Medication Summary
The therapeutic response to the treatment of gastroesophageal reflux disease (GERD) may take several weeks. If treatment is successful, the frequency of posturing and apparent distress will decrease.
Prokinetic agents
Class Summary
These agents are used to augment cholinergic activity. As such, they can improve contractility of the lower esophagus, increase lower esophageal sphincter pressure, and augment the rate of gastric emptying. However, these agents have a limited role in this age group as the risk of adverse side effects generally outweighs benefit. Current guidelines do not support the routine use of prokinetic agents for the treatment of GERD in infants or older children. [8, 20] Use of PPIs should be considered only in specific situations, with thorough consideration of risks and benefit.
Metoclopramide (Reglan)
Dopaminergic antagonist that works by increasing LES tone and gastric emptying. Stimulates muscular activity, leading to decrease in reflux.
Antacids
Class Summary
These agents have traditionally been used as a diagnostic tool, providing symptomatic relief in infants. However, although they may confer short-term relief, they are not recommended for long-term use due to the risk of associated aluminum toxicity, [24, 25, 26] calcium toxicity such as milk-alkali syndrome (hypercalcemia, alkalosis, renal failure), [23] and magnesium toxicity. [27] They are NOT currently recommended for the treatment of GERD or esophagitis in infants and children. [17, 23]
Aluminum hydroxide (ALternaGEL, Amphojel)
Increases gastric pH above 4 and inhibits proteolytic activity of pepsin, reducing acid indigestion. Antacids can initially be used in mild cases. No effect on frequency of reflux but decreases its acidity.
H2 receptor antagonists
Class Summary
Like antacids, these agents do not reduce the frequency of reflux, but they are very effective in decreasing the amount of acid in the refluxate through inhibition of acid production by blocking the histamine H2 receptors on gastric parietal cells. All are equipotent when used in equivalent doses. Long- term use is limited by the development of tachyphylaxis or tolerance. These medications are very useful for short term trial of acid suppression.
Ranitidine (Zantac)
Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Famotidine (Pepcid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Nizatidine (Axid)
Nizatidine is approved by the FDA for use in adolescents aged 12-18 y. Off-label use in children younger than 12 y has been described.
Proton pump inhibitors
Class Summary
Proton pump inhibitors (PPIs) decrease acid secretion by irreversibly binding to and inhibiting the H+-K+-ATPase pump on the gastric parietal cell surface. They are more effective at increasing gastric pH, and for a longer duration, compared with H2 receptor antagonists (H2RA). Additionally, they do not cause the tolerance seen after several weeks use of the H2RAs. As a result, PPIs contribute to more rapid healing of erosive esophagitis. [28] There is mixed evidence as to their efficacy in reducing irritability in infants. [18, 29] Concerns exist regarding overuse and over prescribing of PPIs, and the long-term adverse effects (eg, increased in respiratory infections in infants, headache, nausea, diarrhea and constipation in older children and adults). [8, 23]
Omeprazole, lansoprazole, pantoprazole and esomeprazole have all been studied in infants and young children. Currently, the only PPI approved by the FDA for use in infants aged 1-12 months is esomeprazole.
Omeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting the parietal cell H+-K+-ATP pump.
Lansoprazole (Prevacid, Prevacid 24HR, Prevacid Solu Tab)
Suppresses gastric acid secretion by specific inhibition of the (H+, K+)-ATPase enzyme system (ie, proton pump) at the secretory surface of the gastric parietal cell. It blocks the final step of acid production. The effect is dose-related and inhibits both basal and stimulated gastric acid secretion, thus increasing gastric pH.
Esomeprazole magnesium (Nexium)
S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+-K+-ATPase enzyme system at secretory surface of gastric parietal cells.
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Diagram illustrating the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360º wrap).
