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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1

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.

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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.

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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

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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 . 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

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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.

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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, , 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 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

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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.

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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, , 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9

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

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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 , achalasia, tracheoesophageal fistula, anastomotic strictures, antral web, intestinal malrotation, or peptic strictures.4

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Endoscopy and Histology

Endoscopic evaluation of the upper is indicated for selected patients in whom esophagitis or 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 , 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

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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

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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

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:

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 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)

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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.

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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

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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 (), 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

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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

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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,

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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.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

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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

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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

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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

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Correct Answers:

1. Up to ______percent of children and teens have symptoms of GERD, although GERD is more common in adults. Correct Answer: 25

2. Regurgitation is present in ____ to ____ percent of all infants, peaks at age four months, and typically resolves by one year. Correct Answer: 50 to 70

3. GERD is common in children with ______, and may be manifested only by unexplained or self-injurious behaviors.

Correct Answer: autism

4. H2RAs have ______effect on gastroesophageal reflux.

Correct Answer: moderate

5. True/False. Endoscopy can be performed in infants, toddlers, and older 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25

9. True/False. Sandifer syndrome is most often found in preschool-aged children who are high achievers and with compulsive traits.

Correct Answer: True

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.

Correct Answer: True

15. Baclofen

Correct Answer: inhibits transient relaxations of the lower esophageal sphincter

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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: 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

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