Author(s): Vasundhara Tolia 1
adolescents; children; efficacy; gastroesophageal reflux disease; infants; pantoprazole; safety
Gastroesophageal reflux (GER) is occasionally experienced by almost everyone post-prandially and is a normal physiologic phenomenon under such circumstances. However, when it occurs frequently causing either bothersome symptoms or damage to esophageal mucosa, it is called gastroesophageal reflux disease (GERD)  . Under these situations, it can cause other complications and/or involve extra-esophageal organs  . The single most common cause of GERD is inappropriate transient lower esophageal sphincter relaxation; called (TLESR); which allows backflow of gastric contents into the esophagus. Although GERD can occur without any underlying predisposing factors; it can be due to other coexisting conditions such as esophago-gastric dysmotility, anatomic abnormalities of the esophagus (e.g., tracheoesophageal fistula or developmental delay)  . Then it is called secondary GERD. GERD frequently coexists with obesity. Whether primary or secondary in nature, when GER causes troublesome symptoms and affects the quality of life in an individual, it becomes GERD and needs to be treated. Fortunately, some of the GERD complications observed in adults such as Barrett'âs esophagus and accompanying mucosal dysplasia are infrequent in childhood.
Gastroesophageal reflux disease can present at any age in otherwise healthy children and has a wide range of symptoms which can vary at different ages  . A good history is usually adequate to suggest presence of GERD. Infants can present with crying and/or unexplained irritability, apnea and/or bradycardia, acute life-threatening event, poor appetite or feeding refusal, recurrent vomiting or stridor. In severe cases, persistent emesis can cause actual weight loss or failure to thrive  . Older children can present with recurrent spitting/vomiting, burping/belching, epigastric abdominal pain, chest pain or even heartburn. Atypical manifestations of GER involving respiratory, otolaryngologic and dental regions include wheezing, stridor, hoarseness, chronic cough, dental erosions and recurrent sinusitis/otitis  . Rarely, erosive GERD can manifest with torticollis type of picture called Sandifer'âs syndrome. Dietary habits, alcohol intake and exposure to active or passive smoking should also be part of the clinical assessment.
There are no classic physical signs for diagnosing GER in the pediatric population. In most cases, diagnosis can be suspected from the history and a normal physical examination. Empiric conservative management can be usually initiated without any diagnostic tests. Albeit, if extra-esophageal symptoms are present or if the patient does not respond to treatment; investigations should be performed to exclude other conditions.
Lifestyle modifications are the mainstay of GERD management. These include small volume, frequent feedings, thickening of formula, holding the baby upright after feeding and perhaps consider even an empiric trial of hypoallergenic formula in infancy. In children and adolescents, smaller meals with avoidance of fried, fatty foods, acidic products, peppermint, chocolate and caffeine-containing foods and beverages should be suggested  . Abstinence of alcohol and tobacco is prudent. Proper eating habits with consideration of weight-holding or weight-losing diet should be discussed with the family as indicated tactfully. If the patient does not respond to these conservative measures, then pharmacotherapy is indicated  . It is important to remember that...