GERD: Does it hurt? Prof E De Greef Kidz'HEALTH Castle Colloque de douleur néonatale 'au creux de mon ventre' 6/2/20
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GERD: Does it hurt? Prof E De Greef Kidz’HEALTH Castle Colloque de douleur néonatale ‘au creux de mon ventre’ 6/2/20
WHAT IS GERD? 2 titel 17-2-2020
Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
Statement 1
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 eight weeks.
3 2/17/2020
Regurgitation in infants
20
%
15 %
Nelson 1997
4 17-2-2020
Natural evolution of regurgitation in healthy infants
Hegar B, Vandenplas Y. Acta Paediatr 2009;;98:1189-93
% infants
Natural evolution of regurgitation in infants
Age (months)
5 17-2-2020
Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
6 17-2-2020
Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
7 17-2-2020
Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
8 17-2-2020
GERD DIAGNOSIS?:
DIAGNOSIS
9 titel 17-2-2020
Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
Statement 2
Barium swallows
• The WG suggests NOT to use barium contrast studies
for the diagnosis of GERD in infants and children
Voting: 8,8,9,9,9,9,9,9,9,9 (88)
• Based on expert opinion, the WG suggests to use
barium contrast studies for excluding anatomical abnormalities.
Voting: 8,8,8,9,9,9,9,9,9,9 (87)
10 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
Statement 3
Ultrasonography
• Based on expert opinion, the WG suggests
NOT to use ultrasonography for the diagnosis of GERD
in infants and children.
VOTING: 8, 8, 8, 9, 9, 9, 9, 9, 9, 9 (87)
• Based on expert opinion, the WG suggests to use ultrasonography for
excluding anatomical abnormalities.
VOTING: 8, 8, 8, 9, 9, 9, 9, 9, 9, 9 (87)
11 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-554
Statement 4
Esophago-Gastro-Duodenoscopy :
The working group suggests not to use EGD for diagnosing GERD in
infants and children.
VOTING: 7, 8, 8, 8, 9, 9, 9, 9, 9, 9 (84)
Based on expert opinion,
the working group suggests to use EGD with biopsies to assess
complications of GERD, in case an underlying mucosal disease is
suspected and prior to escalation of therapy.
VOTING: 6, 8, 8, 9, 9, 9, 9, 9, 9, 9 (85)
12 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-54
Statement 7
Scintigraphy:
The working group recommends not to use scintigraphy
for the diagnosis of GERD in infants and children.
VOTING: 8, 8, 8, 9, 9, 9, 9, 9, 9, 9 (87)
13 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-54
Statement 9
PPI-trials
• Based on expert opinion, the WG suggests
a trial up to 8 weeks of PPIs for typical symptoms
(heartburn, retrosternal or epigastric pain)
in children as a diagnostic test for GERD.
VOTING: 3, 7, 7, 7, 8, 8, 8, 9, 9, 9 (75)
14 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-54
Statement 9
PPI trial
• Based on expert opinion, the WG suggests
not to use a trial of PPIs as a diagnostic test for GERD
in patients presenting with extra-intestinal symptoms.
VOTING: 7, 8, 8, 8, 8, 8, 8, 9, 9, 9 (82)
• Based on expert opinion, the WG suggests
not to use a trial of PPIs as a diagnostic test for GERD
in infants.
VOTING: 5, 6, 7, 7, 7, 8, 8, 9, 9, 9 (75)
15 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-54
Statement 10
pH-metry
• Based on expert opinion, in places were pH-MII is not available,
the WG suggests to use pH-metry only
- to correlate persistent troublesome symptoms with acid
GER events
VOTING: 6, 7, 7, 7, 7, 8, 8, 9, 9 (77)
- to clarify the role of acid reflux in the etiology of esophagitis
and other signs and symptoms suggestive for GERD.
VOTING: 6, 7, 7, 7, 7, 8, 8, 9, 9 (77)
- to determine the efficacy of acid suppression therapy.
VOTING: 6, 7, 7, 7, 7, 8, 8, 9, 9 (77)
16 2/17/2020Pediatric GER Clinical Practice Guidelines:
Joint Recommendations of NASPGHAN & ESPGHAN
Rosen R (NASPGHAN) - Vandenplas Y (ESPGHAN) - JPGN 2018;66:516-54
Statement 11
Impedance (pH-MII)
Based on expert opinion, the WG suggests to consider pH-MII testing only to
• correlate persistent troublesome symptoms with
acid and non-acid GER events
VOTING: 6, 7, 7, 7, 8, 8, 8, 9, 9 (78)
• clarify the role of acid and non-acid reflux in the etiology of
esophagitis and other signs and symptoms suggestive for GERD.
VOTING: 6, 7, 7, 7, 8, 8, 8, 9, 9 (78)
• determine the efficacy of acid suppression therapy.
VOTING: 6, 6, 7, 7, 7, 8, 8, 9, 9 (76).
• differentiate patients with NERD, hypersensitive esophagus and
functional heartburn in patients with normal endoscopy.
VOTING: 6, 6, 6, 7, 7, 7, 8, 9, 9 (74)
17 2/17/2020NEONATAL PAINOR
DIAGNOSIS
18 titel 17-2-2020In children unable to talk, pain reporting is reliant
on parents and/or caregivers. Parents usually
know their child’s typical behavioural response to
pain and this can be included in the pain
assessment.
Observation of behaviour in relation to pain is
a valid approach for pain assessment in
children below three years old, and in children
with limited verbal and cognitive skills.
The following self-report pain scales (Faces Pain Scale-Revised, Poker
Chip Tool, the Visual Analogue Scale (VAS), and the Oucher Photographic
and Numerical Rating Scale (NRS) have been recommended to measure
pain intensity in children with acute and persisting pain by both the Ped-
IMMPACT and SPP-ATF reviews.GERD, DOES IT HURT? 24 titel 17-2-2020
Background: • The relation between gastroesophagel reflux (GER) and distressed behavior, expressed as crying in infants is still unclear. • Parents are often very anxious and concerned when their infant is crying and distressed, and these episodes are often interpreted as pain. • Acid inhibitors are often empirically started in distressed infants despite not supported by literature and guidelines
Gastroesophageal reflux disease in infants: how much is
predictable with questionnaires, pH-metry, endoscopy and
histology?
Salvatore S1, Hauser B, Vandemaele K, Novario R, Vandenplas Y. J Pediatr Gastroenterol
Nutr. 2005 Feb;40(2):210-5
Clinical symptoms, histology and pH study show poor
correlation in infants.
Clinical symptoms such as regurgitation and crying are less
frequent in unselected infants than in infants suspected of
gastroesophageal reflux disease.
Questionnaires are poorly predictive for the severity of
gastroesophageal reflux disease
They do not correlate with esophageal acid exposure (pH-
metry) and with esophagitis (histology)
26 titel 17-2-2020 Effect of antireflux medication, placebo and infant mental
health intervention on persistent crying: a randomized
clinical trial.
Jordan B1, Heine RG, Meehan M, Catto-Smith AG, Lubitz L. Paediatr Child Health. 2006
Jan-Feb;42(1-2):49-58
Antireflux medications and IMHC were not superior to
placebo in treating infants with persistent crying.
Although the reduction in maternal distress was similar in all
treatment groups, the individualized IMHC reduced the need
for subsequent admission to a mother-infant unit.
27 titel 17-2-2020“In infants and toddlers there are no symptoms or group of symptoms that can
reliably diagnose GERD or predict treatment response” (evidence B)Pediatric GERD and acid-related conditions (ARC): trends in
incidence of diagnosis and acid suppression therapy.
Nelson SP. J Med Eco 2009;12:348-55.
• Between 2000 and 2005, annual incidence of GERD/ARC
diagnosis among infants (age ≤1 year) more than tripled (from 3.4
to 12.3%) and increased by 30% to 50% in other age groups
• Patients diagnosed by GI specialists (9.2%) were more likely to
be treated with PPIs compared to patients diagnosed by primary
care physician
• PPI-initiated patients doubled: 1999: 31.5% - 2005: 62.6%
• When compared with H²RA-initiated patients:
associated with 30% less discontinuation
90% less therapy switching in 1st month
higher comorbidity burden
29
29 higher pre-treatment total HCU and costs 07-03-16Changes in prescription patterns of acid-suppressant medications
by Belgian pediatricians: analysis of the national database [1997-2009].
De Bruyne P. J Pediatr Gastroenterol Nutr. 2014;58:222-5.
• Increase 7-fold from 20,782 daily defined doses (DDDs)
in January 1997 to 142,912 DDDs in June 2009 per month
• During this study period, reimbursed volume increased of:
H2-RAs from 2575 to 38,996 DDDs per month
PPIs from 3472 to 103,926 DDDs per month
30 07-03-16 20 infants: 584 total reflux episodes, 36% positive for “stress” (16% acid and 84% weakly acidic reflux episodes). Significant association between reflux (both acid and weakly acid GER) and disconfort (> skin conductance) in all infants
5 (DB)RCT eso om lanso eso
DISTRESSED BEHAVIOR AND GER IN
INFANTS: NEW INSIGHTS
• Objectives and study: The relation between
gastroesophagel reflux (GER) and distressed behavior,
expressed as crying in infants is still unclear.
• The "Face, Legs, Activity, Cry, Consolability (FLACC)" scale
is a validated measurement used to assess pain for infants
and young children*.
• The objective of this study was to assess the relation
between GER and the FLACC score.
*Kabes A et al. Further validation of the nonverbal pain scale in intensive care patients Crit Care Nurse 2009;29: 59-66
Voepel-Levis T et al. Merkel S Reliability and validity of the Face, Legs, Activity, Cry, Consolability behavioral tool in assessing acute
pain in critically patients Am J Crit Care 2010;19: 55-61FLACC
0 1 2
FACE No particular Occasional grimace Frequent to constant
expression or smile or frown, withdrawn, quivering chin,
disinterested clenched jaw
LEGS Normal position or Uneasy, restless, Kicking or legs drawn
relaxed tense up
ACTIVITY Lying quietly, normal Squirming, shifting Arched, rigid, or
position, moves back and forth, tense jerking
easily
CRY No cry Moans or whimpers, Crying steadily,
occasional screams or sobs
complaints
CONSOLAB Content, relaxed Reassured by Difficult to console or
ILITY touching, hugging, comfort
voice, distraction
The scale was scored in a range of 0–10 with 0 representing no pain and 2 the
maximum pain expression for any of the five categories (Merkel S. 2002)DISTRESSED BEHAVIOR AND GER IN INFANTS:
NEW INSIGHTS
Methods
• Prospective study (Jan - Nov 2015) consecutively including
infants submitted to MII/pH-monitoring for suspected GER-
disease (GERD) with episodes of crying during the investigation.
• Symptoms considered as temporally associated with GER if within
a 2-minutes period of time. All MII-pH tracings analyzed by a
single author (SS) blind to the result of the FLACC score.
• Parents were instructed to fill in a symptom diary and the FLACC
scale during episodes of crying.
• The medians of the total FLACC score were analysed according to
the presence/absence, duration, kind and extension of GER
events.
• Statistical analysis was performed using Kruskal-Wallis (test H) and t test
when appropriate.DISTRESSED BEHAVIOR AND GER IN INFANTS:
NEW INSIGHTS
Results
• 62 subjects (age 15 days -23 months, mean age
3.5 months – 36 males)
• 452 episodes of crying with the FLACC
completed:
•235 (52%) episodes of crying not associated
with GER.
•217 (48%) of crying associated with GERFigure 1. Comparison of FLACC scores according to temporal association
between distress and GER episodes assessed by MII-pH monitoring
37 titel 17-2-2020FLACC scores in acid GER vs NON-acid GER 38 titel 17-2-2020
DISTRESSED BEHAVIOR AND GER IN INFANTS:
NEW INSIGHTS
Results
The median values of FLACC were not significantly different
between
• EXTENSION:
•Proximal (FLACC 5.5) or only distal (FLACC 4.8) GER,
• DURATION:
•Subjects with (median FLACC 2) or without (median FLACC 5)
abnormal acid exposure.
• AGE:
•Neither younger age or duration of GER were significantly
correlated with high values of FLACC (P=0.15).BUT
• Weakly acidic reflux presented a significant higher
value of FLACC compared to acid reflux events
(FLACC 6 vs 4, Test H di Kruskal-Wallis: P=0.0002).
40 titel 17-2-2020DISTRESSED BEHAVIOR AND GER IN INFANTS:
NEW INSIGHTS
Conclusions
• In infants, most episodes of crying (and pain) were not
associated with GER.
• The presence, kind, temporal sequence, duration,
extension of concomitant GER could not be predicted
by the FLACC scale.
• In infants, weakly acidic reflux was perceived more
painful compared to acid reflux episodes, suggesting
that volume may be more painful than acid.GERD, DOES IT HURT?
WHAT’S YOUR OPINION?
42 titel 17-2-2020 At what age, regurgitations are
experienced as most troublesome by the
parents?
0-3 months
4-6 months
6-12 months
43 titel 17-2-2020 Which of the following statements is
correct in a crying infant suspected of
having GERD:
I suspect the crying to be related to GERD. I do
an Rx follow through to exclude GERD
I suspect the crying to be related to GERD. I
perform a gastroscopy to exclude GERD
before treatment
I suspect the crying to be related to GERD. I do
a pH-monitoring or Impedance as an objective
measurement
I suspect the crying to be related to GERD. I do
44 titela trial with PPI to assess the effect on GERD.
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