NASPGHAN - GERD

Definition

GER - the passage of gastric contents into the esophagus with or without regurgitation and vomiting
GERD - when GER leads to troublesome symptoms and /or complications
Refractory GERD - GERD not responding to optimal treatment after 8 wks

*there is no gold standard diagnostic test for GERD. it is a symptom based diagnosis and many of the symptoms (excessive crying, back arching, regurgutation) can occur in normal infants without GERD

Algorithm (See Below): For infants with frequent regurgitation or vomiting suspected of having GERD, Obtain H&P

H&P

Age of onset
Feeding and Dietary Hx

Length of geeding period
Volume of each feed
Type of formula
Method of mixing formula
Quality of milk supply (BF)
Volume of feeds
Additives to the feed
Restriction of allergens
Time interval between feeds

Growth Curve and Trajectory
Family Medical Hx
Pattern of regurgitation/spitting/vomiting

Nocturnal
Immediately post-prandial
Long after meals
Digested vs undigested

Environmental triggers

2nd hand tobacco smoke

Family Psychosocial hx
Prior pharmacologic or dietary interventions
Warning signs --> GI referral

General		Consider other conditions e.g. systemic infection
	Weight Loss
	Lethargy
	Fever
	Excessive irritability / pain
	Dysuria	UTI? (esp infants)
	Onset of vomiting/regurg >6mo increasing or persisting >12-18 months of age	late onset or Sx increasing or persisting after infancy (based on natural course of disease) may suggest diagnosis other than GERD
Neurological
	Bulging fontanel Rapidly increasing HC	May suggest increased ICP (i.e. meningitis, brain tumor, or hydrocephalus)
	Seizures
	Macro/microcephaly
Gastrointestinal
	Persistent forceful vomiting	IHPS (up to 2mo)
	Nocturnal vomiting	increased ICP
	Bilious Vomiting	Intestinal obstruction (Hirschprung, Intestinal atresia, mid-gut volvulus or intussusception)
	Hematemesis	Potentially serious bleed from esophagus, stomach, upper GI. Possibly GERD-associated, occuring from acid-peptic disease. Mallory weiss Reflux esophagitis
	Chronic Diarrhea	Protein-induced enteropathy
	Rectal Bleeding	Bacterial gastroenteritis IBD Acute Surgical conditions Protein-induced gastroenteropathy rectal bleeding (e.g. proctocolitis)
	Abdominal distension	Indicative of obstruction, dysmotility, or anatomic abnormalities

Symptoms:

General

Discomfort and irritability*
Failure to thrive
Feeding refusal
Dystonic neck posturing (Sandifer)

Gastrointestinal

Recurrent regurgitation
Hematemesis
Dysphagia/odynophagia

Airway

Wheezing
Stridor
Cough
Hoarseness

Signs:

General

Dental erosions
Anemia

Gastrointestinal

Esophagitis
Esophageal stricture
Barrett's esophagus

Airway

Apnea spells
Asthma
Recurrent otitis media
Recurrent PNA assoc w/ aspiration

*if excessive irritability and pain is the single manifestation, it is unlikely to be related to GERD

Algorithm

Infant with suspected GERD
Perform H&P
Presence of Alarm Symptoms?	YES -->	Tailor testing to address alarm signs/symptoms and refer appropriately
No
Avoid overfeeding Thicken Feeds Continue Breastfeeding	Improvement noted -->	Continue management
No improvement
Consider 2-4wks of protein hydrolysate or amino acid based formula or elimination of cow's milk in maternal diet (BF)	Improvement noted -->	Continue management and discuss milk protein reintroduction at follow up
No improvement
Referral to Pediatric GI	Referral not possible -->	Consider 4-8wk trial of acid suppression, then wean if symptoms improved
Referred		Successful weaning
Revisit Ddx, consider testing and / or short medication trial		No further treatment

Diagnositc tests are nor recommended with investigation of GERD in infants with a few exceptions.
Barium contrast studies can rule out anatomical abnormalities
Referral to Peds GI with consideration of

endoscopy
manometry
pH-metry or pH impedance

Treatment

First Line treatment

Avoid overfeeding
Thicken Feeds

using rice cereal with low or no arsenic is recommended

Continue breastfeeding

pumped breastmilk can be thickened with commercial thickeners (carob-bean). It cannot be thickened with rice cereal as breastmilk has amylase and will break down the cereal

Lack of data to support

positional therapy
massage therapy
prebiotics
probiotics
herbal medications

Second line therapy

If optimal non-pharmacologic therapy has failed, a 2-4wk trial of extensively hydrolyzed protein based or amino acid based formula is suggested in infants suspected of having GERD (Sx of GERD and cows milk protein allergy are identical)

Third Line therapy

If no improvement with 1st and 2nd line therapy, Referral to Peds GI is recommended

If referral not possible

Use PPI for a max of 4-8wks
If PPI not available or contraindicated

H2 receptor antagonist (H2RA) for up to 4-8 wks to treat reflux assoc erosive esophagitis

Goal of medication is to use lowest possible dose for the shortest amount of time'

REFRACTORY GERD

if patient is not responding to 4-8wks of optimal pharmacologic therapy, refer to Peds GI to search for alternate cause
Refer to Peds GI if patient cannot be weaned from the pharmacologic treatment by 6-12 months of age
Antireflux surgery should only be considered in infants with GERD under certain circumstances

life threatening complications
symptoms refractory to optimal therapy, after appropriate evaluation to exclude other underlying diseases
chronic conditions with significant risk of GERD related complications, i.e.:

neurologic impairment
cystic fibrosis

Transpyloric/ jejunal feedings in an alternative approach in cases of refractory GERD

Alternative underlying diseases with GERD-like Symptoms

Gastrointestinal obstruction

Pyloric stenosis
Malrotation with volvulus
Intussusception
Hirschprung Disease
Antral/Duodenal Web
Foreign Body
Incarcerated hernia
Superior mesenteric artery (SMA) syndrome

Other GI disorders

Achalasia
Gastroparesis
Gastroenteritis
Peptic Ulcer
Eosinophilic Esophagitis
Food Allergy/ intolerance
Inflammatory bowel disease
Pancreatitis
Appendicitis

Neurologic

Hydrocephalus
Subdural hemorrhage
Intracranal hemorrhage
Intracranial Mass

Metabolic / endocrine

Congenital adrenal gland hyperplasia/adrenal crisis
Galactosemia
Hereditary fructose intolerance
Urea cycle defects
Amino and organix acidemias
Fatty acid oxidation disorders
metabolic acidosis

Toxic

Lead poisoning
other toxins

Cardiac

Heart failure
Vascular ring
Autoimmune dysfunction

Infectious

Sepsis
Meningitis
UTI
URI
PNA
OM
Hepatitis

Renal

Obstructive uropathy
Renal insufficiency

* Exceptions to use of diagnostic interventions:

Diagnostic Intervention	Suggested Use
Barium Contrast Studies	Exclusion of anatomical abnormalities
Ultrasonography	Exclusion of anatomical abnormalities
EGD	Assessment of GERD complications with Bx Assessment for alternative diagnoses including EoE
Manometry	Diagnose rumination, peristaltic abnormalities and EGJ obstruction, UES dysfunction
pH multichannel intraluminal impedance (pH-MII)	Correlate persistent troublesome symptoms with acid and non-acid gastroesophageal reflux events Clarify the role of acid and non-acid reflux in the etiology of esophagitis and other signs and symptoms suggestive of GERD Determine the efficacy of acid suppression therapy Differentiate non-erosive reflux disease, hypersensitive esophagus and functional heartburn in patients with normal endoscopy
pH-Metry (when pH-MII not available)	Correlate persistent troublesome symptoms with acid gastroesophageal reflux events Clarify the role of acid reflux in the etiology of esophagitis and other signs and symptoms suggestive of GERD Determine the efficacy of acid suppression therapy