GASTROENTEROLOGY: First-line therapies for GER/GERD

Part of Contemporary Pediatrics’ coverage of the 2015 AAP Annual Conference. For more coverage, click here.

Not every vomit-prone infant requires acid-blocking pharmaceuticals, said Jonathan Teitelbaum, MD, FAAP, in his presentation “Burning Questions about First-Line Therapies for GER/GERD.” In the pediatric and adult gastrointestinal community, he said, there’s a general sense that acid-blocking medications are overused, and that pediatricians potentially believe these drugs are needed in cases in which they probably will not help.

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Teitelbaum noted that we generally talk about “happy spitters,” meaning babies who are gaining weight and don’t have irritability, but spit up a lot. That’s just normal gastroesophageal reflux (GER). Those babies don’t need an acid-blocking medicine.

Conversely, troublesome symptoms that mark gastroesophageal reflux disease (GERD) in infants include irritability and weight loss or poor weight gain. In older children, one should watch for complaints of heartburn or food getting stuck when swallowing.

In making a diagnosis, x-rays are poor predictors of GERD. In gastroenterology, more invasive tests such as the pH probe and pH impedance test have become the gold standard for diagnosing reflux. However, within pediatrics, the distinction between GER and GERD can rest on clinical, serologic, and endoscopic evidence. In this regard, additional signs and symptoms of GERD can include dysphagia, wheezing, hoarseness, anemia, dental erosions, feeding refusal, and inflammation of the esophagus, larynx, or pharynx.

In managing GERD, effective lifestyle modifications for infants who are not gaining weight include thickening feeds, which has been shown to decrease the height of reflux within the esophagus, and the overt frequency of regurgitation (but not the frequency of reflux episodes). Another often-discussed intervention in this age group is frequent burping. There is, however, no evidence that this is effective. Indeed, no other animal burps its young. For older children with night-time reflux, tilting the head of the bed up 30 degrees is reasonable.

With acid blockers already overused, pediatricians considering these therapies must be sure they are treating a specific disease, not just medicating a happy spitter. Although traditionally it has been believed that these drugs had very few if any side effects, there is increasing evidence that they can increase children’s risk for infections, including pneumonia and Clostridium difficile. Aside from the cost involved with these medications, the way that they manipulate the gut flora may be more harmful than initially realized.

Jonathan Teitelbaum, MD, FAAP, is director of pediatric gastroenterology, Unterberg Children’s Hospital, Long Branch, New Jersey.

NEXT: Commentary and what to look for in older children

Commentary

Dr Teitelbaum very effectively encapsulates most of the current thinking and recommendations regarding reflux in children. And I agree that acid blockers are overused. If you look at the prescribing data, especially in infants-for whom randomized, controlled trials have not shown significant benefit-large numbers of prescriptions are written, particularly for proton pump inhibitors.

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Regarding symptoms to look for in older children, I would add regurgitation or “sour burps.” Many school-aged children will complain of heartburn or abdominal pain, but there is a group of patients who complain more of regurgitation or sour burps than of abdominal pain. In older children with night-time reflux, along with tilting the head of the bed up, recommendations include limiting the child’s intake of caffeine, chocolate, mints, spicy foods, and fatty foods-all of which tend to exacerbate GERD symptoms.

In preschool children, making a clinical diagnosis of GER or GERD can be challenging and somewhat controversial. The consensus is that, around age 8 years and older, you can rely on a child’s history to make a clinical diagnosis.¹ However in preschool children, getting an accurate history is challenging. If a child in that age group complains of abdominal pain, it is harder for the child to discern or describe heartburn or constipation, either of which could be the true culprit.

People may then wonder if it’s appropriate to give a preschool child with abdominal pain a trial of acid-suppression therapy. It is, with a confirmed diagnosis of GERD. The 2009 consensus guidelines say that uncomplicated GER is unlikely to persist beyond the age of 18 months, even in happy spitters who are not severely irritable or failing to thrive. The guidelines recommend referral to a pediatric gastroenterologist if regurgitation or abdominal pain persists beyond 18 months. If a diagnosis of GERD is established in that age group, then acid-suppression therapy is appropriate.

Reference

1. Sherman PM, Hassall E, Fagundes-Neto U, et al. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol. 2009;104(5):1278-1295.

David A. Gremse, MD, FAAP, is professor and chair, Department of Pediatrics, University of South Alabama School of Medicine, Mobile, Alabama.