Treating gastroesophageal reflux in kids: Fact vs. sensationalism

Gastroesophageal reflux (GER) occurs in many children, with a range of symptoms that can result in everything from mild discomfort to intense pain. A recent study indicates that current GER treatment methods may not be as effective in children as they could be, and calls for further pediatric testing to establish their actual worth. Many news outlets have written about the study, and several reports seem to say that because there are questions about current treatments, those treatments are ineffective. Rachel Rosen, MD, MPH, of Children’s Hospital Boston’s Gastroenterology and Child Nutrition Program, disagrees with that sentiment and is blogging on Thrive to offer parents of children with GER a different viewpoint.

You may not hear about Gastroesophageal reflux in the news very often, but it’s actually quite common among toddlers. In fact, primary care physicians treat as many children under the age of five for GER as they do for asthma. GER occurs when gastric acid and other contents of the stomach travel back into the esophagus, mouth or even the lung. It can lead to painful heartburn, chest pain, esophagitis, and sometimes coughing and wheezing. As a parent it can be difficult to watch your child struggle with GER, but fortunately it’s a fully treatable condition, typically with medication called proton pump inhibitors (PPIs) that suppresses the acid and treats other symptoms like heartburn, abdominal pain, coughs and bloating.

But parents of children who have gastroesophageal reflux were thrown a curve ball last week when a study published by the journal Pediatrics suggested that PPIs are less effective in treating GER than many doctors realize. According to researchers, over-the-counter antacids like Maalox or Mylanta or Zantac can work as well as PPIs for easing discomfort caused by GER. The study has gotten a lot of media attention, but many of these headlines are misleading and make assumptions based on very limited pediatric data.

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For starters, GER is diagnosed by symptoms primarily; There isn’t a single, easy to administer test that can definitively conclude that a patient has GER. A child can experience a list of symptoms that may be the result of GER, but they could also be due to other conditions. To accurately identify the cause of a child’s discomfort, his clinician will prescribe a short PPI trial to see if the symptoms improve. This short PPI trial is often the best option because they’re non-invasive and the medications are FDA approved for use in children. Plus, PPIs are usually taken just once a day— antacids need to be given anywhere from two to six times a day—which makes the process far easier for young kids and the moms and dads in charge of getting them to take all their meds.

Secondly, extensive testing in adults has proven that PPIs are better at healing esophagitis and controlling heartburn than antacids. According to these studies, they’re also better at reducing gastric acid than other classes of medications.

So why is it that PPIs don’t work the same for everyone? The best answer is that PPIs may not work because reflux is not always the problem. A patient may be suffering from another

Treating GER with antacids can require up to six pills a day. That can be too much for some children.

condition with similar symptoms and the doctor will prescribe PPIs in hopes that it will ease the pain, but if the cause of the problem isn’t actually reflux, then PPIs may not be effective. They may also not work because PPIs stop acid from forming, but your stomach still makes non-acidic gastric juice, which can still be bothersome to some people. To sort this out, additional tests are needed on a case-to-case basis.

There is no doubt that proton pump inhibitors have been widely prescribed, maybe even to the point of excess, but that doesn’t mean they aren’t still effective for many patients. The information found in the Pediatrics paper is interesting, but it raises more questions than it answers. And based on the small amount of pediatric data on PPIs available, there simply isn’t enough information out there to make any kind of definitive statement. The answers to those questions will be found in future research, which needs to happen because PPIs have too much potential for many patients to be written off because of a few misleading news articles.

I know it can be hard not to be swayed by headlines, but I urge parents not to make snap judgments about PPIs because of what’s being written about them right now. If your child is taking these medications, it is important, as with all medications, to talk to your child’s pediatrician about the pros and cons of PPIs before you make up your mind about discontinuing their use. They may not be the right solution for everyone, but for many children, they have been critical for symptom control and esophageal healing.