Gastroesophageal Reflux Disease (GERD) In The Child reflux disease (GERD) ... gastroesophageal reflux disease (GERD) in the child, ... and/or epigastric pain,

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Gastroesophageal

Reflux Disease

(GERD)

In The Child

Elizabeth Boldon, RN, MSN

Elizabeth Boldon is a Nurse Education

Specialist at Mayo Clinic in Rochester,

Minnesota. She received a BSN from Allen College in Waterloo, Iowa in 2002 and an

MSN with a focus in education from the University of Phoenix in 2008. She has

bedside nursing experience in medical neurology and the neuroscience ICU.

Abstract

Gastroesophageal reflux disease (GERD) is defined as a condition that

develops when the reflux of stomach contents causes troublesome

symptoms with or without mucosal damage and/or complications. GERD

symptoms can include nausea, dysphagia, burning chest or abdominal pain,

respiratory disorders and mild to severe damage to the esophageal lining

and functioning. Patients that are not investigated for symptoms or not

followed up through recommended diagnostic testing when damage to the

esophagus has occurred are at risk of further injury and complications,

including Barrett’s esophagus (a precancerous condition). Although GERD is

more common in adults, up to 25 percent of children and teens have

symptoms of GERD. The diagnosis, symptoms, complications and standard

medical and surgical treatment of GERD in children are discussed.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Nurses need to recognize and stay informed of symptoms of

gastroesophageal reflux disease (GERD) in the child, including the current

and evolving trends in GERD diagnosis and treatment management.

Course Purpose

To provide nursing professionals with knowledge to care for children with

GERD and to help support improved quality of life.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 10/28/2018

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.


1. Up to ______ percent of children and teens have symptoms of GERD,

although GERD is more common in adults.

a. 10

b. 12

c. 25

d. 40

2. Regurgitation is present in ____ to ____ percent of all infants, peaks at

age four months, and typically resolves by one year.

a. 20 to 30

b. 50 to 70

c. 65 to 70

d. none of the above

3. GERD is common in children with _____________, and may be

manifested only by unexplained or self-injurious behaviors.

a. asthma

b. LES deformity

c. autism

d. a strong family history

4. H2RAs have ____________ effect on gastroesophageal reflux.

a. moderate

b. minor

c. high

d. indeterminate

5. True/False. Endoscopy can be performed in infants, toddlers, and older

children.

a. True

b. False


Introduction

Gastroesophageal reflux (GER) happens when stomach contents come back

up into the esophagus. Stomach acid that touches the lining of the

esophagus can cause heartburn, also called acid indigestion. Occasional GER

is common in children and teens — ages 2 to 19 — and doesn’t always mean

that they have gastroesophageal reflux disease (GERD). GERD is a more

serious and long-lasting form of GER in which acid reflux irritates the

esophagus. GER that occurs more than twice a week for a few weeks could

be GERD. GERD can lead to more serious health problems over time.

Up to 25 percent of children and teens have symptoms of GERD, although

GERD is more common in adults. This course will discuss GERD, its

symptoms, causes, methods of diagnosis, complications and treatments.

What Is GERD?

“Gastroesophageal reflux” (GER) refers to the passage of gastric contents

into the esophagus. This is a normal physiologic process that occurs in

healthy infants, children, and adults. Most episodes are brief and do not

cause symptoms, esophageal injury, or other complications. In contrast,

“gastroesophageal reflux disease” (GERD) is present when the reflux

episodes are associated with complications or troublesome symptoms.1

Regurgitation in infants is common and typically decreases or resolves

during the first year of life. Although the problem usually resolves by the end

of infancy, there is a weak association with GERD later in life. As an

example, frequent regurgitation during infancy and a history of GERD in the


mother (but not the father) both

predict the risk of reflux-related

symptoms during childhood. Symptoms

of GERD during childhood are

moderately likely to persist to

adolescence and adulthood.1

Several questions related to the

epidemiology and natural history of

GERD in children remains unanswered.

There is only a partial understanding of

the relationship between GER and

respiratory diseases, including asthma,

chronic cough, and recurrent

pneumonia. In addition, the

relationship between childhood GERD and related complications in adulthood

is unclear. Finally, the healthcare burden related to the diagnosis and

treatment of childhood GERD and the impact of GERD on quality of life for

children and their families have not been fully examined.1

Symptoms of GERD in Children

The most common symptoms of gastroesophageal reflux (GER) and

gastroesophageal reflux disease (GERD) vary according to age, although

overlap may exist.


Infants

Gastroesophageal reflux is common in

infants and usually is not pathological.

Regurgitation is present in 50 to 70

percent of all infants, peaks at age four

months, and typically resolves by one

year. A small minority of infants with

GER develops other symptoms

suggestive of GERD, including feeding

refusal, irritability, hematemesis,

anemia, respiratory symptoms, and

failure to thrive.1

Preschool

Preschool age children with GERD may present with intermittent

regurgitation. Less commonly, they may have respiratory complications

including persistent wheezing. Decreased food intake or poor weight gain

without any other complaints may be a symptom of esophagitis in young

children.

All of these symptoms are nonspecific and insufficient to make a definitive

diagnosis of GERD. A more specific symptom of GERD is Sandifer syndrome,

an unusual posturing consisting of arching of the back, torsion of the neck,

and lifting up of the chin. Sandifer syndrome is most often found in

preschool-aged children who are developmentally delayed, but also may be

seen in children without neurologic abnormalities.1


Older Children and Adolescents

The pattern of symptoms and complications of GERD in older children and

adolescents resemble that seen in adults. The cardinal symptoms are chronic

heartburn and/or regurgitation. Complications of GERD, including

esophagitis, strictures, Barrett's esophagus, and hoarseness due to reflux

laryngitis also may be seen. Older children may complain of nausea,

dysphagia (difficulty swallowing) and/or epigastric pain, but many pre-

adolescents will not localize pain and report diffuse abdominal discomfort.1

Gastroesphageal disorder-related chest pain is not well described by young

children. Young or nonverbal children may be observed pounding their chest.

GERD is common in children with autism, and may be manifested only by

unexplained or self-injurious behaviors. In older children, chest pain typically

is described as squeezing or burning, located substernally and sometimes

radiating to the back, lasting anywhere from minutes to hours, and resolving

either spontaneously or with antacids. It usually occurs after meals, awakens

patients from sleep, and may be exacerbated by emotional stress.1

Etiology Of GERD In Children

Like in adults with the condition, gastroesophageal reflux is the upward

movement of stomach contents into the esophagus and sometimes into or

out of the mouth. Usually infants with the condition are otherwise healthy,

but some infants have other problems affecting their nerves, brain, or

muscles. Generally, a child's immature digestive system is usually to blame.

Most infants grow out of GERD by the time they are one-year old.


In older children, the causes of

GERD are different than what is

seen in infants and adults.

Anything that causes the muscular

valve between the stomach and

esophagus (the lower esophageal

sphincter or LES) to relax, or

anything that increases the

pressure below the LES, can cause

GERD. Such things include obesity,

overeating, constipation, and

certain foods, beverages, and

medications.2

Diagnosis Of GERD In Children

This section briefly covers diagnostic tools to identify GERD in children,

including screening tools, empiric treatment, and more invasive techniques

to identify causes underlying GERD symptoms of abdominal pain and

associated complications.

A number of diagnostic options to

determine management are available to

clinicians evaluating children with

symptoms of GERD. Helicobacter pylori

or H. pylori test-and-treatment as an

initial diagnostic and treatment strategy

is a common approach. If H. pylori

were to be detected, empiric antibiotic therapy can be prescribed to


hopefully eradicate the infection. One technique is to prescribe empiric

antisecretory (reduction of gastric acid level generally through PPI

medication) therapy first and test for H. pylori later if treatment fails to

eradicate symptoms. A final approach to diagnose GERD is to perform upper

endoscopy or esophagogastroduodenoscopy (EGD) for patients with

dyspepsia.

The best diagnostic option for children remains a topic of debate. The Rome

Foundation, discussed later, researches and reviews patient care outcome

data to help guide clinician’s to make a rational decision.

Screening Questionnaires

Screening questionnaires can offer a useful diagnostic aid tool. Working

committees of the Rome Foundation (an international symposium of

gastrointestinal disease and psychiatry experts) has developed screening

questionnaire tools for pediatric gastrointestinal symptoms. Original

questionnaires were used to screen for pediatric functional gastrointestinal

disorders and symptoms. Newer screening tools have been developed with

input from recent Child and Adolescent Committees of the Rome Foundation

with updated criteria and scoring methods to diagnose GERD in the pediatric

population.

Screening questionnaires include a patient and parent-report for children

four years of age and older. A child self-report has been identified as more

appropriate to children ten years of age and older, and has been

recommended as preferred to a parent report. The questionnaire uses scales

to measure frequency, severity, and duration of GERD symptoms and may


be scored to assess whether a patient meets the criteria to diagnose

pediatric GERD as well as other gastrointestinal functional disorders. A

diagnostic coding system is included that allows the health provider to

assign a provisional diagnosis to symptoms identified in the screening

questionnaire. Screening questionnaires are considered a supportive method

to diagnose pediatric GERD, and not intended to replace medical evaluation

and clinical judgment important to an accurate diagnosis.3

Empiric Treatment

An empiric trial of acid suppression is often used as a diagnostic test, and is

suggested for older children and adolescents with uncomplicated heartburn.

The trial typically consists of a two- to four-week course of acid-suppressing

medication (i.e., a proton pump inhibitor). Empiric treatment is not a

valuable diagnostic test in infants and young children, in whom symptoms of

GERD are less specific. Studies in adults suggest that empiric treatment may

be a cost-effective approach in selected patients, although the applicability

of these results to children is uncertain.4

Barium Contrast Radiography

Barium studies of the esophagus are neither sensitive nor specific for the

diagnosis of GERD. Thus, radiologic evaluation is not useful to confirm or

exclude GERD in children. However, it can be useful in the evaluation of

selected patients with atypical or severe presenting features, particularly

those with dysphagia or odynophagia. In such patients, the barium contrast

study is used to evaluate for the possibility of anatomic abnormalities,

including hiatal hernia, achalasia, tracheoesophageal fistula, anastomotic

strictures, antral web, intestinal malrotation, or peptic strictures.4


Endoscopy and Histology

Endoscopic evaluation of the upper gastrointestinal tract is indicated for

selected patients in whom esophagitis or gastritis is suspected. These

include children or adolescents with heartburn, hematemesis, or epigastric

abdominal pain that fails to respond to or relapses quickly after empiric

treatment. In addition, endoscopy may be valuable in the evaluation of

patients with recurrent regurgitation, dysphagia, odynophagia, or a history

of food impaction, or in children with frequent reflux that continued from

infancy until after two years of age.

During endoscopy, the examiner inspects the visual appearance of the

esophageal mucosa and anatomy, and usually takes a series of biopsies for

histologic examination. The findings help to determine the presence and

severity of esophagitis and complications, such as strictures or Barrett’s

esophagus, and to exclude other disorders such as eosinophilic esophagitis,

allergic esophagitis, or infectious esophagitis.

Endoscopy can be performed in infants, toddlers, and older children.

Procedure-related complications of diagnostic endoscopy and biopsy are

rare. Complications may occur due to over- or under-sedation.4

Esophageal pH Monitoring or Impedance Monitoring

Esophageal pH monitoring permits the assessment of the frequency and

duration of esophageal acid exposure and its relationship to symptoms.

However, the results do not correlate consistently with symptom severity or

objective findings on endoscopy. Therefore, pH monitoring can raise or lower


suspicion of GERD, but is not a definitive diagnostic test, and is not useful in

many clinical situations, especially in infants.

The test involves passing a catheter through the nose into the lower

esophagus, where pH is continuously measured by a microelectrode. The pH

electrode is positioned according to a formula that takes into account the

length of the child. Radiologic or manometric confirmation of the position of

the tip of the probe usually is not necessary. A device is worn by the patient

and records esophageal acid exposure during the period of monitoring. The

procedure is considered to be very safe, but keeping the probe in place may

be difficult in toddlers and uncooperative children.

Newer pH study devices that clip a capsule to the esophageal mucosa and

remain in place for 24 – 48 hours allow recording of intraesophageal pH

without the transnasal catheter. This technology can be used for older

children and is particularly beneficial for children with autism in whom

transnasal pH monitoring studies may be difficult to perform.

The type of recording device, 24-hour pH probe or 24-48 hour capsule

placement in the esophagus, the patient’s diet, body position (erect or

supine), and the activity of the patient during the study will influence the

result or final report of a pH study. Interpretation of the test results after

longer periods of monitoring (24 - 48 hours) generally is more reliable than

after shorter periods (i.e., < 24 hours), although longer periods of

monitoring may not always be feasible.4


Multichannel intraluminal impedance monitoring (MII) is a newer technique

that permits measurement of all reflux episodes, including those that are

acid, weakly acidic and alkaline. MII is now available at many centers, and

usually is used in combination with pH monitoring so that episodes of acid

reflux may be distinguished from non-acid reflux. Although pediatric

standards for MII have not been established, the technique can be helpful to

determine whether there is a correlation between reflux episodes and certain

symptoms.4

Complications Of GERD In Children

Without treatment, GERD can sometimes cause serious complications over

time. Complications of GERD are identified briefly below.5

Esophagitis and Esophageal Stricture

Esophagitis involves mucosal injury of the esophagus and may lead to

ulcerations, a sore in the lining of the esophagus.

An esophageal stricture happens when a person’s esophagus becomes too

narrow. Esophageal strictures can lead to problems with swallowing.

Respiratory Problems

A child or teen with GERD might breathe stomach acid into his or her lungs.

The stomach acid can then irritate the throat and lungs, causing respiratory

problems or symptoms, such as:


asthma

chest congestion, or extra fluid in the lungs

a dry, long-lasting cough or a sore throat

hoarseness

laryngitis

pneumonia

wheezing

Treatment Of GERD In Children

Medical providers often suggest lifestyle changes as an initial approach to

treatment for children and adolescents with mild or infrequent symptoms of

gastroesophageal reflux, such as occasional heartburn or painless

regurgitation. Lifestyle changes also may be helpful as an adjunct to

pharmacologic treatment in patients with moderate or severe symptoms

suggestive of gastroesophageal reflux disease.3 The type of lifestyle changes

that may be beneficial depend upon the patient's age and symptom

characteristics, as described below.

Infants:

Elevating the head of the baby's crib or bassinet

Holding the baby upright for 30 minutes after a feeding

Thickening bottle feedings with cereal (should not be done without a

medical provider's supervision)

Changing feeding schedules

Trying solid food (with a provider's approval)


Older children:

Elevating the head of the child's bed

Keeping the child upright for at least two hours after eating

Serving several small meals throughout the day, rather than three

large meals

Limiting foods and beverages that seem to worsen the child's reflux

Encouraging the child to get regular exercise

Medications that are used for treatment of gastroesophageal reflux disease

can be grouped into the following categories:

Proton pump inhibitors (PPI)

Histamine type 2 receptor antagonists (H2RA)

Antacids

Prokinetics

Surface agents

Proton Pump Inhibitors

Proton pump inhibitors (PPIs) block acid secretion by irreversibly binding to

and inhibiting the hydrogen-potassium ATPase pump that resides on the

luminal surface of the parietal cell membrane. The drugs in this class include

omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole.

The differences in pharmacology and efficacy among drugs in this class

appear to be small and of uncertain clinical significance, thus it is reasonable

to make treatment decisions based on cost and on which dosing formulation

is accepted by the child.


Omeprazole, esomeprazole, and lansoprazole have been most extensively

studied in children and are approved by the U.S. Food and Drug

Administration (FDA) for this age group, but not in infants.4

Histamine Type 2 Receptor Antagonists

For patients with mild or intermittent symptoms of GERD, providers often

suggest a trial of histamine type 2 receptor antagonists (H2RAs) rather than

PPIs or other drugs. H2RAs have moderate effects on gastroesophageal

reflux, as measured by relief of symptoms and mucosal healing, but because

these medications have a relatively rapid onset of action they are well suited

for providing symptomatic relief. However, they are somewhat less effective

than the PPI class, especially for chronic use.

The H2RAs inhibit acid secretion by blocking histamine H2 receptors on the

parietal cell. Four H2RAs are available in the United States, in both

prescription strength and a lower strength for non-prescription (over-the-

counter) sales:4

Cimetidine (Tagamet)

Ranitidine (Zantac)

Famotidine (Pepcid)

Nizatidine (Axid)

Antacids

Antacids are appropriate for short-

term relief of heartburn in older

children, adolescents, or adults with


infrequent symptoms (less than once a week). Antacids begin to provide

relief of heartburn within five minutes but have a short duration of effect of

30 to 60 minutes. The efficacy and safety of antacids have not been well

studied, and chronic use is generally not recommended, especially in infants.

Antacids work by neutralizing gastric pH and thereby decreasing the

exposure of the esophageal mucosa to gastric acidity during episodes of

reflux. Various preparations that are commercially available usually contain

the combination of magnesium and aluminum hydroxide or calcium

carbonate.4

Prokinetics

Prokinetic drugs have a very limited role in management of GERD because of

significant safety concerns and limited efficacy. Systematic reviews have not

supported the use of metoclopramide, cisapride, or domperidone for

treatment of GERD. These drugs should be considered for use only in

carefully selected patients who have problems with gastric emptying because

of gastric dysmotility (gastroparesis), contributing to GERD. Erythromycin

also is used for patients with gastric dysmotility, such as post-viral

gastroparesis, but its use is limited by side effects and tachyphylaxis

(tolerance).

Baclofen is a gamma-amino-butyric acid B (GABA-B) receptor agonist that

inhibits the transient relaxations of the lower esophageal sphincter that are a

predominant mechanism of reflux. A limited body of evidence in adults and

children suggests that baclofen reduces reflux symptoms after acute or


chronic dosing, reduces the frequency of esophageal sphincter relaxation

and esophageal acid exposure, and accelerates gastric emptying.

Potential side effects include dyspepsia, drowsiness, and lowered seizure

threshold. Because of side effects, baclofen is rarely used to treat GERD in

children without underlying neurological problems. However, it is

occasionally used for children with cerebral palsy, in whom it may also

improve spasticity.4

Surface Agents

Surface agents work by creating a barrier that impedes peptic injury to

mucosal surfaces. Only two such substances have been evaluated in the

treatment of GERD: sodium alginate and sucralfate.

Sucralfate (aluminum sucrose sulfate) adheres to the mucosal surface,

promoting healing and protecting from further peptic injury by mechanisms

that are incompletely understood. Because of short duration of action,

concerns related to aluminum toxicity and limited efficacy as compared with

PPIs, sucralfate has a minimal, if any, role in the treatment of GERD in

children (or adults).

Sodium alginate, which is derived from seaweed, forms a surface gel that

creates a physical barrier against regurgitation of gastric contents and

protects the esophageal mucosa. Studies comparing its efficacy on

symptoms and esophageal acid exposure with other available treatments

have produced conflicting results. It currently is used infrequently in the

treatment of children with GERD.4


Surgery

Antireflux surgery appears to be successful in controlling reflux in many

patients with debilitating gastroesophageal reflux disease (GERD) that is

refractory to medical management,2 but the indications for and outcome of

the intervention have not been systematically studied. Many of the children

who have undergone antireflux surgery have underlying neurological

impairment such as cerebral palsy.

Surgery is most often considered for patients with intractable esophagitis or

emesis that does not respond to proton pump inhibitors (PPIs), or pulmonary

disease that is clearly due to aspiration from refluxed material. It may be

challenging to discriminate pulmonary disease from aspiration associated

with swallowing from that related to reflux.

The Nissen fundoplication is the most often performed surgery. During this

procedure, the top part of the stomach is wrapped around the esophagus

forming a cuff that contracts and closes off the esophagus whenever the

stomach contracts - preventing reflux. The procedure is usually effective, but

it is not without risk. Potential risks and benefits of this operation should be

discussed with health care providers before it is performed.

Endoscopic Techniques

Endoscopic techniques, such as endoscopic sewing and radiofrequency, help

control GERD in a small number of people. Endoscopic sewing uses small

stitches to tighten the sphincter muscle. Radiofrequency creates heat

lesions, or sores, that help tighten the sphincter muscle. A surgeon performs

both operations using an endoscope at a hospital or an outpatient center,


and the child or teen receives general anesthesia. The results for endoscopic

techniques may not be as good as those for fundoplication.5

Summary

Gastroesophageal reflux disease occurs in children when acid from the

stomach backs up into the esophagus. This can cause a range of symptoms

as well as discomfort for the child. Through proper diagnosis, there can be

effective treatments. Screening tools are useful to support diagnostic

decisions, however evaluation and follow up of patients are generally

recommended for providers treating individuals with GERD in a primary care

setting. A number of treatment management options are available for

clinicians managing GERD symptoms in children. Often, patient and parent

reassurance and education is generally pursued, with possible use of over-

the-counter antacids, H2-blockers or PPIs. Other strategies may be used to

evaluate treatment response and determine further evaluation if symptoms

do not abate. New data in patient trends and research are continually

evolving to support clinicians making diagnostic and treatment choices.

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a. 10

b. 12

c. 25

d. 40



a. 20 to 30

b. 50 to 70

c. 65 to 70

d. none of the above



a. asthma

b. LES deformity

c. autism

d. a strong family history


a. moderate

b. minor

c. high

d. indeterminate


children.

a. True

b. False


6. GERD symptoms in children:

a. are no different than adults

b. vary according to age

c. may include overlap

d. answers b and c above

7. Omeprazole is an example of a(n):

a. Antacid (over the counter)

b. H2 blocker

c. Proton pump inhibitor

d. Either a or b above

8. Antacids begin to provide relief of heartburn within 5 minutes but have

a duration of effect of ___________.

a. more than 2 hours

b. 30 – 60 minutes

c. 8 hours

d. that is unknown

9. True/False. Sandifer syndrome is most often found in preschool-aged

children who are high achievers and with compulsive traits.

a. True

b. False

10. Sodium alginate

a. is derived from seaweed

b. forms a surface gel that creates a physical barrier

c. protects against regurgitation of gastric contents and the esophageal

mucosa

d. All of the above


11. Many of the children who have undergone antireflux surgery have

a. significant food allergies

b. underlying neurological impairment, such as cerebral palsy

c. celiac sprue

d. Answers a and c above

12. Sucralfate (aluminum sucrose sulfate)

a. adheres to the mucosal surface

b. promotes healing and protects from further peptic injury

c. protects mucosal tissue by mechanisms that are well

documented and understood

d. Answers a and b above

13. True/False. Endoscopic sewing uses small stitches to close an ulcer.

a. True

b. False

14. True/False. Surgery is most often considered for patients with

intractable esophagitis or emesis that does not respond to proton pump

inhibitors (PPIs), or pulmonary disease that is clearly due to aspiration

from refluxed material.

a. True

b. False

15. Baclofen

a. a gamma-amino-butyric acid A (GABA-A) receptor agonist

b. inhibits transient relaxations of the lower esophageal sphincter

c. reduces reflux symptoms for only chronic conditions

d. slows gastric emptying


Correct Answers:



Correct Answer: 25



Correct Answer: 50 to 70



Correct Answer: autism


Correct Answer: moderate


children.

Correct Answer: True

6. GERD symptoms in children:

Correct Answer: answers b and c above

7. Omeprazole is an example of a(n):

Correct Answer: Proton pump inhibitor

8. Antacids begin to provide relief of heartburn within 5 minutes but have

a duration of effect of ___________.

Correct Answer: 30 – 60 minutes


9. True/False. Sandifer syndrome is most often found in preschool-aged

children who are high achievers and with compulsive traits.


10. Sodium alginate

Correct Answer: All of the above

11. Many of the children who have undergone antireflux surgery have

Correct Answer: underlying neurological impairment, such as cerebral

palsy

12. Sucralfate (aluminum sucrose sulfate)

Correct Answer: Answers a and b above

13. True/False. Endoscopic sewing uses small stitches to close an ulcer.

Correct Answer: False

14. True/False. Surgery is most often considered for patients with

intractable esophagitis or emesis that does not respond to proton pump

inhibitors (PPIs), or pulmonary disease that is clearly due to aspiration

from refluxed material.


15. Baclofen

Correct Answer: inhibits transient relaxations of the lower esophageal

sphincter


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Winter, H.S. (2015). Clinical manifestations and diagnosis of

gastroesophageal reflux disease in children and adolescents in Hoppin,

A.G. (Ed.), UpToDate. Waltham, Mass: UpToDate. Retrieved October 19,

2015 from www.uptodate.com

2. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint

Recommendations of the North American Society for Pediatric

Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the

European Society for Pediatric Gastroenterology, Hepatology, and

Nutrition (ESPGHAN) (2009). Journal of Pediatric Gastroenterology and

Nutrition; 49:498-547 (2009). Retrieved online on October 27, 2015 @

http://www.naspghan.org/files/documents/pdfs/position-

papers/FINAL%20-%20JPGN%20GERD%20guideline.pdf.

3. Rome III Diagnostic Questionnaire for the Pediatric Functional GI

Disorders: Appendix E. (2007). Rome Foundation. Retrieved online

October 25, 2015 from http://www.romecriteria.org/pdfs/pediatricq.pdf.

4. Winter, H.S. (2015). Management of gastroesophageal reflux disease in

children and adolescents in Hoppin, A.G. (Ed.), UpToDate. Waltham,

Mass: UpToDate. Retrieved October 11, 2015 from www.uptodate.com

5. Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease

(GERD) in Children and Teens. (2015). National Institute of Diabetes

and Digestive and Kidney Diseases. Retrieved October 20, 2015 from

www.niddk.nih.gov

http://www.uptodate.com/

http://www.naspghan.org/files/documents/pdfs/position-papers/FINAL%20-%20JPGN%20GERD%20guideline.pdf

http://www.naspghan.org/files/documents/pdfs/position-papers/FINAL%20-%20JPGN%20GERD%20guideline.pdf

http://www.romecriteria.org/pdfs/pediatricq.pdf

http://www.uptodate.com/

http://www.niddk.nih.gov/

Documents

Gastroesophageal Reflux Disease (GERD) In The Child reflux disease (GERD) ... gastroesophageal reflux disease (GERD) in the child, ... and/or epigastric pain,