Bharadia L, Moidutty S, Panda M, Hegde R. Diagnosis and management of pedatric GERD in real world practice: A Questionnaire-based survey among Indian pediatricians (GERDCIP Study). Poster presented at: Pedicon 2019. 56th Annual Conference of the Indian Academy of Pediatrics; 2019 Feb 6-10th; Mumbai, India

Background

• Pediatric GERD has become a common problem in the pediatric age group and has shown upward trend over the past decades.¹
• It difficult to diagnose, as symptoms are diverse and often difficult to interpret.²
• Accurate diagnosis, appropriate management strategies, and timely referral to specialist are important principles in the effective management of GERD.³
• There is a scarcity of literature on GERD in children from India.⁴

Aims and Objectives

This survey was conducted to comprehend the existing disease trends of GERD in children and its management.

Materials and Methods

A real world questionnaire-based survey was conducted amongst Indian pediatricians using MCQs.

Results

• A total of 149 pediatricians responded to the survey.
• Over 50% respondents diagnosed GERD in about 6-10% of children in their daily practice.

• Two common GERD manifestations in infants apart from regurgitation were poor weight gain and generalised irritability (46% & 29% respondents).

• Recurrent vomiting and abdominal pain were frequent presentations in older children according to 66% and 45% respondents, respectively.

• Majority of the pediatricians (46%) observed extra-esophageal manifestations in 5-15% of GERD patients. Asthma-like symptoms and chronic cough were the most common extra-esophageal symptoms according to 73% and 70% respondents, respectively.

• More than 1/3 of the total pediatricians chose to treat 10-20% of asthma patients.

• Nearly, 72% respondents labelled GERD diagnosis on basis of history and clinical examination.
• About 37% pediatricians labelled GERD on the basis of response to empiric PPI trial.

• 70% pediatricians agreed on the usefulness of Orenstein’s scale for diagnosis of GERD in infants, though only 32% of them used it.

• Most pediatricians reported a strong correlation between faulty lifestyle and GERD. Frequent consumption of junk food/ aerated drinks (> 2 times/ week) and erratic sleep pattern with no much gap between sleep and meals were most common factors associated with GERD.

• PPI was opted as first line of therapy by majority of pediatricians (83%) with preference for lansoprazole by 90% of them.
• About 44% and 40% respondents chose either a 2 or 4 week PPI empiric trial, respectively.

• 65% pediatricians treated GERD for less than 3 months, which was lesser than the recommended duration.

• Apart from symptomatic relief, the desirable goals while treating GERD were, achieving better quality of life and prevention of complications

• Most pediatricians (76%) reported that fewer than 5% of patients had uncontrolled GERD post-treatment; most common reasons stated were therapy non-adherence (52%), presence of co-morbidities (48%) and delayed diagnosis (39%).
• About 85% of paediatricians referred uncontrolled GERD to a specialist. 

Observations and Discussion

Epidemiology

• Prevalence of GERD in regurgitant infant and children is 30.8% in India⁵
• Contrary to the previous held belief, prevalence of GERD in India is in fact much higher and similar to that reported in the western world.¹
• Traditionally GERD thought to be uncommon in developing countries; studies in multi-ethnic population showed people of Indian origin at higher risk of GERD than ethnic Malay and Chinese.¹

Diagnosis

• Indian Health care professionals overlook GERD in differential diagnosis.¹
• No gold standard for GERD diagnosis; no single test sufficient to make its reliable diagnosis.^4,6
• Several conformational studies* for GERD available only in selected centres thus limiting its use.¹
• Because of its simplicity (just 20 min to complete) and reproducibility, iGERQ can be used to identify infants who need further evaluation.⁷
• Empiric therapy with PPI significantly decreases need for extensive evaluations⁸

o   Out of 100 children (mean age: 9.4± 4.2 yrs) with suspected GERD, 78% responded to empiric PPI of 2 wks

o   Monotherapy of PPIs alone was sufficient; 94% patients used lansoprazole as single PPI

o   Significant decrease in symptom scores noted even at 1st week of study

o   Empiric treatment as initial treatment found to be more cost effective than other approaches

• A proton pump inhibitor (PPI) trial is a valuable diagnostic tool for GERD.⁶
• Greatest symptomatic improvement occurs in the first 2 to 4 weeks of PPI administration⁴

Risk factors¹

• GERD is a well-documented disease in infants and affluent middle aged.
• With spread of means of mass communication like television, children of rural area too have started consuming fast food, aerated drinks etc.
• These life-style changes may subtly contribute to the burden of GERD.
• Simple measures like eating small and frequent meals and to avoid lying down 3 hrs after a meal might help this group of patients.

Limitation

• Number of pediatricians (N=149) in the survey was much lesser than universe of pediatricians in India (20,000+)
• Survey was in MCQ format and not open ended; answers/information were captured from the limited given options.

Conclusion

• GERD in Indian children is diagnosed on basis of history, clinical examination and response to treatment.
• Lansoprazole is the most preferred medication for GERD.

References

1.    Int J Med Public Health 2013; 3: 321-4

2.    Nat Rev Gastroenterol Hepatol. 2014 Mar;11(3):147-57

3.    Paediatr Drugs. 2012 Apr 1;14(2):79-89.

4.    Indian Pediatr. 2013 Jan 8; 50(1):119-2

5.    Int J Contemp Pediatr. 2018 Mar;5(2):395-399

6.    Int. J. Mol. Sci. 2017, 18, 1671

7.    Paediatr Int Child Health. 2018 Aug 6:1-6.

8.    The Turkish Journal of Pediatrics, 2015; 57 (5): 482-486

9.    J Pediatr Gastroenterol Nutr. 2018; 66 (3) :516-554

10. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. National Institute for Health and Care Excellence (NICE) Guidelines 2015

11. Pediatrics. 2013 May;131(5):e1684-95