Gastroesophageal Reflux: Medical Treatment

Episodes of GER occur in normal children and adults (1). GER-disease (GERD) is one of the most common gastrointestinal diseases encountered in clinical practice. Since GER is both a physiologic event and a manifestation of disease, there is a lot of controversy on the topic. Primary GER results from a primary disorder of function of the upper gastrointestinal tract, due to an insufficiency at the level of the lower esophageal sphincter (LES) function. Secondary GER is caused by disease within or outside the gastrointestinal tract. Examples of diseases commonly causing secondary GER in infants are cow’s milk protein (CMP) allergy and idiopathic pyloric hypertrophy. Treatment of the primary cause, elimination of CMP from the diet or pylorotomy, respectively, will make the symptoms disappear. Because symptoms suggesting GERD are frequent and non-specific, especially during infancy, and because there is no golden-standard diagnostic technique, many infants are exposed to anti-reflux treatment (2). Therapeutic intervention should always be a balance between intended improvement of symptoms and risk for sideeffects (3). UntreatedGERDmay be associatedwith severe complications such as esophagitis, failure to thrive in children, esophageal stricture, Barrett esophagus and adenocarcinoma. The first approach should be careful observation of feeding and handling of the child during and after feedings. Reassurance showing comprehension for the comfort problems and impaired quality of life of the infant and parents is of importance. Many infants are overfed or fed with an inappropriate technique. Nonpharmacological therapies for reflux do not have proven efficacy, although some may decrease the incidence of regurgitation. The supine and right lateral positions are associated with the highest incidence of GER; the prone position with the lowest, and the left lateral position with intermediate GER. The prone anti-Trendelenburg position (head elevated 30 C) is the position with the lowest GER-incidence. Milk thickeners have been reported to reduce regurgitation in infants. Milk-thickening agents include bean gum, carboxymethylcellulose, cereals and starch from rice, potato, corn, etc. There are many different compositions of anti-regurgitation formula: caseinpredominance, protein hydrolysates, etc. Although there is consistency in the finding of significant reduction in regurgitation, there is almost constant absence of evidence for a significant reflux-reducing benefit of thickened formula or thickening agents. One exception may be cornstarch; 2 independent studies with cornstarchthickened formula indicate a decrease of esophageal acid exposure time; these observations need confirmation. Although the effect of thickened feeds is (only) cosmetic, this may help to bring reassurance to the parents and to improve the quality-of-life of infant and parents. Prokinetic agents such as metoclopramide, domperidone and cisapride act on regurgitation through their effects on LES pressure, esophageal peristalsis or clearance and/or gastric emptying. Metoclopramide and domperidone also have anti-emetic properties due to their dopamine-receptor blocking action, while cisapride is a prokinetic mainly acting via indirect release of acetylcholine from the myenteric plexus. Use of metoclopramide in infants is limited because of severe adverse occurring in more than 20% of patients, including central nervous system effects and interactions with the endocrine system. Studies supporting efficacy of domperidone in improving GER in infants and young children are limited. Some efficacy of erythromycin has been suggested in gastric emptying and improving food tolerance, but there are no data on GER or reflux symptoms. A Cochrane review on cisapride in children concluded that there was a significant efficacy on ‘‘symptom present/absent’’ or on reflux index (4). However, cisapride can be considered as off market. Data with other prokinetic agents such as prucalopride, clebopride, itopride, etc., are disappointing or non-existing. Also, there are no pediatric data with ondansetron or tegaserod. Baclofen is a gamma-aminobutyric acid (GABA)-B receptor agonist, and decreased emesis in 6/8 children. Baclofen decreased significantly the number of acid reflux episodes, but did not change the reflux index (% of esophageal acid exposure time). Experience with antacids is limited in infants. Alginate-based raft-forming formulations usually contain sodium or potassium bicarbonate. Since alginatebased raft-forming formulations need to float on the gastric contents for effectiveness, the time at which this medication is taken is of great importance. Studies in Yvan Vandenplas, MD, PhD, (e-mail: yvan.vandenplas@az.vub.ac.be). Journal of Pediatric Gastroenterology and Nutrition 41:S41–S42 September 2005 Lippincott Williams & Wilkins, Philadelphia