GER or GERD :

How to Treat

Badriul Hegar
Departement of Child Health University of Indonesia
 Physiology

pharynx

esophagus

stoma
pH
ch

*sleeve
Gastroesophageal Reflux
(GER)
The passage of gastric
contents
into the esophagus with or
without regurgitation

Regurgitation : the passage of refluxed contents into

pharynx, mouth or out from the mouth
Mechanism of Gastroesophageal Reflux
Transient Lower Esophageal Sphincter
Relaxation
Prolonged relaxations of the LES which are not associated with
swallowing

GER

Activity of cc
crural
diaphragm
inhibited

TLESR
GER Physiologic
several times per day in healthy
infants
 GastroEsophagealReflux
Mucosal
Acid clearance defense
Peristalsis prostaglandin
salivary bicarbonate
Crural diaphragm

Lower Acid
pepsin
esophageal
sphincter Bile,
tryps
in Gastric
emptying

(M. Gilger, 2004)

 Acid GER
sw
pharynx

esoph 1

esoph 2

esoph 3

pH
LES

TLESR
stomach

pH 4 310

Acid GER 10sec

Acid Clearance
Pathogenic
Factors
Mechanisms of GER
in GERD Transient LES relaxation
Intra-abdominal pressure
Gastric compliance
Delayed gastric emptying
pharynx & esophagus
(reflux clearance) Mechanisms of Esophageal
Complications
lower esophageal Impaired esophageal
sphincter clearance
(anti reflux barrier)
Defective tissue resistance
Noxious composition of
stomach refluxate
(gastric emptying)

Mechanisms of Airway
Complications
Vagal reflexes
GER Disease (GERD)
Reflux of gastric contents cause
mucosal damage (esophagitis) and/or
complications
(anemia, hematemesis, FTT,..)

troublesome symptoms
on well-being of pediatric patient
 There is no clear cut-of
separating physiologic from pathologic GER

2/16/17
 GER and GERD
do not differ in
the presence or absence of reflux

but in its
frequency, intensity, symptoms
 Pathologic
Physiologic
GER
GER
reflux during the
occurs mainly after day/night
meal
frequent reflux of
does not normally longer duration
cause symptoms
inflamation/mucosal
short duration of
injury symptoms
reflux episodes
Children < 8 ( up to 11) years
old
cannot report symptoms
in a reliable / reproducible way

2/16/17
Differentiating GER from GERD
is critical for the clinician

to avoid unnecessary
diagnostic testing and exposure to
medications
 Symptoms that may be
associated with GERD
Recurrent regurgitation with/without vomiting
Irritability in infants
Feeding refusal How frequent
Weight loss or poor weight gainand specific ?
Heartburn or chest pain
Hematemesis
Dysphagia
.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines : Joint Recommendations of

2/16/17 NASPGHAN 15
and ESPGHAN. Vandenplas Y. J Pediatr Gastroenterol Nutr 2009;49:498-547
 Children who are at higher risk for
developing severe chronic GERD
Onyeador N. Paediatric GER clinical practice guidelines, Arch Dis Child Educ Pract Ed. 2014;99:190-
3

History of neurological impairment (fluctuation

of symptoms)
Esophageal and anatomical disorders (hiatus
hernias, )
Chronic respiratory disorders
History of prematurity
Obesity
Certain genetic disorders (Down's syndrome, ..)
 Diagno
sis
1. Questionnaires 1st to do, but ...
Limitation
2. Endoscopy (+ biopsy) ? Esophagitis
3. pH metry ? acid GERD in extra-esoph
4. Impedance-metry ? acid & non-acid
GERD (future)

5. Therapeutic trial golden standard

2/16/17
in adults ! 17
 Endoscopy (+ biopsy)

Barium meal
pH metry
2/16/17
Reflux Questionnaire - Orenstein
Answer based on what you remember from the last two weeks and
check the appropriate line.

1. How often does your baby usually spit up ?

2. How much does your baby spit up ?
3. Does the spitting up seem to be uncomfortable for your baby ?
4. Does your baby refuse feedings even when hungry ?
5. Does your baby have trouble gaining enough weight ?
6. Does your baby cry a lot during or after feedings ?
7. Do you think your baby cries or fuses more than normal ?
8. How many hours does your baby cry or fuss each day ?
9. Do you think your baby hiccups more than most babies ?
10.Does your baby have spells or arching back ?
11.Has your baby ever stopped breathing while awake and
struggled to breathe or turned purple or blue ?

Score : Possible reflux >7 Probable reflux >9

Therapeutic approach of GERD

Needs to be balanced
both efficacy and the side effects.

over-investigation and over-treatment

should be avoided
Step-treatment GER /
GER(D)
1. A. Parental reassurance
B. Regurgitation : Milk-thickeners / AR-
formula

2. Prokinetics
3. Adjuvant treatment Prone-elevated
30
4. Esophagitis : H-blocker
(Ranitidine) , PPI (omeprazole, ..)
5. Surgery
2/16/17 GER Amsterdam 22
Infants with Uncomplicated
Recurrent Regurgitation

Anamnesis, physical examination,

warning signs are sufficient to establish the
diagnosis of uncomplicated GER.

Parental & anticipatory guidance

Thickened formula in formula-fed

infants
Protein hidrolisat ekstensif
selama 2-4 minggu

bayi mendapat susu formula

muntah berlebihan
gejala klinis alergi atau atopi keluarga
 GER tidak perlu
diintervensi
Evaluasi lebih lanjut
Gejala makin berat,
Tidak membaik pada usia 12-18 bulan,
Warning sign
 Natural Evolution of Infantile
Regurgitation versus the Efficacy of
Thickened Formula
Hegar B, Rantos R, Firmansyah A, De Schepper DJ,, Vandenplas Y. J Pediatr Gastroenterol
Nutr 2008; 47:26-30

Thickening formula
dapat dipertimbangkan untuk mengurangi
volume regurgitasi

Figure : Frequency of regurgitation

26 during the intervention
2/16/17
Prokinetik : Potensi efek samping lebih
besar dibanding potensi manfaat

Metoklopramid : tidak terbukti efektif

untuk terapi GERD

Eritromisin atau Domperidone :

belum cukup bukti untuk terapi GERD secara
rutin
Prone positioning decreases the amount of
acid esophageal exposure
Prone & lateral positions are associated with an increased
incidence of SIDS
The risk of SIDS > the benefit of prone & lateral sleep position
on GER

Supine positioning during sleep

is recommended
from birth to 12 months of age
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of NASPGHAN and ESPGHAN;
J Pediatr Gastroentoerol Nutr 2009;49: 498-547
 Infants with Recurrent GER and
Poor Weight Gain
A diagnosis of physiologic GER should not be made in an infant with
vomiting and poor weight gain

Initial evaluation / screening test !!

Management :
2 week trial of thickened formula,
EHF to exclude CMPA, or
appropriate daily formula volume required for
N growth
Infants with Recurrent GER and
Poor Weight Gain

Infeksi, gangguan elektrolit, kelainan organik,

barium meal
 Reflux is not a common cause of unexplained crying,
irritability, or distressed behavior
in otherwise healthy infants

No effect of proton pump inhibitors

on crying and irritability in infants

Systematic review of randomized controlled

trials
Gieruszczak-Biaek D, Konarska,Z, Skrka A, Vandenplas Y, Szajewska H.
J Pediatr (2014)
2/16/17 31
Specificity of symptoms to predict esophagitis is
very low
Heine RG, et all. J Pediatr 2002;140:14-9;Salvatore S, et all.. J Pediatr Gastroenterol Nutr.
2009;49:566-70

There is no evidence
to support the empiric use of acid
suppression
for the treatment of irritable infants
Other causes :
cows milk protein allergy, neurologic disorders, constipation, and
infection (UTI)
Clinical predictors of
pathological GER in infants
with persistent distress.
Heine RG. J Paediatr Child Health. 2006;42:134-9
GERD in Irritable Infants are
Still Contradictory

pH monitoring was normal in 55% of

infants with esophagitis. Vandenplas Y, et all. Eur J Pediatr
2004;163:300-4;

Acid GERD and histological esophagitis are

diagnosed in 66% and 43% of irritable
infants respectively Vandenplas Y, et all. Eur J Pediatr
2004;163:300-4
Irritability with no explanation
other
than suspected GERD
Investigations to diagnose esophagitis
(pH monitoring, endoscopy, ...)

?? 2-week trial of anti-secretory therapy

May be considered, but there is a potential risk of

adverse effects
Spontaneous symptoms resolution or a placebo
response

 Dysphagia and Food Refusal

GERD is not a prevalent cause of difficulty in swallowing

Dysphagia occurs in association with

anatomic
neurologic and motor, inflammatory, and psychological
disorders

Evaluation (barium meal and

endoscopy) if physical examination
and history of disease do not reveal a cause

Therapy with acid suppression without

 Apnea or Apparent Life threatening
Event (ALTEs)
In the majority of infants with apnea or ALTEs,
GER is not the cause

MII/pH esophageal monitoring + polysomnographic recording +

synchronous symptom recording may establishing cause and effect.
 Histamine-2 receptor antagonists (H2RAs)
produce
relief of symptoms and mucosal healing.
The efficacy of H2RA in achieving mucosal healing is much
greater
in mild esophagitis than in severe esophagitis.

Proton pump inhibitors (PPIs) are superior to

H2RAs
in relieving symptoms and healing esophagitis
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of
NASPGHAN and ESPGHAN
Tersedia obat yang lebih efektif (H2RA dan PPI)

Antasid dan Sukralfat tidak

disarankan
untuk terapi GERD
 Systematic review to determine
effectiveness and safety of PPIs in children
with GERD
Van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA. Pediatrics. 2011
May;127(5):925-35.

Conclusions
PPIs are not effective in reducing GERD
symptoms in infants
Placebo-controlled trials in older children are
lacking
PPIs seem to be well tolerated during short-
term use, evidence supporting the safety of
PPIs is lacking
 A systematic
review Efficacy in infants : PPIs were no
more effective than placebo in
reducing irritability and spilling (4
12 studies , 895 studies)
children (age range, Efficacy in children: PPIs were
017 years) equally effective in reducing GERD
symptoms as a control (5 studies).
examine the efficacy
and safety of PPIs Efficacy in adolescents:
when used to treat pantoprazole were equally
symptoms of GERD effective in reducing GERD
and gastric acidity. symptoms compared with a
different PPI (2 studies).
meta-analysis
Howard Bauchner, MD, Journal Watch Efficacy in infants and
Pediatrics and Adolescent Medicine
May 4, 2011 children : PPIs were more
effective in reducing gastric acidity
than placebo or ranitidine (4
studies).
Multicenter, DB, R, PC trial assessing
the efficacy and
safety of PPI lansoprazole in infants
with symptoms
ofSymptoms
GER disease.
were tracked through
Orenstein daily diaries
SR. J Pediatr. and weekly visits;
2009;154:514-520.e4.
Efficacy: > 50% reduction of feeding-related crying ; 216 infants
screened, 162 randomized

Lansoprazole
Placebo
Responder 44/81 (54%) 44/81
(54 %)
No difference in any secondary measures or
analyses of efficacy (crying, fussing, iiritable,
spitting up/vomiting, stopping feeding after after
starting)
Chronic heartburn in older children or adolescents

4 week PPI trial are recommended

If symptoms resolve, continue PPI for 2 month

If symptoms persist or recur after treatment

the patient be referred to a pediatric gastroenterologist
 Infant or Child with Reflux
Esophagitis
Initial treatment :
lifestyle changes and acid suppression therapy

In most cases,
efficacy of therapy can be monitored by
the degree of symptom relief
Pediatric
GER BandungGastroesophageal Reflux Clinical Practice
44 Guidelines: Joint Recommendations of
2/16/17
NASPGHAN and ESPGHAN
 Children with reflux esophagitis,
non erosive reflux disease,
PPIs for 2 months constitute initial therapy

Not all reflux esophagitis are chronic or relapsing,

tapering and withdrawal of PPI therapy
should be performed

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of

NASPGHAN and ESPGHAN;
Anecdotic symptoms
chronic otitis
halitosis (bad smelling breath)
globus sensation
laryngeal lesions

dental erosions
Reactive Airways Disease

No strong evidence to support empiric

PPI therapy in unselected pediatric patients with
asthma

Asthma with heartburn, nocturnal

symptoms, steroid-dependent may derive
some benefit from long-term medical or surgical anti
reflux therapy

pH-metry before a long-term PPI

therapy
 Upper Airway Symptoms

The association of GER and UAS

chronic hoarseness, cough, otitis media, and sinusitis
have not been proven by controlled studies

Patients with UAS symptoms should not be assumed to

have GERD without consideration of other potential
etiologies
 Rekomendasi
Diagnosis dan Tata Laksana Penyakit
Refluks Gastroesofagus

UKK Gastrohepatologi - Ikatan Dokter Anak Indonesia

 Regurgitation

Red Flag
Vomiting
No Hematemesis? Yes
Irritability/crying
?
Fussiness ?
Physiology Arching Pathology
(Sandifer) ?
Excessive Coughing fits ? History of Allergy
Failure to thrive ?
Feeding
Yes No problems? Yes No
Neurology ab N

Reassurance Consider CMPA GERD

Reassuran
the parents eHF Quetionare
ce the pH metry,
parents edoscopy
Consider Yes N
Thickenin Questionaire : Empirical o
g
therapy H2 Antagonist
Formula/E Consider
HF or PPI 2 weeks other
pH metry/Endoscopy : H2A diseases
Bayi yang tinggal di wilayah terbatas
alat penunjang diagnostik ??

Kuesioner GERD
Kuesioner (+) : H2RA atau PPI selama 2
minggu dengan pemantauan respons
terapi
Thank
you