GER or GERD :

How to Treat

Badriul Hegar
Departement of Child Health University of Indonesia
 Physiology

pharynx

esophagus

stomach
pH

*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 crural cc
diaphragm
inhibited

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

Acid
Lower esophageal pepsin
sphincter Bile,
trypsin
Gastric emptying

(M. Gilger, 2004)

 Acid GER
sw
pharynx

esoph 1

esoph 2

esoph 3

pH
LES

stomach TLESR

pH 4 3 ”

Acid GER Acid Clearance 10sec

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

stomach Mechanisms of Airway Complications

(gastric emptying)
• Vagal reflexes
• Impaired airway protection
 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

9/15/2016
 GER and GERD
do not differ in
the presence or absence of reflux

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

15-9-2016
 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 and
• Weight loss or poor weight gain specific ?
• Heartburn or chest pain
• Hematemesis
• Dysphagia
• …….

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines : Joint Recommendations of NASPGHAN

15/9/16 and ESPGHAN. Vandenplas Y. J Pediatr Gastroenterol Nutr 2009;49:498-547 15
 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 her ias, …
• Chronic respiratory disorders
• History of prematurity
• Obesity
• Certain genetic disorders (Down's syndrome, ..)
 Diagnosis

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 in adults !

15-9-2016 17
 Endoscopy (+ biopsy)

Barium meal
pH metry

15-9-2016
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 : H²-blocker (Ranitidine) , PPI
(omeprazole, ..)
5. Surgery
15/9/16 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,
”War i g sig ”
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

Thicke i g for ula

dapat dipertimbangkan untuk mengurangi
volume regurgitasi

Figure : Frequency of regurgitation

26
during the intervention 15-9-2016
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
 No effect of proton pump inhibitors
on crying and irritability in infants

Systematic review of randomized controlled trials

Gieruszczak-Białek D, Ko arss
p SsA D rs s

15-9-2016 31
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

• The risk/benefit ratio is not clear

 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 earlier

evaluation is not recommended
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 studies)
• 12 studies , 895 children • Efficacy in children: PPIs were equally
(age range, 0–17 years) effective in reducing GERD symptoms as a
• examine the efficacy and control (5 studies).
safety of PPIs when used • Efficacy in adolescents: pantoprazole were
to treat symptoms of equally effective in reducing GERD
GERD and gastric acidity. symptoms compared with a different PPI (2
studies).
• meta-analysis
• Efficacy in infants and children : PPIs were
more effective in reducing gastric acidity
Howard Bauchner, MD, Journal Watch Pediatrics
and Adolescent Medicine May 4, 2011 than placebo or ranitidine (4 studies).
Multicenter, DB, R, PC trial assessing the efficacy and
safety of PPI lansoprazole in infants with symptoms
of GER disease. Orenstein SR. J Pediatr. 2009;154:514-520.e4.

Symptoms were tracked through daily diaries and weekly visits; 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)

> 1 AEs 62 % 46% (P .058)

Serious AEs
lower RTI (n) 10 2 (P .032)
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 Gastroesophageal Reflux Clinical Practice Guidelines:

GER Bandung 44 Joint Recommendations of NASPGHAN and15-9-2016
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;
J Pediatr Gastroentoerol qNutr 2009;49: 498-547
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 Yes
• Hematemesis?
• Irritability/crying ?
• Fussiness ?
• Arching (Sandifer) ?
Physiology Pathology
• Coughing fits ?
• Failure to thrive ?
Excessive • Feeding problems? History of Allergy
• Neurology ab N

Yes No Yes No

Consider CMPA • GERD Quetionare

• Reassurance Reassurance
• pH metry, edoscopy
the parents eHF
the parents
• Consider
Thickening Yes N
Formula/EHF • Questionaire : Empirical therapy o
H2 Antagonist or PPI 2 weeks Consider other
• pH metry/Endoscopy : H2A /PPI 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