gastroesophageal%20reflux%20disease%20in%20children
GASTROESOPHAGEAL REFLUX DISEASE IN CHILDREN

Gastroesophageal reflux is categorized as a disease [gastroesophageal reflux disease (GERD)] when reflux is associated with warning signs &/or complications, & requires further evaluation.

It is more common in formula-fed infants than in purely breastfed infants.

There is increased incidence in infants at 4 months of age.

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, & 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 & to rule out presence of dysplasia

Treatment Goals:

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

Pharmacotherapy

Empiric Therapy

  • Appropriate initial management for uncomplicated symptomatic gastroesophageal reflux disease in older children & adolescents
    • Not recommended for infants & young children with uncomplicated gastroesophageal reflux
    • May be considered in infants whose gastroesophageal reflux are accompanied by complications & 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 w/ chronic use

Proton Pump Inhibitors (PPIs)

  • Eg Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole
    • Demonstrates superior efficacy compared to other acid suppressants for older children & adolescents
      • Maintains intragastric pH at or above 4 longer & inhibits food-induced acid secretion
      • Reduces symptoms & 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 w/ chronic use compared to H2RAs

Maintenance Therapy

  • Goal is to have a symptom-free patient without esophagitis
  • Use the lowest dose & least potent medication that can obtain a complete & 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, & 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 & 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 are 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 & warrant diagnostic testing & 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 Aluminun 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 & are not for routine use in patients with gastroesophageal reflux disease
  • Cisapride increases gastric emptying & 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 & 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 & 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
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