Short-term acid-suppression advised for pediatric gastroesophageal reflux

Last Updated: 2018-07-10

By Will Boggs MD

NEW YORK (Reuters Health) - Typical reflux symptoms in children should be treated with four to eight weeks of acid-suppression therapy, and in infants this should occur only after dietary modifications, according to a new Pediatric Gastroesophageal Reflux Clinical Practice Guideline.

"Too much testing is done before referral," Dr. Leo A. Heitlinger from Lewis Katz School of Medicine at Temple University in Philadelphia told Reuters Health. "In infants, a trial of hypoallergenic formula, formula thickened with cereal or both should be considered for those with typical symptoms. In toddlers and children, a trial of acid suppression lasting no more than four to eight weeks for those with typical symptoms could be considered."

The guideline was developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Dr. Heitlinger provides a synopsis in his June 28th JAMA Otolaryngology-Head and Neck Surgery online report.

Besides the treatment recommendations mentioned above, the guideline advises that acid suppression be avoided in infants and children with extraesophageal symptoms, such as cough, wheezing, and asthma, especially in the absence of typical reflux symptoms.

The guideline addresses several diagnostic approaches, recommending esophagogastroduodenoscopy (EGD) with biopsies to assess complications of gastroesophageal reflux disease (GERD) and favoring pH impedance studies over prolonged pH monitoring to correlate troublesome symptoms with acid reflux, clarify the role of acid reflux in esophagitis, and determine efficacy of acid-suppression therapy.

Expert opinion recommended against salivary pepsin, currently available extraesophageal biomarkers, and scintigraphy for diagnosing GERD in infants and children and supported manometry only if an underlying motility disorder is suspected.

The guideline recommends against positional therapy to treat reflux in infants, but supports the use of proton pump inhibitors as treatment for erosive esophagitis.

Wherever possible, clinicians should use less aggressive means to provide relief, and they should refer to specialists early when desired outcomes are not achieved in a timely fashion.

"Reflux is common; those with typical symptoms can be cared for in the primary care provider's office," Dr. Heitlinger concluded. "Those with atypical or refractory symptoms should be referred to specialists."

Dr. Rachel Rosen from Children's Hospital Boston, who co-authored the Clinical Practice Guideline, told Reuters Health by email, "Symptoms of reflux in children are varied, ranging from pain to crying and feeding difficulties. Making a diagnosis is particularly difficult in infants and young children who cannot verbalize their symptoms. Because these symptoms are common and nonspecific, physicians frequently have previously prescribed acid suppression such as proton pump inhibitors at incredibly high rates wrongly assuming they are related to reflux. The new guidelines advocate for nonpharmacologic therapies, earlier testing, and, when needed, only short courses of acid suppression followed by weaning of medications."

"There are two controversial recommendations," she said. "First, the guidelines recommend referral to pediatric gastroenterologists, even before starting acid suppression. Why? Because acid suppression may not be indicated if the symptoms are not related to reflux, and they result in side effects, including infection, without benefit based on pediatric clinical trials, and this pretreatment prior to testing can result in erroneous diagnoses."

"To clarify this latter point, pretreatment with proton pump inhibitors prior to diagnostic testing may result in mucosal healing, thus preventing the affirmative diagnosis of erosive reflux disease or proton pump inhibitor-responsive eosinophilic esophagitis," Dr. Rosen explained. "In short, this pretreatment could result in the wrong diagnosis being made, the wrong therapy being prescribed, or the wrong prognosis being given."

"Second, the guidelines do not recommend acid suppression therapy for extraesophageal symptoms such as cough, wheezing, hoarseness or pneumonias unless there is clear evidence of gastroesophageal reflux disease present," she said. "There are no pediatric studies showing benefit of acid suppression for these extraesophageal symptoms, and there is a risk that these medications actually increase respiratory infection risk, which may make the original symptoms even worse."

"While many patients and families are seeking a quick solution to treat symptoms, making the correct diagnosis is critical to avoid the use of medications and surgeries that may not be helpful and, in fact, may cause harm," Dr. Rosen concluded.

SOURCE: http://bit.ly/2KTXdYT

JAMA Otolaryngol Head Neck Surg 2018.