• Histamine2 receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.
• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.
• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.
The bottom line
Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.
Reference
J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.