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TABLE 23.2. Presentation and differential diagnosis of GORD in the older child/adolescent.
Dyspepsia |
Peptic ulcer disease, non-ulcer |
|
dyspepsia (gastritis), gallstones |
|
(cholecystitis), chronic pancreatitis |
Waterbrash |
Causes of upper GI dysmotility |
|
(coeliac, cholecystitis |
Vomiting/regurgitation |
Migraine, esophageal stricture |
|
General medical clerking to identify |
|
other body system disorders |
Dysphagia |
Esophageal webs, peptic stricture |
|
(due to GORD usually), esophageal |
|
tumors |
Nausea, halitosis |
Any cause of vomiting |
Laryngitis and dysphonia |
Vocal cord palsy (consider Raised |
|
intracranial pressure) |
Respiratory problems |
Asthma |
(dry cough) |
Endobronchial infection |
|
23.2 Investigations
Infants with symptoms suggestive of simple gastroesophageal reflux can be empirically treated with feed thickeners (alginate preparations such as Gaviscon®) or formula feeds changed with thickeners pre-added i.e., (Enfamil AR® Mead Johnson Nutrition). It is reasonable to empirically try an antacid (Ranitidine 2 mg/kg tds) and consider Domperidone 0.4 mg/kg tds (although efficacy of latter is poor).
Children with eczema or strong family history of atopy, or with symptoms of fore gut disturbance (GORD) plus midgut disturbance (bloating, colic, iron deficiency) or hind gut disease (diarrhoea) should be considered to have possible cow’s milk protein intolerance. How these children should be treated will be dealt with elsewhere, but will include a dairy (or a dairy and soya free diet) together
222 D.I. Campbell
with the use of an extensively hydrolyzed milk (Pepti® and Peptijuniour® both Danone Baby Nutrition or Nutramigen I or II® Mead Johnson Nutrition). More resistant cases may require an amino acid based formula (Neocate® SHS Nutrition.1
Children with troublesome symptoms or failure to thrive should have diagnosis confirmed, but also it should be defined what the cause of reflux is (hiatus hernia, dysmotility due to enteropathy, gastritis, etc.). This should be done by endoscopy and ph study (catheter based as a combined impedance study or wireless Bravo Ph®).
23.3 Treatment
Empirical treatments can be continued if a positive response is seen.
We do not recommend more potent acid suppression (using a proton pump inhibitor) beyond 3 months duration without a confirmed diagnosis (see above). Treatment with any form of PPI beyond 3 months increases the risk of community acquired Clostridium difficile colitis, which can present acutely as a fulminating disease.2
PPI such as Omeprazole at 0.7 mg/kg od (max dose 20 mg/ day) in <2 year olds, or 10 mg od up to 20 kg body weight or 20 mg od for body weight above 20 kg. Higher doses should be used for shorter periods.3
23.4 Indications For Pediatric
Gastroenterology Referral
Severe disease with FTT or anemia. Requirements for PPI. Confirm diagnosis. More complex food allergy than simple dairy intolerance.
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References
1.Vandenplas Y, Brueton M, Dupont C, et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child. 2007;92(10):902-908.
2.Thachil J, Time for a hospital antacid policy on Clostridium difficile. BMJ. 2008; 336(7636):109-a.
3.Children BNFf. Proton Pump Inhibitors. In: BNFC, editor. BNFC. London: BMJ Group; 2009:63–64.