focus on GERD ,definition ,red flags,features ,management ,algorhtym

1. Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah ,UAE
saadsalani@yahoo.com

2. Gastro-esophageal reflux is the passage of
contents from the stomach back into the
esophagus
GER is a physiological event and it is
often associated with visible regurgitation
of feeds, or ‘overt regurgitation
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 2

3. Gastro-esophageal reflux is more common
in infants
GER affects up to 40% of infants , generally
starts < 8weeks of age
GER resolve completely in 90% of infants
by 1 year of age
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 3

4. In presence of effortless regurgitation in an
infant who is otherwise well ,reassurance of
parents is the only needed
No investigations nor treatment are needed
,only advise and support
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 4

5. If any of the following occur ,parents have
to return their infant for re-evaluation:
• Persistent projectile regurgitation
• Bile stained vomitus or hematemesis
• Faltering growth ,marked distress or
feeding difficulties
• Persistent ,frequent regurgitation
beyond the first year of life
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 5

6. GERD in children describes gastro-
esophageal reflux that causes:
• Symptoms that need medical
treatment , or
• Complications e.g. esophagitis
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 6

7.  Thorough and careful history
 Feeding history
In a bottle fed :
• The formula
• The preparation
• The volume and frequency
• Any resistance or refusal to feed
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 7

8. In breastfed :
• When symptoms started
• Frequency of vomiting
• Any distress
• Any respiratory symptoms
• Any episodes of back arcing or apnea
In addition to breastfeeding techniques ,
positioning and attachment
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 8

9.  Persistent faltering growth with overt
regurgitation
 Dysphagia
 Unexplained distress
 Retrosternal ,epigastric or upper
abdominal pain refractory to medical
treatment
 Aversion to feeding with regurgitation
 Unexplained iron deficiency anemia
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 9

10.  Premature birth
 Parental history of GERD
 History of repaired congenital
diaphragmatic hiatus hernia
 Repaired congenital esophageal atresia
 Neurodisability
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young
people: diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 10

11. • Hematemesis :upper digestive tract
bleeding
• Melena: Cow’s milk protein intolerance
(CMPI) , bacterial gastroenteritis
,intussusception
• Bile stained vomitus :Intestinal
obstruction
• Persistent Projectile vomitus:
hypertrophic pyloric stenosis
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 11

12. • Abdominal distension , tenderness ,
or a palpable mass
• Dysphagia: Scarring or a stricture
• Dysuria: urinary tract infection
• Continuity of symptoms after one
year of age
• Presence of atopy or a high risk of
atopy :Cow’s milk protein allergy
(CMPA)
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 12

13. National Institute for Health and Care Excellence.Food allergy in under 19s:assessment and
diagnosis.NICE guidelines{CG116).2011. http://www.nice.org.uk/guidance/cg116
Non-IgE mediated allergy:
 Blood and /or mucus in the stools
 Abdominal pain
 Loose stools
 Passing stool more frequently
 Erythema
 Atopic eczema
 Constipation
 Infantile colic
 Gastro-esophageal reflux disease
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 13

14. National Institute for Health and Care Excellence.Food allergy in under 19s:assessment and
diagnosis.NICE guidelines{CG116).2011. http://www.nice.org.uk/guidance/cg116
IgE- mediated allergy:
 Acute urticaria
 Acute angioedema
 Pruritus , erythema
 Angioedema of the lips ,tongue , and palate
 Vomiting
 Diarrhea
 Colicky abdominal pain
 wheezing
 Shortness of breath
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 14

15.  There may be an association
between respiratory symptoms
and GERD
 The laryngeal irritation by
refluxate is the possible effect of
cough reflex
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 15

16.  The usage of Alginate therapy ,proton
pump inhibitors (PPIs) or H2 receptor
antagonists (H2 RAs) decrease
respiratory symptoms associated with
GERD
http://www.llli.org
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 16

17.  In breastfed infants with
frequent regurgitation that is
associated with marked
distress , alginate therapy for 2
weeks is to be considered
http://www.llli.org
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 17

18.  In formula fed infant with overt
regurgitation associated with marked
distress , the reduction of volume of
feed and frequent feeding or usage of
thickener will help in relive of distress
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 18

19.  If no benefit from reduction of volume
and frequency of feed or even
thickener usage so use alginate
therapy
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 19

20. • Preterm neonates
• Patients with intestinal obstruction
• In presence of diarrhea ,vomiting
,high fever
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 20

21.  Re-evaluate the infant after 2 weeks
 If no improvement of symptoms, Stop
alginate
 If improvement occurs ,continue
 Periodic stoppage is to be done and
looks for recovery
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 21

22.  In infants or neurodisabled children with
overt regurgitation with at least one of the
following:
• Distressed behaviour
• Unexplained feeding difficulties e.g.
gagging ,chocking ,or refusing feeds
• Faltering growth
Usage of PPIs or H2 RAs for 4 weeks
can be started
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 22

23.  Do not prescribe PPIs or H2RAs to
infants with overt regurgitation as an
isolated symptom
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 23

24.  Do not offer:
 Metoclopramide
 Domperidone
 Erythromycin
To treat patients with GER or GERD
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 24

25.  Metoclopramide side effects include:
 Tardive dyskinesia
 Extrapyramidal disorders
 Domperidone side effects include:
 Cardiac arrhythmias:
• Ventricular arrhythmias
• Prolongation of QTc
 Sudden death
National Institute for Health and Care Excellence. Gastro-esophageal reflux in children and young people:
diagnosis and management. NICE guidelines {}.2015. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 25

26. https://www.nice.org.uk/guidance/ng1
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 26

27. Thank you
12/10/2017
Focus on GERD
Prof. Dr. Saad S Al Ani 27