GERD research

[Anonymous]

I thought I’d post this for those of you who are into research in general, or GERD research specifically.

Yesterday at work I attended a workshop about the do’s and don’ts in searching for literature/research using the www. The best tip they gave was that most of the research worth reading from a literature point of view isn’t actually published in the “free web” but needs to be researched from the “invisible web” aka the paid web. We were given access to some of the most expensive and reputable medical databases, so of course I took the opportunity to look up pediatric GERD.

My favourite database was called Up to Date. The intention of this database is to find the most up to date literature on various medical conditions, and it is updated every 6 months. All literature is from reputable, peer-reviewed sources, and is supposed to outline the gold standard for treatment, since it’s intended to be used at point of care.

For those interested, here’s what the database had to say about pediatric GERD. (Unfortunately, because it’s a paid subscription, you can’t view all the links, just the main data, but it’s very thorough and I thought very informative). FYI, there’s a very long list of references, and one of Dr. Phillips’ articles was included.

If anyone would like me to post about additional topics (like MSPI/allergies etc) please let me know as I have access to this subscription.

Here’s the article:

Management of gastroesophageal reflux disease in children and adolescents

Carlos H Lifschitz, MD

UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.1 is current through December 2006; this topic was last changed on January 12, 2007. The next version of UpToDate (15.2) will be released in June 2007.

INTRODUCTION — The passage of gastric contents into the esophagus (gastroesophageal reflux) 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 symptoms or complications. The range of symptoms and complications of GERD in children are variable depending upon the child’s age.

Several treatment options are available for controlling symptoms and preventing complications in children with GERD. The choice among them depends upon the patient’s age, the type and severity of symptoms, and response to treatment. The following sections review the available options. Specific recommendations for how these options should be used are provided separately. (See “Summary and recommendations” below).

This topic review focuses on the management of GERD in children and adolescents. Discussion of GERD in infants, and the clinical manifestations, diagnosis, and pathophysiology of GERD are provided separately. (See “Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents”, see “Gastroesophageal reflux in infants” and see “Gastroesophageal reflux in premature infants”). The discussions in all of these topic reviews reflect an official consensus statement and systematic review issued by the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) [1]. The full text of these guidelines is available on the Internet (http://www.naspghan.org).

LIFESTYLE CHANGES — The type of lifestyle changes that may be beneficial depend upon the patient’s age and symptom characteristics. Few studies have focused on the benefit of lifestyle modifications in children and adolescents with GERD. Thus, recommendations can be extrapolated mostly from studies in adults. Even in adults, there is limited evidence supporting efficacy for these interventions, as is discussed separately. (See “Medical management of gastroesophageal reflux disease in adults”, section on Lifestyle modification”).

The following approaches have some benefit in adult patients with reflux, but have not been rigorously evaluated in either adults and children [1,2].

• Head of bed elevation is important for individuals with nocturnal or laryngeal symptoms, but its value for other situations is unclear.
• Weight loss or weight management for individuals who are overweight.

The following lifestyle approaches also are used frequently. There is some evidence that these lifestyle changes improve laboratory measures of reflux (such as lower esophageal sphincter pressure), but no clinical evidence that they improve reflux symptoms [2]:

• Dietary modification — A practical approach is to avoid a core group of reflux-inducing foods, including chocolate, peppermint, and alcohol, which may reduce lower esophageal sphincter pressure. Acidic beverages, including colas and orange juice also may exacerbate symptoms. The benefit of reducing fat intake in children is unproven.

• Avoiding the supine position soon after eating.

• Promotion of salivation by either chewing gum or using oral lozenges. Salivation neutralizes refluxed acid, thereby increasing the rate of esophageal acid clearance.

• Avoidance of tobacco and alcohol, as these substances reduce lower esophageal sphincter pressure, and smoking also diminishes salivation.

PHARMACOTHERAPY — There are five main classes of drugs that have been evaluated for treatment of GERD (show table 1). Pharmacotherapy for gastroesophageal reflux is discussed in detail separately. (See “Medical management of gastroesophageal reflux disease in adults”, section on Acid-suppressive medications).

• Proton pump inhibitors
• Histamine type 2 receptor antagonists
• Antacids
• Prokinetics
• Surface agents

Proton pump inhibitors — Proton pump inhibitors 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 pharmacology and efficacy of proton pump inhibitors are discussed in detail separately. 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. (See “Overview and comparison of the proton pump inhibitors for the treatment of acid-related disorders”).

Efficacy — The proton pump inhibitors (PPIs) are superior to H2RAs in relieving symptoms and healing esophagitis in adults [1,3]. They produce a greater reduction in acid secretion, have a longer duration of action, and tolerance does not develop. There are no similar randomized trials in children, but several case series report that PPIs have healed severe esophagitis that had been unresponsive to H2RAs [4,5]. (See “Medical management of gastroesophageal reflux disease in adults”).

Evidence for efficacy of PPIs in children is primarily from open-label trials [1,6,7], although at least two controlled trials have been published [8,9]. One such trial included 32 children (age 6 months to 13.4 years) with severe esophagitis who were randomly assigned to receive standard doses of omeprazole (40 mg/day per 1.73 m2 surface area) or high-dose ranitidine (20 mg/kg per day) [8]. Both regimens were associated with significant improvement in symptoms and in endoscopic and histologic findings and were effective in reducing esophageal acid exposure during 24-hour pH monitoring. Thus, in this small short-term trial, omeprazole offered no advantage over high-dose ranitidine. A second placebo-controlled crossover trial focused on 30 infants (ages 3 to 12 months) all of whom were considered to be “irritable” and demonstrated abnormal results on pH monitoring [9]. Although treatment with omeprazole significantly reduced esophageal acid exposure, it had no effect on irritability.

The benefit of PPIs on extraesophageal manifestations of GERD in children such as asthma has not been well-studied, although they are already being used for this purpose in children based upon data in adults. (See “Gastroesophageal reflux and asthma” and see “Asthma” below).

Dosing — Dosing guidelines for PPIs vary considerably; infants and younger children appear to metabolize PPIs more rapidly and may require higher per-kilogram dosing than older individuals (show table 1) [10,11]. In some pediatric studies, effective doses of omeprazole ranged from 0.3 to 3.5 mg/kg/day (maximum 80 mg/day); doses of lansoprazole were 0.73 to 1.66 mg/kg/day (maximum 30 mg/day) [12].

Several of these drugs are formulated as capsules containing enteric-coated granules that can be sprinkled onto soft foods for administration to young children. Lansoprazole and omeprazole are also available as flavored powders for preparing a suspension.

Safety — More than 10 years of follow-up data have attested to the safety of omeprazole in adults [13]. The longest-term safety and efficacy data in children are for up to two years [14]. The long-term consequences of PPI-induced hypergastrinemia are unknown. Other potential safety concerns include an increased susceptibility to enteric infections (particularly Clostridium difficile) and community-acquired pneumonia [15,16], and vitamin B12 malabsorption. (See “Pathophysiology and epidemiology of Clostridium difficile infection”, section on Community-associated C. difficile infection and see “Medical management of gastroesophageal reflux disease in adults”, section Safety).

Histamine type 2 receptor antagonists — The histamine type 2 receptor antagolists (H2RAs) have moderate effects on gastroesophageal reflux, as measured by relief of symptoms and mucosal healing. However, they are somewhat less effective than the proton pump inhibitor class.

The H2RAs inhibit acid secretion by blocking histamine H2 receptors on the parietal cell. Four H2RAs are used in the United States:

• Cimetidine (Tagamet®)
• Ranitidine (Zantac®)
• Famotidine (Pepcid®)
• Nizatidine (Axid®)

Over-the-counter preparations containing doses less-than-prescription strength are available for cimetidine, ranitidine, and famotidine.

Multiple controlled trials in adults have evaluated the efficacy of H2RAs in adults [3]. These studies have shown that H2RAs are superior to placebo for healing esophagitis and improving symptoms. However, their benefit is greatest for patients with mild esophagitis, and tolerance eventually develops, limiting efficacy for long-term management. (See “Medical management of gastroesophageal reflux disease in adults”, section on Maintenance therapy).

Fewer studies have been performed in children, but the results are similar to the experience in adults. The following summaries describe two of the few controlled trials that have been published:

• One study included 32 children (21 to 29 months) with esophagitis who were randomly assigned to receive cimetidine (30 to 40 mg/kg per day) or placebo [17]. After 12 weeks, healing was observed significantly more often in the cimetidine-treated group. Improvement of esophagitis was seen in all patients with mild or moderate esophagitis compared to only 57 percent of patients with severe esophagitis.

• Another trial included 26 children with endoscopically proven mild to moderate esophagitis who were randomly assigned to receive nizatidine (10 mg/kg per day in two doses) or placebo [18]. At the end of eight weeks, healing was observed significantly more often in children who received nizatidine (69 versus 15 percent), a response that also was reflected in decreased acid exposure as assessed by esophageal pH monitoring.

The use of histamine type 2 receptor antagonists is associated with an increased risk of enteric infection, particularly C. difficile, and community-acquired pneumonia [15]. (See “Pathophysiology and epidemiology of Clostridium difficile infection”, section on Community-associated C. difficile infection).

Antacids — Antacids are commonly used for short-term relief of symptoms of GER in infants and children. Neither efficacy nor safety has been well studied, and chronic use is generally not recommended.

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. At least two studies suggested that high-dose antacid therapy with magnesium/aluminum-containing acids was as effective as cimetidine for the short-term treatment of esophagitis in children [19,20]. However, treatment with aluminum-containing antacids can significantly increase plasma aluminum levels in infants to levels that have been associated with complications such as osteopenia, microcytic anemia, and neurotoxicity [21-23]. As a result, their use generally is restricted to short-term relief of symptoms in older children and adolescents. The efficacy and safety of other types of antacids in children have not been well studied.

Prokinetics — Prokinetic drugs enhance esophageal peristalsis and accelerate gastric emptying, providing a rationale for their use in GERD. However, the agents that have some established efficacy also have significant safety concerns. Thus, they should be considered for use only in carefully selected patients, including those who have failed antisecretory therapy (PPIs or H2RAs). In addition, prokinetic agents may be considered for patients who are healthy (no evidence or acid reflux or other disease on evaluation) except that their quality of life is adversely affected by recurrent vomiting or regurgitation.

Careful monitoring for drug interactions and other safety concerns is necessary if these drugs are chosen. (See “Medical management of gastroesophageal reflux disease in adults”, section on Prokinetic drugs/reflux inhibitors).

• Cisapride — Cisapride is a serotonergic agent that facilitates the release of acetylcholine within the myenteric plexus. Although cisapride has generally had a good safety profile, it also has been associated with rare but potentially life-threatening cardiac arrhythmias [24]. As result, its availability has been severely restricted in the United States and Europe. Prescriptions for the drug can only be filled directly through the manufacturer after providing documentation as to the need for the drug and assessment of risk factors for cardiac arrhythmias in the individual patient. The drug has been removed from the market entirely in some countries but remains freely available in others. Thus, although cisapride continues to be used in children in some countries, it currently has little role in the management of GERD in the United States and Europe.

Cardiac toxicity is most likely to occur when cisapride is taken in combination with macrolide antibiotics (erythromycin and clarithromycin) or drugs in the imidazole class (ketoconazole, fluconazole, itraconazole, or metronidazole) and HIV protease inhibitors, which inhibit the cytochrome P-4503A4 enzyme and increase cisapride levels.

The efficacy of cisapride in children with GERD has been studied in controlled trials, at least six of which focused on infants younger than 2 years old [25-31]. A systematic review evaluating nine trials of cisapride treatment for GERD in children concluded that although cisapride reduces esophageal acid exposure, as measured by the reflux index, there was no clear evidence that cisapride reduces the symptoms of GERD [32]. The authors found statistical evidence of publication bias in the literature, accounting for the preponderance of studies showing a positive effect on GERD.

• Metoclopramide — Because of the uncertain efficacy and the frequent side effects, metoclopramide is indicated infrequently in the treatment of GERD in children.

Metoclopramide causes central and peripheral dopamine D2 antagonism, stimulates cholinergic receptors on gastric smooth muscle cells, and enhances acetylcholine release at the neuromuscular junction.

At least five controlled trials in children with GERD have been reported [33-37]. Two of the trials demonstrated a benefit on the frequency and volume of vomiting [33,36], whereas in three other studies the benefit was similar to that of placebo [34,35,37].

A meta-analysis of seven trials evaluating metoclopramide for GERD in children younger than 2 years of age, including four controlled trials [33-35], found some benefit in comparison to placebo, but at the expense of increased side effects [38]. However, a systematic review of 12 case-control, cohort, and randomized studies, including three of the controlled trials described above [33-35], reached a different conclusion [39]. The authors found marked heterogeneity in the patient populations, dosing, and outcomes studied; they did not perform a meta-analysis and concluded that the available evidence is insufficient to support or oppose the use of metoclopromide [39].

Central nervous system side effects of metoclopramide include extrapyramidal reaction, which is relatively common but is reversible, and tardive dyskinesia, which is very rare but may be irreversible.

• Baclofen — 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. In adults, baclofen reduces reflux symptoms after acute or chronic dosing [40]. In children, baclofen also reduced the frequency of esophageal sphincter relaxation and esophageal acid exposure, and accelerated gastric emptying [41,42]. Although these findings are encouraging, further study is required before baclofen can be generally recommended to pediatric patients with GERD. Potential side effects include dyspepsia, drowsiness, and lowered seizure threshold.

• Domperidone — Results of trials examining the efficacy of domperidone have been ambiguous. Although it may have fewer central nervous system side effects than metoclopramide, its safety has not been carefully examined, and it is currently not available in the United States.

Domperidone (Motilium) is a D2-blocker with selective peripheral activity in the upper gastrointestinal tract. Its major advantage is that it does not cross the blood-brain barrier and, therefore, lacks the neurologic side effects of metoclopramide.

Experience with domperidone in the treatment of GERD in children is limited. Two controlled trials that included a total of 107 infants concluded that domperidone drops or suppositories were more effective than was placebo or metoclopramide in controlling nausea, vomiting, and regurgitation [36,43]. In contrast, two other studies found no improvement in any of these measures after four and eight weeks of therapy [44,45].

• Bethanechol — There is minimal evidence supporting the use of bethanechol for treatment of gastroesophageal reflux in children or adults [46]. The only clinical trials are old and they use outcomes of questionable clinical importance.

Bethanechol is a direct cholinergic agonist and acutely increases the contraction of the lower esophageal sphincter. However, there is little evidence that this causes clinical improvement in gastroesophageal reflux.

One crossover trial involving 30 infants suggested that active treatment was associated with a decrease in the frequency of vomiting [47]. A study comparing bethanechol to antacids found no significant difference in clinical outcomes or esophageal acid exposure [48].

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.

Sodium alginate (derived from a 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 [49-52]. It currently is used infrequently in the treatment of children with GERD. A preparation available in the United States (Gaviscon) also contains an antacid and is used for the temporary relief of heartburn in adults.

Sucralfate (aluminum sucrose sulfate) adheres to the mucosal surface, promoting healing and protecting from further peptic injury by mechanisms that are incompletely understood. A study in adults with nonerosive esophagitis found that it decreased symptoms and promoted healing [53]. One controlled trial in children suggested that it was as effective as cimetidine for treatment of esophagitis [54]. However, because of concerns related to aluminum toxicity and the availability of other treatments, sucralfate has a minimal, if any, role in the treatment of GERD in children.

SURGERY — Antireflux surgery typically is considered for children with GERD who have symptoms that persist following medical management or who cannot be weaned from medical therapy. However, the efficacy of surgery for either of these indications has been supported by only the results of numerous case series that used different inclusion criteria, focused predominantly on neurologically impaired children, had short follow-up periods, and reported variable endpoints [55-73]. These limitations and the absence of controlled trials represent potentially critical issues in defining the role of surgery in the management of GERD in children.

Experience in adults has demonstrated that patients who do not respond to adequate doses of medical therapy (particularly those with typical features of GERD such as heartburn) also may have a poor response to surgery, questioning the role of antireflux surgery in patients with symptoms refractory to medical therapy. Furthermore, long-term follow-up of patients who underwent standard antireflux surgery has revealed that many continued to depend upon medical therapy to control symptoms. (See “Surgical management of gastroesophageal reflux in adults”).

Technique — The most commonly performed operation is a Nissen fundoplication. This procedure originally involved passage of the gastric fundus behind the esophagus to encircle up to 6 cm of the distal esophagus. However, many variations and modifications have been described, and a Nissen fundoplication may be performed differently by different surgeons. Variables include approach (transthoracic or abdominal), portion of stomach wall used (anterior and posterior or anterior only), combination with other procedures (eg, vagotomy or gastroplasty), the looseness of the wrap, the completeness of the wrap, and the length of the wrap. The latest advance has been the introduction of the laparoscopic Nissen fundoplication [55,56].

Most surgeons choose to perform a loose (“floppy”) Nissen fundic wrap that is approximately 1 to 2 cm in length, including a posterior crural repair. A common modification is a 360º fundic wrap without ligation of the short gastric vessels (Rosetti-Nissen). A partial 270º wrap (Toupet) is used for patients with severe associated motor abnormalities.

The following general conclusions regarding surgery for GERD in children can be derived from the multitude of case series:

Efficacy — Symptom improvement has been described in approximately 60 to 90 percent of children [1]. In one study, 30 to 40 percent of children had objective evidence of ongoing reflux three months following fundoplication [74]. In studies that have reported longer-term outcomes, most demonstrate higher rates of failure within one to three years [75]. Most of the studies reporting on efficacy do not distinguish between patients with and without neurological impairment.

Complications — Complications of antireflux surgery range from 2 to 45 percent [1]. The most common complications included breakdown of the wrap (1 to 13 percent), small bowel obstruction (1 to 11 percent), gas bloat syndrome (2 to 8 percent), infection (1 to 9 percent), atelectasis or pneumonia (4 to 13 percent), perforation (2 to 4 percent), persistent esophageal stricture (1 to 9 percent), and esophageal obstruction (1 to 9 percent). Complications that occurred less frequently included dumping syndrome, an incisional hernia, and gastroparesis. Reoperation was required in 3 to 19 percent of patients, and operative mortality ranged from 0 to 5 percent.

Patients with neurological impairment or those requiring a second antireflux operation appear to have somewhat higher frequency of complications [75]. However, children without underlying disorders also may have poor outcomes.

Although not described in these reports, we also have frequently observed retching (dry heaves) in children who have undergone fundoplication, particularly children who are neurologically impaired. Treatment for this complication is difficult; however, anticholinergic drugs and histamine type 1 receptor antagonists may be helpful [76]. Symptoms tend to improve after several months.

In aggregate, these data suggest that surgery is often associated with favorable outcomes, although potential risks should be considered. However, the benefit of surgery versus medical therapy in subsets of infants and children with specific symptoms has not been adequately studied.

Pre-surgical evaluation — The diagnostic tests that may be used to help determine whether anti-reflux surgery is appropriate depend on the patient’s clinical presentation.

• Children with chronic esophagitis unresponsive to acid suppression might be considered for anti-reflux surgery. However, they should first undergo an upper endoscopy with biopsies and prolonged esophageal pH monitoring to exclude other causes of esophageal inflammation such as eosinophilic esophagitis. (See “Eosinophilic esophagitis”).

• Children with predominantly respiratory symptoms should undergo thorough evaluation to document association of GERD with respiratory symptoms. This evaluation may include review of all radiographic studies, bronchoalveolar lavage, esophageal pH monitoring, polysomnography, and swallowing studies. However, because even normal degrees of reflux may have adverse effects in some children, surgery may be beneficial for some children with respiratory symptoms even if the esophageal pH study is normal [57].

EXTRAESOPHAGEAL MANIFESTATIONS OF GERD

Asthma with GER — Gastroesophageal reflux is an established trigger for asthma in many patients. In about 60 percent of children with asthma and clinical or laboratory evidence of GER, asthma control will improve with aggressive treatment for reflux [1,77]. However, it is difficult to predict responders [78]. Therefore, we suggest a three-month trial of vigorous acid suppression for patients with persistent asthma and symptoms suggesting GERD. Management after three months depends upon the response and is shown in the algorithm (show algorithm 1).

The utility of treating for GERD in selected patients with asthma has been better studied in adults, using randomized controlled trials. This evidence and recommendations are similar to those in children, and are discussed separately. (See “Gastroesophageal reflux and asthma”).

In many patients with asthma, GERD may be silent and diagnosed only with esophageal pH monitoring. Thus, pH monitoring or an emipric trial of antireflux treatment should be considered in patients with severe symptoms of asthma, even in the absence of apparent symptoms of GERD. (See “Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents”, section on Asthma).

There is inadequate evidence to determine the role of anti-reflux surgery for patients with asthma and GERD. Case series in adults and children generally report improvement in respiratory symptoms after fundoplication for selected patients with severe asthma, in whom a relationship to GERD is strongly suspected [1,79,80]. Clinical findings predicting response to surgery include a clear history of reflux symptoms preceding the onset of asthma, a history of recurrent pneumonia, and nocturnal episodes of asthma. However, these results should be interpreted with caution because of variations in selection criteria and lack of randomization. (See “Surgical management of gastroesophageal reflux in adults”, section on Asthma).

Recurrent pneumonia — There are no definitive tests to determine whether GERD is causing recurrent pneumonia in a given patient. Clinical decisions must be based on an individual patient’s clinical risk and a combination of tests for reflux and aspiration. (See “Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents”, section on Recurrent pneumonia).

When aspiration and recurrent pneumonia are strongly suspected to be related to GERD, aggressive treatment is appropriate to prevent chronic progression of pulmonary disease [1,4]. If pulmonary disease is mild, medical treatment with acid suppression and/or prokinetic agents can be used, as long as pulmonary function can be monitored carefully in follow-up. If pulmonary disease is severe or progressive, surgical treatment with fundoplication should be considered. (See “Surgical management of gastroesophageal reflux in adults”).

SUMMARY AND RECOMMENDATIONS — The preceding discussion underscores the limited data available from well-designed controlled trials to guide optimal strategies for the management of GERD in children. However, in children with distinct symptoms of heartburn or documented esophagitis, the evidence base for treatment recommendations is analogous to and strengthened by observations in adults. The following recommendations are based upon a review of the available evidence by a committee of experts [1] and from clinical experience.

Treatment options

• Lifestyle changes, including avoidance of specific foods and positional changes, confer modest improvement in some reflux-related symptoms in adults. However, they have not been carefully evaluated in children and may be difficult to implement. Thus, they should not be used as the sole intervention for children with significant gastroesophageal reflux disease. (See “Lifestyle changes” above).

• Acid-suppressing medications are reasonably safe and effective for the treatment of disease related to acid-related gastroesophageal reflux. Proton pump inhibitor (PPI) medications are the most effective for short- or long-term acid suppression and are valuable for the treatment of reflux esophagitis and often for asthmatic symptoms caused by reflux. (See “Proton pump inhibitors” above).

• Treatment with prokinetic agents improves gastric emptying and/or the action of the lower esophageal sphincter, and could thus decrease both acidic and non-acidic gastric gastroesophageal reflux. However, the prokinetic agents that are currently available either have limited efficacy or significant safety concerns. Thus, we recommend NOT using prokinetic agents for the routine treatment of children with gastroesophageal reflux disease (Grade 1B). These drugs can be considered in patients who have failed antisecretory therapy, with careful monitoring for drug interactions and other adverse effects. (See “Prokinetics” above).

Heartburn

• For children or adolescents with heartburn, we suggest a trial of treatment with the lifestyle changes described above (weight loss and smoking cessation; head of bed elevation; and avoidance of chocolate, caffeine, spicy foods, alcohol, and other foods that exacerbate symptoms) (Grade 2C). (See “Lifestyle changes” above).

• If the symptoms are moderate or severe, or fail to respond to lifestyle changes, we recommend a trial of acid suppression therapy (Grade 1A). Either a histamine type 2 receptor antagonist or proton pump inhibitor is a reasonable first choice, and a typical trial duration is two to four weeks. However, for patients who do not improve on a histamine type 2 receptor blocker, we recommend treatment with a PPI (Grade 1A). Persistent or recurrent symptoms on a PPI should prompt referral for an upper endoscopy with biopsy (show algorithm 2). (See “Lifestyle changes” above and see “Pharmacotherapy” above).

Esophagitis

• For children with endoscopically documented reflux-related esophagitis, we recommend treatment with an acid-suppressing medication (Grade 1A). We also suggest a concurrent trial of lifestyle changes (Grade 2C). For initial treatment, we suggest a proton-pump inhibitor (PPI) rather than a histamine type 2 receptor antagonist (Grade 2B). Infants and younger children appear to metabolize PPIs more rapidly and may require higher per-kilogram dosing than older individuals. (See “Proton pump inhibitors” above).

• Further evaluation and treatment depends on the severity of the esophagitis at baseline and on the degree of symptom relief

(show algorithm 3). Patients with only mild esophagitis can be reassessed based upon the degree of symptom relief. Those with erosive esophagitis should undergo a repeat endoscopy to demonstrate healing. If healing or symptom relief is incomplete, medical therapy should be optimized. (See “Pharmacotherapy” above).

• Long-term treatment with acid suppressing medications is appropriate if symptoms or endoscopy indicate chronic or recurrent esophagitis. Because tolerance develops to histamine type 2 receptor antagonists, these are not ideal choices for continuous maintenance therapy, but might be useful in an intermittent treatment regiment for milder disease. When continuous therapy is necessary, we suggest treatment with a proton pump inhibitor (Grade 2C).

Dysphagia or odynophagia — Dysphagia and odynophagia are rarely caused by GERD. Children with these symptoms should be carefully evaluated for other causes. Empiric treatment for reflux is not recommended unless other causes of the symptoms have been excluded. (See “Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents”).

Asthma — In about 60 percent of children with asthma and clinical or laboratory evidence of GER, asthma control will improve with aggressive treatment for reflux, but it is difficult to predict responders. Therefore, we suggest a three-month trial of a PPI for patients with persistent asthma and symptoms suggesting GERD (Grade 2B) (show algorithm 1). (See “Asthma with GER” above).

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[Anonymous]

Hey Lori…could you summarise that for me

[Anonymous]

AWESOME… thanks for the info!!!!

-Sarah

[Anonymous]

Thanks!!!!

[Anonymous]

Thanks Lori. Is the subscription open to the general public or do you have to be in the medical field?

Also, I would like to see more info. on the MSPI if you get time. Seth was never officially diagnosed with this but I am almost certain that is what caused a lot of his issues.

I also tried to click on the link to Famotidine (Pepcid) but it would not give me any more info. I have been trying to research the safety of this in children. I did find yesterday some guidelines for pediatric dosing on another site (alone for GERD treatment) and the amount I am giving Seth is well within the limits. The Pepcid Complete is really helping him!

Thanks again.

Mom2Seth2007-4-27 8:54:49

[Author]

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