Reflux and PPI’s in the young

 

Gastrooesophageal reflux (GOR) in infants and children remain one of the commonest presentations to GP’s and paediatricians. It is characterised by regurgitation of stomach contents (acidic and/or non-acid) in the oesophagus in the absence of any organic features that would suggest the presence of Gastrooesophageal Reflux Disease (GORD). A few children with GORD may need medical therapy (acid-blocking agents, feed thickeners or prokinetic agents) and/or surgical therapy (Fundoplication).

 

Proton pump inhibitors (PPI) remain the most commonly utilised medical therapy for children with GORD.

Common complications from PPI therapy are an increased risk of respiratory and gastrointestinal infections. There may be an increased predisposition to certain gastrointestinal diseases like coeliac disease, gastric fundic gland polyps and eosinophilic oesophagitis (EoE), for children on PPI’s. Malabsorption of certain vitamins and minerals, (calcium, magnesium, iron and Vitamin B12) and disturbances of the gut microbiome may occur. Cardiovascular, bone and renal complications have also been reported.

 

GOR in infants is defined as frequent effortless regurgitation of feeds. It causes anxiety in parents but resolves in almost 90% of children by 12 months of age. Detailed history to rule out any red flag signs such as bile stained vomiting, hematemesis, unexplained feeding difficulties, blood in stool/Malena, faltering growth, distressed behaviour and any other systemic features are needed. There is enough evidence to suggest that the crying time of an infant is not related to GOR nor can it be reduced with PPI therapy.

 

Effective management of GOR requires repeated and confidence reassurance. Simple and cheap interventions such as minor feed modifications or thickening agents should be used for infants and where possible avoid the use of PPI’s. However, special consideration needs to be given for infants with a history of back arching (Sandifer’s syndrome), premature birth, repaired congenital diaphragmatic hernia, repaired oesophageal atresia, recurrent aspiration pneumonia, frequent otitis media, episodic apnoea, or neuro-disability. This group warrants further investigation and referral to a specialist physician.

 

Gastro-oesophageal reflux in children and adolescents needs further assessment to rule out other diseases especially EoE. History of dysphagia, food bolus impactions, retrosternal or epigastric discomfort, hematemesis, melena, unexplained iron deficiency anaemia and symptoms refractory to acid-suppressive therapy helps differentiate functional dyspepsia/GOR from GORD or other oesophageal diseases. Those on chronic, difficult to wean, PPI therapy may need by further investigations such as an endoscopy.

 

Author competing interests- no relevant disclosures. Questions? Contact the author on 9340 8355

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