Gastroesophageal%20reflux%20disease%20(gerd)%20in%20children Treatment
Principles of Therapy
- 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
Pharmacotherapy
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
- Demonstrates superior efficacy compared to other acid suppressants for older children and adolescents
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