERD that is not being relieved by proton pump inhibitor therapy. Therefore, further work-up to rule out non-gastrointestinal causes (cardiac, respiratory, musculoskeletal, medication induced, infectious) and evaluation by a pediatric gastroenterologist is warranted. Surgical correction may be a treatment option, such as Nissen fundoplication (Orenstein, 1999).
CASE 3:
Albert is a 16-year-old boy that has recently been complaining of chest pain, epigastric pain, and food "coming back up" for the past 3 weeks. He describes the pain as a burning sensation in the middle of his chest that worse after meals. He wakes up in the middle of the night with chest discomfort and needs to sleep with 2 pillows to gain some relief. Upon further questioning, his grades are dropping in school, he often feels nausea and does not want to eat. He has begun to hang out with an older crowd at school and is experimenting with cigarettes and alcohol. His exam reveals a hoarse voice and 5 lb weight loss in past 3 months.
Q13. How does GERD present in older children and adolescents?
A13. This age group has manifestations similar to that of adults. Most commonly, chronic heartburn or regurgitation with re-swallowing is seen. The chest pain usually occurs after meals, awakens patients from sleep, and may be exacerbated by emotional stress. Esophagitis may present as dysphagia or food impaction. Untreated inflammation may cause circumferential scarring and strictures. Chronic inflammation may result in the change of the distal esophageal mucosa into a metaplastic potentially malignant specialized epithelium (Barrett's mucosa). Chronic cough and hoarseness due to reflux laryngitis may also be seen (Shaker R, et al., 1995).
TABLE 3 Most common presentation of GERD at different ages
A. Infants: Regurgitation , poor weight gain or weigh loss.
B. Children: Regurgitation and/or substernal pain.
C. Adolescents: Similar to adults with "heartburn", chest pain after meals, difficulty sleeping, and cough or hoarse voice.
TEACHING CAPTION: GERD will have signs or symptoms related to one of the triad: 1) Failure to grow, 2) Gastrointestinal, or 3) Respiratory Symptoms
Q14. What are the nutritional consequences for Albert?
A14. Albert's nutritional problems are two fold. The first come from the inability to eat because of GERD and smoking/alcohol use can lead to serious health problems. The vomiting will reduce the number of calories that he actually adsorbs. The smoking will lead to a further decrease in appetite and decrease in respiratory function. Alcohol contains a lot of calories, but very little nutrition. Therefore, he will be at risk for malnutrition.
Q15. What are the treatment options for older children and adolescents?
A15. They are similar to those for younger children; lifestyle changes, medications, or surgery. Lifestyle changes include smoking cessation, abstinence from alcohol, eliminating acidic or spicy food, no carbonated drinks, no caffeine, no peppermint, no fatty food, or eating close to bedtime. In addition, propping up the head during sleep can relief nighttime symptoms. Medications include antacids, H2 receptor blockers, and proton pump inhibitors. The last option is surgery. "The question of whether to subject a child to surgery if medical management controls reflux disease only while it is being administered is a difficult one. The pros and cons of lifetime pharmacotherapy versus surgical therapy must be weighed with the family," says Orenstein (Orenstein, 1999).
References:
Orenstein SR. Gastroesophageal reflux. Pediatr Rev 1999;20:24-8.
Orenstein SR. Infantile reflux: different from adult reflux. Am J Med 1997;103:S114-9.
Koufman, James A. Laryngopharyngeal reflux 2002: a new paradigm of airway disease. Ear, Nose & Throat Journal. Sept, 2002.
Vandenplas Y, Lifshitz JZ, Orenstein S, Lifschitz CH, Shepherd RW, Casaubon PR, et al. Nutritional management of regurgitation in infants. J Am Coll Nutr 1998;17:308-16
Putnam PE, Ricker DH, Orenstein SR. Gastroesophageal reflux. In: Beckerman RC, Brouillette RT, Hunt CE, eds. Respiratory control disorders in infants and children. Baltimore: Williams & Wilkins, 1992:324
Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, Gerson WT, Werlin SL; North American Society for Pediatric Gastroenterology and Nutrition. 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 Suppl 2:S1-31.
Nelson SP, Chen EH, Syniar GM, et al. One-year follow-up of
symptoms of gastroesophageal reflux during infancy. Pediatric Practice Research Group. Pediatrics 1998;102:E67.
Lifshitz, F, Cervantes, CD. Short Stature. In: Pediatric Endocrinology, Lifshitz, F (Ed), Marcel Dekker, New York 1996. p.3. VIA Normal Pediatric Growth, Julie A. Boom, MD, UpToDate
Jung AD. Gastroesophageal Reflux in Infants and Children. American Family Physician 2001; 64 (11):1853-1860.
Werlin SL, Dodds WJ, Hogan WJ, et al. Mechanisms of gastroesophageal
reflux in children. J Pediatr 1980;97:244-9.
Kawahara H, Dent J, Davidson G. Mechanisms responsible for
gastroesophageal reflux in children [see comments]. Gastroenterology
1997;113:399-408.
Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms
of gastroesophageal reflux during infancy. A pediatric practice based
survey. Pediatric Practice Research
Sondheimer JM. Gastroesophageal reflux:
Update on pathogenesis and diagnosis. Pediatr Clin North Am. 1988;35:103-1 16
Gorrotxategi P, Reguilon MJ, Arana J, et al. Gastroesophageal
reflux in association with the Sandifer syndrome. Eur J Pediatr
Surg 1995;5:203-5.
Shaker R, Milbrath M, Ren J, et al. Esophagopharyngeal distribution
of refluxed gastric acid in patients with reflux laryngitis.
Gastroenterology 1995;109:1575-82.
Annotated Pre-test Answers:
A1. Answer = False. Most infants with GER do not suffer inadequate growth. However, infants with GERD can have persistent regurgitation that leads to secondary poor weight gain and failure to thrive (Orenstein, 1999).
A2. Answer = E. GER is a functional process, it is not pathological, that occurs in most children with a peak prevalence at 1-4 months of age (Orenstein, 1997) and is usually a "self-limited process…that usually resolves by six to 12 months of age," says Vandenplas (Vandenplas et al., 1998).
A3. Answer = True. GERD is a non-pulmonary differential diagnosis for the symptom of wheezing. Three mechanisms can lead to respiratory symptoms from GERD (1. aspirated material can cause obstruction 2. stimulate mucous secretion, edema, smooth muscle contraction 3. release inflammatory mediators) (Putnam PE et al., 1992).
A4. Answer = False. Vomiting is a very nonspecific symptom in children. A careful history and physical should be performed. Persistent vomiting with poor weight gain, weight loss, hematoemesis, difficulty sleeping, irritability, asthma-like symptoms, and anemia should be referred to a pediatric gastroenterologist.
A5. Answer = D. The first step in any diagnostic work-up is a thorough history and physical.
A6. Answer = C. The first step in treatment of infants with GER or GERD is to thicken feedings with (1 tablespoon dry cereal per 1 oz formula) with enlarged nipple opening. "Conservative treatment for mild symptoms of GER involves thickened feedings and positional changes in infants, and dietary modification in children. Healthy infants who regurgitate without signs of GERD may be managed by thickening feedings with up to one tablespoon of dry rice cereal per 1 oz of formula," says Vandenplas (Vandenplas et al., 1998). Do not rush into treatment with medication, nor should you tarry. Failure of the first step of diet manipulation requires treatment with medication.
A7. Answer = F. Infants present most commonly with regurgitation with poor weight gain or weigh loss. Children present most commonly with regurgitation and/or substernal pain. Adolescents present similar to adults with "heartburn", chest pain after meals, difficulty sleeping, and cough or hoarse voice (Rudolph CD et al., 2001).
