Gastroesophageal%20reflux%20disease%20(gerd)%20in%20children Treatment

• Conservative therapy is always the initial management scheme for pediatric patients with gastroesophageal reflux disease
• 3 steps involved in the management of gastroesophageal reflux disease includes lifestyle modification, acid-suppressive medications, and administration of gastric lining protectants (prokinetic agents) to improve transit of stomach contents
• Following proton pump inhibitor therapy, histological exams is recommended to be able to characterize Barrett esophagus and to rule out presence of dysplasia

Treatment Goals

• Relief of symptoms
• Healing of esophagitis
• Prevention of recurrence and complications

Empiric Therapy

• Appropriate initial management for uncomplicated symptomatic gastroesophageal reflux disease in older children and adolescents
  
  • Not recommended for infants and young children with uncomplicated gastroesophageal reflux
  • May be considered in infants whose gastroesophageal reflux are accompanied by complications and in cases where nonpharmacologic therapies have been deemed ineffective 

• A 4-week trial period is recommended

Histamine-2 Receptor Antagonists (H2RAs)

• Eg Cimetidine, Famotidine, Nizatidine, Ranitidine
  
  • Inhibits gastric acid secretion by blocking histamine 2 receptors in the parietal cells
  • Effectively reduces gastric pH by up to 90% when given 3 times daily
  • Also possesses therapeutic properties against erosive esophagitis
  • Use is limited due to tachyphylaxis or tolerance with chronic use

Proton Pump Inhibitors (PPIs)

• Eg Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole
  
  • Demonstrates superior efficacy compared to other acid suppressants for older children and adolescents
    
    • Maintains intragastric pH at or above 4 longer and inhibits food-induced acid secretion
    • Reduces symptoms and possesses therapeutic properties against erosive esophagitis
  • Inhibits gastric acid secretion by blocking the Na⁺-K⁺ ATPase enzyme activity in parietal cells
  • Efficacy remains unchanged even with chronic use compared to H2RAs

Maintenance Therapy

• Goal is to have a symptom-free patient without esophagitis
• Use the lowest dose and least potent medication that can obtain a complete and sustained symptomatic response
• The need for maintenance therapy is determined by the impact of the residual symptoms on the patient’s quality of life
• Recommended duration of therapy for moderate to severe heartburn is 2-4 weeks, 4-8 weeks for diagnosed esophagitis, and 3-6 months for severe erosive esophagitis (followed by repeat endoscopy)

Options for Chronic Acid Suppression

• Step-up therapy involves starting treatment with the less potent agents and moving up for treatment response
  
  • If patient does not respond to an H2RA within 2 weeks, switch to proton pump inhibitor
  • If patient does not respond to this regimen but some improvement in symptoms is seen, dose of proton pump inhibitor may be increased
  • Consider other therapeutic options in PPI-resistant gastroesophageal reflux disease include switching to a different proton pump inhibitor, changing medication time, or adding a prokinetic agent or an H2RA at night
  • If patient still does not respond to above regimens, patient’s symptoms are likely not secondary to reflux and warrant diagnostic testing and referral to pediatric gastroenterologist 

• Step-down therapy makes use initially of a potent acid suppressant, then decreasing dose or switching to less-potent agents
  
  • Proton pump inhibitor dose should be tapered for at least 4 weeks, then weaning from proton pump inhibitors using H2RA to control rebound may be considered
  • This is followed by stepping down further to on-demand use of antacids if patient was asymptomatic while taking an H2RA

Adjunctive Pharmacotherapy

Antacids

• Eg Aluminum hydroxide, Bismuth salicylate, Calcium carbonate, Magnesium hydroxide, Sodium bicarbonate
• Neutralizes gastric secretions in the gastrointestinal tract
• Long-term antacid therapy for pediatric patients is not recommended

Prokinetic Agents

• Eg Baclofen, Bethanecol, Cisapride, Domperidone, Erythromycin, Metoclopramide
• Alternative treatment and are not for routine use in patients with gastroesophageal reflux disease
• Cisapride increases gastric emptying and helps improve esophageal/intestinal peristalsis
  
  • Significantly reduces the reflux index (RI) but efficacy for symptom control is not established
  • The need for Cisapride therapy should be weighed against its adverse effects (eg QT-interval prolongation, ventricular tachycardia, ventricular fibrillation) before initiating therapy 

• Antidopaminergic agents (eg Domperidone, Metoclopramide) help facilitate gastric emptying and reflux index, reducing symptoms in infants with reflux
• Bethanecol, a quarternary ammonium sympathomimetic, has been used as an alternative treatment for gastroesophageal reflux disease but efficacy and safety are yet to be proven
• Baclofen, a γ-amino-butyric-acid receptor agonist, possess functions that reduce the time for gastric emptying
  
  • Studies have shown that Baclofen may also decrease emesis frequency 

• Erythromycin is another treatment option that may be considered to reduce the time for gastric emptying
• Further studies are needed to prove the efficacy of prokinetic agents for the treatment of gastroesophageal reflux disease in children

Surface Protective Agents

• Eg Alginate, Sucralfate
• Treatment option against mucosal erosion; should not be used as monotherapy for gastroesophageal reflux disease
• Alginate may be used for formula-fed infants to help thicken liquid preparations during feeding