Gastroesophageal reflux

GE reflux is common in children with special health care needs. The mechanisms are not entirely understood, but may include abnormal esophageal motility and delayed gastric emptying, possibly exacerbated by constipation. Suggestive clinical symptoms include:

• regurgitation;
• vomiting;
• chronic abdominal pain; or
• history of pulmonary aspiration and/or hematemesis.

In many situations, empiric treatment without specific evaluation is appropriate (see below for treatment options) with further evaluation or referral to gastroenterology if symptoms do not resolve.

A radiographic upper gastrointestinal series can be ordered to evaluate anatomy and to document the presence of reflux, but the study lacks sensitivity (reflux may not occur during a brief study and sensitivity to diagnose esophagitis is also low) and specificity (it may occur during a study if the child is very upset and crying but not be a clinical issue for the child). An upper gastrointestinal series also has limited ability to determine the severity of the reflux, evaluate for alternative diagnoses, and cannot correlate reflux with symptoms (e.g., behaviors and/or pulmonary symptoms). The clinician may want to include delayed films to evaluate gastric emptying, an abdominal x-ray to look at fecal load (is the child's constipation causing delayed gastric emptying?), a fluoroscopic video swallow study to evaluate aspiration risk, and/or a pH probe for evidence of reflux over a prolonged period of time.

For children with significant symptoms, a hemoglobin or hematocrit should be considered to screen for iron deficiency anemia secondary to chronic esophagitis.

Consider referral to a GI specialist for:

• recurrent symptoms;
• failure of empiric therapy;
• GI bleeding; or
• if a feeding tube or reflux surgery (e.g., Nissen fundoplication) is being considered.

In consultation with the gastroenterologist, additional evaluation might include endoscopy, pH probe monitoring (primarily to correlate reflux with symptoms if the diagnosis is unclear), and evaluation for alternative diagnoses as indicated (e.g., celiac disease, H. pylori, inflammatory bowel disease).

Typically, gastro-esophageal reflux is treated using a combination of lifestyle changes, a prokinetic agent, and an acid suppressing agent.

Lifestyle changes:

• Elevate the head while sleeping.
• Avoid recumbency for 3 hours after a meal.
• No Smoking; avoid secondhand smoke.
• Sleeping in the left lateral decubitus position.
• Avoid: fatty meals, foods purported to increase reflux (chocolate, peppermint, onions, garlic, alcohol) and acidic foods (citrus and tomato based foods).
• For children utilizing feeding tubes, adjustments in feeding schedule (reducing bolus sizes and limiting feedings given in the recumbent position) may be helpful.

Improve nutrition:
Studies have documented resolution of gastro-esophageal reflux in malnourished children with CP with combined nutritional and medical interventions (i.e., chronic tube feeds, prokinetic agents, and acid suppression).

Medications:

• Proton Pump Inhibitors (e.g., lansoprazole, omeprazole):
  • Lansoprazole (Prevacid):
    • Treatment is generally with lansoprazole (Prevacid), (15 mg in children < 30 kg, 30 mg in children > 30 kg), which comes in several different forms including solutabs (available as 15 and 30 mg which dissolve on the child's tongue or can be added to an oral syringe with water), capsules (15 and 30 mg which can be sprinkled on food or swallowed whole), and strawberry packets (15 and 30 mg packets which can be added to water for administration). Treatment of reflux can be augmented by the use of a motility agent (reglan or low dose erythromycin) but the clinician must monitor closely for side effects (particularly irritability or dystonia with reglan).
    • If reflux, burping, and gas continue to be a problem, pepcid may be added on a prn basis.
    • Common side effects: headache, nausea, stomach pain, diarrhea, and constipation.
    • This medication should be avoided or given cautiously if the patient has liver disease or is taking theophylline, digoxin, ampicillin, ketoconazole, iron, or coumadin.
  • Omeprazole (Prilosec):
    • Dosage: 0.6 - 0.7 mg/kg/dose PO/GT QD. May increase to BID if needed. Administer before meals. For those unable to swallow a pill, the enteric coated granules may be dumped on food stuff and eaten, but should not be chewed. They may also be given in an acidic beverage. Sometimes parents have had trouble with the granules sticking to the sides of feeding tube. A liquid preparation can be compounded and information about compounding may be obtained from an outpatient pharmacy from a children's hospital: see all Hospitals services providers (50) in our database.
    • Common side effects: headache, diarrhea, nausea, and vomiting.
    • Induces CYP 450 1A2, so prolongs the half life of diazepam, phenytoin, and warfarin.
• Acid Suppression (H2 Blockers, e.g., ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)):
  • While many consider proton pump inhibitors to be more effective for treatment of gastro-esophageal reflux disease, histamine receptor blockers (e.g., ranitidine) are still an option and may be cheaper if the family is paying out of pocket or a percentage co-pay for medications. These are available as prescription and non-prescription forms, although prescription forms are stronger than non-prescription.
  • Dosage is generally twice a day. They can be used on a prn basis, although they take longer to work than antacids.
  • When using these agents, monitor for CNS side-effects (e.g., sedation, insomnia). Tachyphylaxis may develop with long term use.
• Prokinetics (Metoclopropramide, low dose erythromycin):
  • Metoclopromide:
    • Mechanism of action: Metoclopropramide may mediate its impact through increased lower esophageal sphincter pressure, accelerated of gastric emptying, and increased small bowel peristalsis. However, the data for efficacy of this drug is conflicting and, in general, suggests modest impacts. Metoclopropramide also has centrally acting anti-emetic properties.
    • Major Side Effects: May cause significant central nervous system side effects in a large percentage of children, including fatigue, restlessness, tremors, increased tone, extrapyramidal reactions (dystonic, occulargyric), and tardive dyskinesia. Monitor for irritability, sedation, diarrhea, increased emesis/feeding intolerance, and neurological symptoms.
    • Dosage: 0.1-0.2 mg/kg/dose up to QID PO/GT (maximum dose 0.8mg/kg/24hr). For children eating orally or on bolus feeds, give 30 min before feed. For children on continuous feeds, space doses evenly through the feeding time.
  • Low Dose Erythromycin:
    • Mechanism of action: Erythromycin may have better efficacy than metoclopramide with regard to increasing gastric motility. However, when used for chronic treatment, tachyphylaxis may develop.
    • Major Side Effects: Safety profile is better than metoclopropramide but development of tachyphylaxis is a concern for long term efficacy.
    • Dosage: 20 mg/kg/day divided into 4 doses.

Surgical therapy:
Medical therapy is not successful in some patients or despite optimal treatment of reflux, the child remains underweight and surgical procedures may be necessary. When medical therapy is not successful, Nissen or other type of fundoplication may be recommended and can be performed laparoscopically in some cases which shortens hospital and overall recovery time. For children who do not feed orally who are poor surgical candidates, another option is moving the distal end of the feeding tube to the small intestine (ie, GJ tube or J tube). A referral should be made to gastroenterology if fundoplication and/or tube feedings are being considered. Kidswithtubes.org has helpful information for families regarding tubefeeding issues.