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Tighe MP, Andrews E, Liddicoat I, Afzal NA, Hayen A, Beattie RM. Pharmacological treatment of gastro-oesophageal reflux in children. Cochrane Database Syst Rev 2023; 8:CD008550. [PMID: 37635269 PMCID: PMC10443045 DOI: 10.1002/14651858.cd008550.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self-limiting condition that improves with age, but older children and children with co-existing medical conditions can have more protracted symptoms. The distinction between gastro-oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. OBJECTIVES To assess the effects of pharmacological treatments for GOR in infants and children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any currently-available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. DATA COLLECTION AND ANALYSIS We used standard methodology expected by Cochrane. MAIN RESULTS We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta-analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low-certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/- standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) -89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI -4.7 to -9.3). Omeprazole versus ranitidine: one study (76 infants; very low-certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD -4.97 (95% CI -7.33 to -2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low-certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD -3.2 (95% CI -4.6 to -1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low-certainty evidence). In the lower-dose group (0.5 mg/kg), symptom scores improved in both a low-weight group of children (< 15 kg) (mean -10.6 ± SD 11.13) and a high-weight group of children (> 15 kg) (mean -13.6 ± 13.1). In the higher-dose groups (1 mg/kg), scores improved in the low-weight (-9 ± 11.2) and higher-weight groups (-8.3 ± 9.2). For the higher-weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI -2 to 6.6), and for the lower-weight group, symptom score MD was 4.6 (95% CI -2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean -2.4 ± 1.7; 1.2 mg/kg -1.7 ± 1.2: MD 0.7 (95% CI -0.4 to 1.8)) (one study, 60 children; very low-certainty evidence). There were insufficient summary data to assess other medications. AUTHORS' CONCLUSIONS There is very low-certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low-certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low-certainty evidence). Further studies with longer follow-up are needed. In older children with GORD, in studies with summary data extracted, there is very low-certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities).
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Affiliation(s)
- Mark P Tighe
- Department of Paediatrics, University Hospitals Dorset, Poole, UK
| | - Edward Andrews
- Department of Paediatrics, University Hospitals Dorset, Poole, UK
| | - Iona Liddicoat
- Department of Paediatrics, University Hospitals Dorset, Poole, UK
| | - Nadeem A Afzal
- Faculty of Science & Health, Portsmouth University, Portsmouth, UK
| | - Andrew Hayen
- Australian Centre for Public and Population Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - R Mark Beattie
- Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Abstract
BACKGROUND Current recommendations do not support the use of anti-reflux medications to treat gastro-oesophageal reflux disease (GORD) among preterm infants. OBJECTIVE To describe the prevalence of GORD and the use of anti-reflux medications amongst very preterm infants (<32 weeks' gestational age (GA)) in neonatal units in England and Wales. DESIGN Retrospective cohort study using the National Neonatal Research Database. RESULTS Among 58,108 infants [median GA (IQR) 29 (27-30) weeks], 15.8% (n = 9191) had a diagnosis of GORD and 36.9% (n = 12,446) received anti-reflux medications. Those who received anti-reflux medications were more preterm [GA, median (IQR): medications, 28 (26-30) vs. no medications, 30 (28-31); p < 0.001] and had lower birth weight [mean (SD): medications, 1124 g (354) vs. no medications, 1265 g (384); p < 0.001]. Most (57%, n = 12,224) received Gaviscon, or Histamine-2 Receptor Antagonist (H2RA) (56%, n = 11,959). Over time, prokinetic use has declined substantially, the use of H2RAs and Gaviscon has reduced although they continue to be used frequently, whilst the use of PPIs has increased. CONCLUSIONS Anti-reflux medications are frequently prescribed in very preterm infants, despite evidence to suggest that they are not effective and may be harmful. Clear guidelines for diagnosing GORD and the use of anti-reflux medications are required to rationalise the pharmacological management of GORD in preterm infants. IMPACT Anti-reflux medications are frequently prescribed, often without a diagnosis of gastro-oesophageal reflux disease, to very preterm infants while in the neonatal unit and at discharge. Half of the infants born at <28 weeks' gestational age receive anti-reflux medications in hospital and a quarter are discharged home on them. Although the use of prokinetics declined following alerts of adverse events, histamine2-receptor antagonists and alginates such as Gaviscon continue to be used and the use of proton-pump inhibitors has increased more than 2-fold.
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Potential applications of algae in biochemical and bioenergy sector. 3 Biotech 2021; 11:296. [PMID: 34136333 DOI: 10.1007/s13205-021-02825-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/04/2021] [Indexed: 01/08/2023] Open
Abstract
Algae have gained substantial importance as the most promising potential green fuel source across the globe and is on growing demand due to their antioxidant, anticancer, antiviral, antihypertensive, cholesterol reducing and thickening properties. Therefore, it has vast range of application in medicines, pharmaceutical, cosmetics, paper and nutraceutical industries. In this work, the remarkable ability of algae to convert CO2 and other toxic compounds in atmosphere to potential biofuels, foods, feeds and high-value bioactive compounds is reviewed. Algae produce approximately 50% of the earth's oxygen using its photosynthetic activity, thus acting as a potent tool to mitigate the effects of air pollution. Further, the applicability of algae as a desirable energy source has also been discussed, as they have the potential to serve as an effective alternative to intermittent renewable energy; and also, to combustion-based fossil fuel energy, making them effective for advanced biofuel conversions. This work also evaluates the current applications of algae and the implications of it as a potential substrate for bioplastic, natural alternative to inks and for making paper besides high-value products. In addition, the scope for integrated biorefinery approach is also briefly explored in terms of economic aspects at the industrial scale, as such energy conversion mechanisms are directly linked with sustainability, thus providing a positive overall energy outlook.
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Bor S, Kalkan İH, Çelebi A, Dinçer D, Akyüz F, Dettmar P, Özen H. Alginates: From the ocean to gastroesophageal reflux disease treatment. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:109-136. [PMID: 31624050 DOI: 10.5152/tjg.2019.19677] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Serhat Bor
- Division of Gastroenterology, Department of Internal Medicine, Ege University School of Medicine, Ege Reflux Study Group, İzmir, Turkey
| | - İsmail Hakkı Kalkan
- Department of Gastroenterology, TOBB University of Economics and Technology School of Medicine, Turkey
| | - Altay Çelebi
- Division of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Dinç Dinçer
- Division of Gastroenterology, Department of Internal Medicine, Akdeniz University School of Medicine, Antalya, Turkey
| | - Filiz Akyüz
- Division of Gastroenterology, Department of Internal Medicine İstanbul School of Medicine, Istanbul University, İstanbul, Turkey
| | - Peter Dettmar
- RD Biomed Limited, Castle Hill Hospital, Cottingham, UK
| | - Hasan Özen
- Department of Pediatrics, Hacettepe University School of Medicine, Ankara, Turkey
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Baldassarre ME, Di Mauro A, Pignatelli MC, Fanelli M, Salvatore S, Di Nardo G, Chiaro A, Pensabene L, Laforgia N. Magnesium Alginate in Gastro-Esophageal Reflux: A Randomized Multicenter Cross-Over Study in Infants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010083. [PMID: 31861951 PMCID: PMC6981691 DOI: 10.3390/ijerph17010083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/23/2022]
Abstract
The aims of this study were to evaluate the efficacy of magnesium alginate in decreasing functional regurgitation symptoms in infants, and to assess the cost-benefit ratio of magnesium alginate compared to a thickened formula. A multicenter perspective cross-over study was conducted in formula-fed infants with persisting regurgitation, randomly assigned to receive two weeks of a magnesium-alginate-based formulation followed by two weeks of thickened formula, or vice-versa. Infants, exclusively breast-fed, were followed up for two weeks while receiving magnesium alginate. Symptoms of gastroesophageal reflux (GER) were evaluated through the Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R). Direct cost of treatments was also calculated. Seventy-two infants completed the study. We found a significant reduction of I-GERQ-R scores over time (F = 55.387; p < 0.001) in all groups with no difference between the sequences of administration (F = 0.268; p = 0.848) in formula-fed infants and between exclusively breast-fed and formula-fed infants receiving magnesium alginate (t = 1.55; p = 0.126). The mean cost savings per infant was € 4.60 (±11.2) in formula-fed infants treated with magnesium alginate compared to thickened formula (t = 2.91, p < 0.0005). Conclusions were that the magnesium-alginate formulation reduces GER symptoms both in formula-fed and breast-fed infants. In formula-fed infants, clinical efficacy is similar to thickened formulas with a slightly lower cost of treatment.
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Affiliation(s)
- Maria Elisabetta Baldassarre
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy; (A.D.M.); (M.C.P.); (N.L.)
- Correspondence:
| | - Antonio Di Mauro
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy; (A.D.M.); (M.C.P.); (N.L.)
| | - Maria Cristina Pignatelli
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy; (A.D.M.); (M.C.P.); (N.L.)
| | - Margherita Fanelli
- Department of Interdisciplinary Medicine, “Aldo Moro” University of Bari, 70100 Bari, Italy;
| | - Silvia Salvatore
- Department of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy;
| | - Giovanni Di Nardo
- Chiar of Pediatrics, NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy;
| | - Andrea Chiaro
- Department of Pediatrics, “Maggiore” Hospital, 26013 Crema, Italy;
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Nicola Laforgia
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy; (A.D.M.); (M.C.P.); (N.L.)
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Yousaf M, Nirwan JS, Smith AM, Timmins P, Conway BR, Ghori MU. Raft‐forming polysaccharides for the treatment of gastroesophageal reflux disease (GORD): Systematic review. J Appl Polym Sci 2019. [DOI: 10.1002/app.48012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Maria Yousaf
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Jorabar Singh Nirwan
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Alan M. Smith
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Peter Timmins
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Muhammad Usman Ghori
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
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7
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Walls E. Understanding reflux problems in infants, children and young people. ACTA ACUST UNITED AC 2019; 28:920-923. [DOI: 10.12968/bjon.2019.28.14.920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elaine Walls
- Senior Lecturer, Department of Health and Life Sciences, Northumbria University
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8
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Leung AK, Hon KL. Gastroesophageal reflux in children: an updated review. Drugs Context 2019; 8:212591. [PMID: 31258618 PMCID: PMC6586172 DOI: 10.7573/dic.212591] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 12/14/2022] Open
Abstract
Background Gastroesophageal reflux is a common disorder in pediatrics. Clinicians should be familiar with the proper evaluation and management of this condition. Objective To provide an update on the current understanding, evaluation, and management of gastroesophageal reflux in children. Methods A PubMed search was performed with Clinical Queries using the key term ‘gastroesophageal reflux’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to the English literature and the pediatric age group. Results Regurgitation is the most frequent symptom of gastroesophageal reflux and is present in nearly all cases. Gastroesophageal reflux occurs normally in infants, is often physiological, peaks at 4 months of age, and tends to resolve with time. Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce troublesome symptom(s) and/or complication(s). A thorough clinical history and a thorough physical examination are usually adequate for diagnosis. When the diagnosis is ambiguous, diagnostic studies may be warranted. A combined esophageal pH monitoring and multichannel intraluminal esophageal electrical impedance device is the gold standard for the diagnosis of gastroesophageal reflux disease if the diagnosis is in doubt. In the majority of cases, no treatment is necessary for gastroesophageal reflux apart from reassurance of the benign nature of the condition. Treatment options for gastroesophageal reflux disease are discussed. Conclusion In most cases, no treatment is necessary for gastroesophageal reflux apart from reassurance because the condition is benign and self-limiting. Thickened feedings, postural therapy, and lifestyle changes should be considered if the regurgitation is frequent and problematic. Pharmacotherapy should be considered in the treatment of more severe gastroesophageal reflux disease for patients who do not respond to conservative measures. Proton pump inhibitors are favored over H2-receptor antagonists because of their superior efficacy. Antireflux surgery is indicated for patients with significant gastroesophageal reflux disease who are resistant to medical therapy.
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Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong.,PICU, The Hong Kong Children's Hospital, Kowloon, Hong Kong
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Maier T, Kerbs A, Fruk L, Slater NKH. Iron delivery from liquid-core hydrogels within a therapeutic nipple shield. Eur J Pharm Sci 2019; 131:119-126. [PMID: 30710620 DOI: 10.1016/j.ejps.2019.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/19/2019] [Accepted: 01/28/2019] [Indexed: 12/28/2022]
Abstract
To aid oral therapeutic administration to infants, a novel delivery technology, referred to as a Therapeutic Nipple Shield (TNS), was previously developed. It consists of a silicone nipple shield device and a dosage form containing a therapeutic (or Active Pharmaceutical Ingredient (API)) to enable delivery during breastfeeding. A range of dosage forms were investigated in past literature, but sufficient API release into human milk had not been achieved. The presented work illustrates the delivery of iron sulphate pentahydrate from liquid-core sodium alginate hydrogels, inserted into a commercially available ultra-thin silicone nipple shield into human milk during in-vitro breastfeeding simulation. Release of iron was quantified employing absorbance measurements of a salicylic assay. An absolute recovery of 44.35 ± 5.43% of loaded iron(III)sulphate pentahydrate was obtained after 10.58 ± 0.09 g of human milk had passed through the nipple shield. This finding is superior to previous investigations involving the delivery of zinc from rapidly disintegrating tablets and non-woven fibres within a TNS. Due to their superior delivery properties, ease of fabrication and cost-efficiency, liquid-core sodium alginate hydrogels consequently represent a promising dosage form for use as part of the TNS. Further improvements can be made to enhance handling stability and shelf-life characteristics.
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Affiliation(s)
- Theresa Maier
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom; University of Cambridge, Department of Paediatrics, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom.
| | - Antonina Kerbs
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom
| | - Ljiljana Fruk
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom
| | - Nigel K H Slater
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom
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Ciciora SL, Woodley FW. Optimizing the Use of Medications and Other Therapies in Infant Gastroesophageal Reflux. Paediatr Drugs 2018; 20:523-537. [PMID: 30198060 DOI: 10.1007/s40272-018-0311-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroesophageal reflux (GER) is the retrograde movement of gastric (and sometimes duodenal) contents into the esophagus. While the majority of GER is physiologic, for patients, it can be associated with symptoms. While some symptoms are merely bothersome (crying), others can be life threatening (cough, gagging, choking). The main driver of GER in infants is the frequent feedings that produce increased intra-abdominal pressure, which is known to trigger transient relaxations of the lower esophageal sphincter. The recent 2018 clinical practice guidelines reported by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN/ESPGHAN) have recommended non-pharmacologic management initially with subsequent consideration of brief trials with acid suppressants. The main target for these acid suppressants is the gastric parietal cells. Our review of the literature has revealed a paucity of data regarding the use of histamine-2 receptor antagonists and proton pump inhibitors in infants. Despite the absence of well-controlled clinical studies, the prescription rate of these medications has increased internationally. Risks to patients of all ages have become increasingly recognized, with new associations being reported all too often. Here we report our review of all pharmacologic modalities as well as some non-surgical options.
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Affiliation(s)
- Steven L Ciciora
- Division of Gastroenterology, Hepatology and Nutrition, Center for Functional Motility Disorders, Nationwide Children's Hospital, Columbus, OH, 43205, USA.,Department of Pediatrics, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Frederick W Woodley
- Division of Gastroenterology, Hepatology and Nutrition, Center for Functional Motility Disorders, Nationwide Children's Hospital, Columbus, OH, 43205, USA. .,Department of Pediatrics, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
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Eichenwald EC, Cummings JJ, Aucott SW, Goldsmith JP, Hand IL, Juul SE, Poindexter BB, Puopolo KM, Stewart DL. Diagnosis and Management of Gastroesophageal Reflux in Preterm Infants. Pediatrics 2018; 142:peds.2018-1061. [PMID: 29915158 DOI: 10.1542/peds.2018-1061] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Gastroesophageal reflux (GER), generally defined as the passage of gastric contents into the esophagus, is an almost universal phenomenon in preterm infants. It is a common diagnosis in the NICU; however, there is large variation in its treatment across NICU sites. In this clinical report, the physiology, diagnosis, and symptomatology in preterm infants as well as currently used treatment strategies in the NICU are examined. Conservative measures to control reflux, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of GER in the preterm infant. In addition, preterm infants with clinically diagnosed GER are often treated with pharmacologic agents; however, a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in preterm infants.
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Affiliation(s)
| | - James J. Cummings
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Wright Aucott
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay P. Goldsmith
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ivan L. Hand
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandra E. Juul
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Karen M. Puopolo
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dan L. Stewart
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Salvatore S, Ripepi A, Huysentruyt K, van de Maele K, Nosetti L, Agosti M, Salvatoni A, Vandenplas Y. The Effect of Alginate in Gastroesophageal Reflux in Infants. Paediatr Drugs 2018; 20:575-583. [PMID: 30182358 PMCID: PMC6267531 DOI: 10.1007/s40272-018-0314-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Guidelines are contradictory regarding the use of alginate in infants with persisting gastroesophageal reflux (GER). While The British National Institute for Health and Care (NICE) guidelines consider alginate as a treatment option, the guidelines of the European and North-American Societies for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN, NASPGHAN) do not recommend alginates. AIMS We assessed the efficacy of alginate to reduce GER episodes in infants. METHODS In a prospective, observational study, we consecutively enrolled all infants referred for pH-multiple intraluminal impedance (pH-MII) recording because of persisting GER symptoms not responsive to behavior and dietetic modifications. A 48-h pH-MII was performed in all infants; a baseline recording was performed during the first 24 h while magnesium or sodium alginate was administered during the second 24 h. The primary endpoint was the difference in the total number of GER episodes per 24 h between the baseline day and the second day during which the alginate was administered. The secondary outcome was the difference in symptoms between each period. We also compared other pH-MII data from before and during alginate administration. RESULTS We recruited 43 infants (median age 68 days, range 25-306); three pH-MII tracings were excluded because of artifacts. The median number of all MII reflux episodes was significantly reduced during alginate administration (76.0 vs 69.5; p < 0.001). Crying-fussiness, cough and regurgitation episodes all significantly improved during alginate administration (p = 0.00012; p = 0.005 and p = 0.04, respectively). The following MII parameters also decreased during the alginate administration: acid (19.0 vs 14.5; p < 0.04), non-acid (52.0 vs 49.5; p < 0.004), proximal GER episodes (46.0 vs 41.4; p < 0.007), and bolus exposure index (1.9 vs 1.6; p = 0.002). At least three out of seven pH-MII parameters decreased by > 10% during the alginate period in 31/40 infants (77.5%), without a significant difference between magnesium and sodium alginate. CONCLUSION These results suggest that alginate significantly decreases the number and extension of both acid and non-acid reflux episodes and associated symptoms in infants.
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Affiliation(s)
- Silvia Salvatore
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Antonio Ripepi
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Koen Huysentruyt
- 0000 0001 2290 8069grid.8767.eKidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, 101, 1090 Brussels, Belgium
| | - Kristel van de Maele
- 0000 0001 2290 8069grid.8767.eKidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, 101, 1090 Brussels, Belgium
| | - Luana Nosetti
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Massimo Agosti
- Division of Neonatology and Neonatal Intensive Care Unit, “F. Del Ponte” Hospital, Varese, Italy
| | - Alessandro Salvatoni
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Yvan Vandenplas
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, 101, 1090, Brussels, Belgium.
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Dermyshi E, Mackie C, Kigozi P, Schoonakker B, Dorling J. Antacid therapy for gastroesophageal reflux in preterm infants: a systematic review. BMJ Paediatr Open 2018; 2:e000287. [PMID: 30019019 PMCID: PMC6045735 DOI: 10.1136/bmjpo-2018-000287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Gastro-oesophageal reflux is prevalent in preterm infants. Despite widespread use in clinical practice, there is still much controversy over the efficacy and safety of drug interventions, particularly antacid therapy. OBJECTIVE To systematically review the effects of antacid therapy on preterm infants with symptoms of gastro-oesophageal reflux, and to assess the safety of these interventions. METHODS We carried out an electronic search of the Cochrane central register of controlled trials (CENTRAL, The Cochrane Library), MEDLINE (1966-present), EMBASE (1980-present) and CINAHL (1982-present) as well as other online sources. Participants were preterm infants (<37 weeks gestation) with gastro-oesophageal reflux disease who were receiving care on a neonatal unit. We assessed the effects of histamine-2 receptor antagonists, proton pump inhibitors and alginates against placebo, primarily to see if they reduced the symptoms of reflux. RESULTS Six studies were included in this review. Meta-analysis could not be carried out due to a lack of studies assessing the same intervention with the same outcomes. Omeprazole therapy significantly reduced the oesophageal acid exposure percentage time with pH<4 (p<0.01) and sodium alginate significantly decreased gastro-oesophageal reflux episodes (p=0.024). Metoclopramide and ranitidine showed a significant increase in gastro-oesophageal reflux disease symptoms versus placebo (p<0.04). No significant results were found for the use of esomeprazole or lansoprazole versus placebo. CONCLUSIONS There is insufficient evidence available to conclude whether antacid therapy is effective or safe when treating gastro-oesophageal reflux disease in preterm infants. Further research is needed into this topic and caution should be taken when administering antacids to preterm infants. TRIAL REGISTRATION NUMBER CRD42017078778.
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Affiliation(s)
- Elda Dermyshi
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Charley Mackie
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Phoebe Kigozi
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Bernard Schoonakker
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Jon Dorling
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
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Kwok TC, Ojha S, Dorling J. Feed thickener for infants up to six months of age with gastro-oesophageal reflux. Cochrane Database Syst Rev 2017; 12:CD003211. [PMID: 29207214 PMCID: PMC6485971 DOI: 10.1002/14651858.cd003211.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is common in infants, and feed thickeners are often used to manage it in infants as they are simple to use and perceived to be harmless. However, conflicting evidence exists to support the use of feed thickeners. OBJECTIVES To evaluate the use of feed thickeners in infants up to six months of age with GOR in terms of reduction in a) signs and symptoms of GOR, b) reflux episodes on pH probe monitoring or intraluminal impedance or a combination of both, or c) histological evidence of oesophagitis. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed (1966 to 22 November 2016), Embase (1980 to 22 November 2016), and CINAHL (1982 to 22 November 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials. SELECTION CRITERIA We included randomised controlled trials if they examined the effects of feed thickeners as compared to unthickened feeds (no treatment or placebo) in treating GOR in term infants up to six months of age or six months of corrected gestational age for those born preterm. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible studies from the literature search. Two review authors independently performed data extraction and quality assessments of the eligible studies. Differences in opinion were resolved by discussion with a third review author, and consensus was reached among all three review authors. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS Eight trials recruiting a total of 637 infants met the inclusion criteria for the systematic review. The infants included in the review were mainly formula-fed term infants. The trials were of variable methodological quality. Formula-fed term infants with GOR on feed thickeners had nearly two fewer episodes of regurgitation per day (mean difference -1.97 episodes per day, 95% confidence interval (CI) -2.32 to -1.61; 6 studies, 442 infants, moderate-certainty evidence) and were 2.5 times more likely to be asymptomatic from regurgitation at the end of the intervention period (risk ratio 2.50, 95% CI 1.38 to 4.51; number needed to treat for an additional beneficial outcome 5, 95% CI 4 to 13; 2 studies, 186 infants, low-certainty evidence) when compared to infants with GOR on unthickened feeds. No studies reported failure to thrive as an outcome. We found low-certainty evidence based on 2 studies recruiting 116 infants that use of feed thickeners improved the oesophageal pH probe parameters of reflux index (i.e. percentage of time pH < 4), number of reflux episodes lasting longer than 5 minutes, and duration of longest reflux episode. No major side effects were reported with the use of feed thickeners. Information was insufficient to conclude which type of feed thickener is superior. AUTHORS' CONCLUSIONS Gastro-oesophageal reflux is a physiological self resolving phenomenon in infants that does not necessarily require any treatment. However, we found moderate-certainty evidence that feed thickeners should be considered if regurgitation symptoms persist in term bottle-fed infants. The reduction of two episodes of regurgitation per day is likely to be of clinical significance to caregivers. Due to the limited information available, we were unable to assess the use of feed thickeners in infants who are breastfeeding or preterm nor could we conclude which type of feed thickener is superior.
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Affiliation(s)
| | - Shalini Ojha
- University of NottinghamDivision of Medical Sciences and Graduate Entry Medicine, School of MedicineNottinghamUK
- Derby Teaching Hospitals NHS Foundation TrustChildren’s HospitalDerbyUK
| | - Jon Dorling
- Neonatal Unit, Queen's Medical CentreSchool of Medicine, University of NottinghamDerby RoadNottinghamUKNG7 2UH
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15
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Pharmacological management of gastroesophageal reflux disease in infants: current opinions. Curr Opin Pharmacol 2017; 37:112-117. [DOI: 10.1016/j.coph.2017.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
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16
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Cohen S, Bueno de Mesquita M, Mimouni FB. Adverse effects reported in the use of gastroesophageal reflux disease treatments in children: a 10 years literature review. Br J Clin Pharmacol 2015; 80:200-8. [PMID: 25752807 DOI: 10.1111/bcp.12619] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/03/2015] [Accepted: 02/26/2015] [Indexed: 12/16/2022] Open
Abstract
Gastroesophageal reflux (GER) is commonly observed in children, particularly during the first year of life. Pharmacological therapy is mostly reserved for symptomatic infants diagnosed with GER disease (GERD), usually as defined in a recent consensus statement. The purpose of the present article was to review the reported adverse effects of pharmacological agents used in the treatment of paediatric GERD. We conducted this review using the electronic journal database Pubmed and Cochrane database systematic reviews using the latest 10-year period (1 January 2003 to 31 December 2012). Our search strategy included the following keywords: omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, rantidine, cimetidine, famotidine, nizatidine, domperidone, metoclopramide, betanechol, erythromycin, baclofen, alginate. We used Pubmed's own filter of: 'child: birth-18 years'. All full articles were reviewed and we only included randomized controlled trials retrieved from our search. We addressed a summary of our search on a drug-by-drug basis with regard to its mechanism of action and clinical applications, and reviewed all of the adverse effects reported and the safety profile of each drug. Adverse effects have been reported in at least 23% of patients treated with histamine H2 receptor antagonists (H2 RAs) and 34% of those treated with proton pump inhibitors (PPIs), and mostly include headaches, diarrhoea, nausea (H2 RAs and PPIs) and constipation (PPIs). Acid suppression may place immune-deficient infants and children, or those with indwelling catheters, at risk for the development of lower respiratory tract infections and nosocomial sepsis. Prokinetic agents have many adverse effects, without major benefits to support their routine use.
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Affiliation(s)
- Shlomi Cohen
- The Pediatric Gastroenterology unit.,Department of Pediatrics, 'Dana-Dwek' Children's Hospital, Tel Aviv Medical Center and, the.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel and
| | - Mirjam Bueno de Mesquita
- The Pediatric Gastroenterology unit.,Department of Pediatrics, 'Dana-Dwek' Children's Hospital, Tel Aviv Medical Center and, the
| | - Francis B Mimouni
- Department of Pediatrics, 'Dana-Dwek' Children's Hospital, Tel Aviv Medical Center and, the.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel and.,Division of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
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17
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Abstract
OBJECTIVES Gastroesophageal reflux (GER) is a frequently occurring condition in infants capable of causing distressing symptoms. The aim of our study is to evaluate the efficacy of Mg alginate plus simethicone (Gastrotuss Baby, DMG Italia SRL, Pomezia, Italy), compared with rice-starch-thickened formula or with reassurance alone, in the treatment of GER in infants. METHODS The present randomized controlled trial was conducted in full-term infants affected by symptoms suggestive of GER, evaluated through a validated questionnaire (Infant Gastroesophageal Reflux Questionnaire Revised). The patients were randomized into 3 groups according to treatment (group A: Mg alginate plus simethicone; group B: thickened formula; group C: reassurance with lifestyle changes). Evaluation of symptom scores was performed after 1 month (T1) and 2 months (T2). RESULTS A total of 64 (85.3%) of 75 enrolled infants (median age 5 months; range 1-10) concluded the study. After 1 month of treatment (T1), infants treated with Mg alginate plus simethicone showed a statistically significant improvement in symptoms compared with the thickened formula and reassurance (P < 0.03, <0.0001, respectively). At the end of the study, all 3 groups of patients showed a significant reduction in symptom scores (P < 0.002, <0.038, <0.03, respectively). Median symptom score values were more significantly reduced in group A than in group B and in group C (group A vs group B P < 0.002; group A vs group C P < 0.0001; group B vs group C P < 0.001). CONCLUSIONS Mg alginate plus simethicone seems to be more efficacious on GER symptom scores than thickened formula and reassurance with lifestyle changes alone.
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18
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Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Pharmacological treatment of children with gastro-oesophageal reflux. Cochrane Database Syst Rev 2014; 2014:CD008550. [PMID: 25419906 PMCID: PMC8947620 DOI: 10.1002/14651858.cd008550.pub2] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is a common disorder, characterised by regurgitation of gastric contents into the oesophagus. GOR is a very common presentation in infancy in both primary and secondary care settings. GOR can affect approximately 50% of infants younger than three months old (Nelson 1997). The natural history of GOR in infancy is generally that of a functional, self-limiting condition that improves with age; < 5% of children with vomiting or regurgitation continue to have symptoms after infancy (Martin 2002). Older children and children with co-existing medical conditions can have a more protracted course. The definition of gastro-oesophageal reflux disease (GORD) and its precise distinction from GOR are debated, but consensus guidelines from the North American Society of Gastroenterology, Hepatology and Nutrition (NASPGHAN-ESPGHAN guidelines 2009) define GORD as 'troublesome symptoms or complications of GOR.' OBJECTIVES This Cochrane review aims to provide a robust analysis of currently available pharmacological interventions used to treat children with GOR by assessing all outcomes indicating benefit or harm. SEARCH METHODS We sought to identify relevant published trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5), MEDLINE and EMBASE (1966 to 2014), the Centralised Information Service for Complementary Medicine (CISCOM), the Institute for Scientific Information (ISI) Science Citation Index (on BIDS-UK General Science Index) and the ISI Web of Science. We also searched for ongoing trials in the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com).Reference lists from trials selected by electronic searching were handsearched for relevant paediatric studies on medical treatment of children with gastro-oesophageal reflux, as were published abstracts from conference proceedings (published in Gut and Gastroenterology) and reviews published over the past five years.No language restrictions were applied. SELECTION CRITERIA Abstracts were reviewed by two review authors, and relevant RCTs on study participants (birth to 16 years) with GOR receiving a pharmacological treatment were selected. Subgroup analysis was considered for children up to 12 months of age, and for children 12 months to 16 years of age, and for those with neurological impairment. DATA COLLECTION AND ANALYSIS Trials were critically appraised and data collected by two review authors. Risk of bias was assessed. Meta-analysis data were independently extracted by two review authors, and suitable outcome data were analysed using RevMan. MAIN RESULTS A total of 24 studies (1201 participants) contributed data to the review. The review authors had several concerns regarding the studies. Pharmaceutical company support for manuscript preparation was a common feature; also, because common endpoints were lacking, study populations were heterogenous and variations in study design were noted, individual drug meta-analysis was not possible.Moderate-quality evidence from individual studies suggests that proton pump inhibitors (PPIs) can reduce GOR symptoms in children with confirmed erosive oesophagitis. It was not possible to demonstrate statistical superiority of one PPI agent over another.Some evidence indicates that H₂antagonists are effective in treating children with GORD. Methodological differences precluded performance of meta-analysis on individual agents or on these agents as a class, in comparison with placebo or head-to-head versus PPIs, and additional studies are required.RCT evidence is insufficient to permit assessment of the efficacy of prokinetics. Given the diversity of study designs and the heterogeneity of outcomes, it was not possible to perform a meta-analysis of the efficacy of domperidone.In younger children, the largest RCT of 80 children (one to 18 months of age) with GOR showed no evidence of improvement in symptoms and 24-hour pH probe, but improvement in symptoms and reflux index was noted in a subgroup treated with domperidone and co-magaldrox(Maalox(®) ). In another RCT of 17 children, after eight weeks of therapy. 33% of participants treated with domperidone noted an improvement in symptoms (P value was not significant). In neonates, the evidence is even weaker; one RCT of 26 neonates treated with domperidone over 24 hours showed that although reflux frequency was significantly increased, reflux duration was significantly improved.Diversity of RCT evidence was found regarding efficacy of compound alginate preparations(Gaviscon Infant(®) ) in infants, although as a result of these studies, Gaviscon Infant(®) was changed to become aluminium-free and has been assessed in its current form in only two studies since 1999. Given the diversity of study designs and the heterogeneity of outcomes, as well as the evolution in formulation, it was not possible to perform a meta-analysis on the efficacy of Gaviscon Infant(®) . Moderate evidence indicates that Gaviscon Infant(®) improves symptoms in infants, including those with functional reflux; the largest study of the current formulation showed improvement in symptom control but was limited by length of follow-up.No serious side effects were reported.No RCTs on pharmacological treatments for children with neurodisability were identified. AUTHORS' CONCLUSIONS Moderate evidence was found to support the use of PPIs, along with some evidence to support the use of H₂ antagonists in older children with GORD, based on improvement in symptom scores, pH indices and endoscopic/histological appearances. However, lack of independent placebo-controlled and head-to-head trials makes conclusions as to relative efficacy difficult to determine. Further RCTs are recommended. No robust RCT evidence is available to support the use of domperidone, and further studies on prokinetics are recommended, including assessments of erythromycin.Pharmacological treatment of infants with reflux symptoms is problematic, as many infants have GOR, and little correlation has been noted between reported symptoms and endoscopic and pH findings. Better evidence has been found to support the use of PPIs in infants with GORD, but heterogeneity in outcomes and in study design impairs interpretation of placebo-controlled data regarding efficacy. Some evidence is available to support the use of Gaviscon Infant(®) , but further studies with longer follow-up times are recommended. Studies of omeprazole and lansoprazole in infants with functional GOR have demonstrated variable benefit, probably because of differences in inclusion criteria.No robust RCT evidence has been found regarding treatment of preterm babies with GOR/GORD or children with neurodisabilities. Initiation of RCTs with common endpoints is recommended, given the frequency of treatment and the use of multiple antireflux agents in these children.
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Affiliation(s)
- Mark Tighe
- Poole Hospital NHS Foundation TrustDepartment of PaediatricsLongfleet RoadPooleDorsetUKBH15 2JB
| | - Nadeem A Afzal
- University Hospital Southampton NHS Foundation TrustChild HealthTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation TrustDepartment of PharmacyTremona RoadSouthamptonHampshireUK
| | - Andrew Hayen
- University of TechnologyFaculty of HealthUltimoNSWAustralia2007
| | - Alasdair Munro
- Poole Hospital NHS Foundation TrustDepartment of PaediatricsLongfleet RoadPooleDorsetUKBH15 2JB
| | - R Mark Beattie
- University Hospital Southampton NHS Foundation TrustChild HealthTremona RoadSouthamptonHampshireUKSO16 6YD
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Kahrilas PJ, McColl K, Fox M, O'Rourke L, Sifrim D, Smout AJPM, Boeckxstaens G. The acid pocket: a target for treatment in reflux disease? Am J Gastroenterol 2013; 108:1058-64. [PMID: 23629599 DOI: 10.1038/ajg.2013.132] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 03/26/2013] [Indexed: 12/11/2022]
Abstract
The nadir esophageal pH of reflux observed during pH monitoring in the postprandial period is often more acidic than the concomitant intragastric pH. This paradox prompted the discovery of the "acid pocket", an area of unbuffered gastric acid that accumulates in the proximal stomach after meals and serves as the reservoir for acid reflux in healthy individuals and gastroesophageal reflux disease (GERD) patients. However, there are differentiating features between these populations in the size and position of the acid pocket, with GERD patients predisposed to upward migration of the proximal margin onto the esophageal mucosa, particularly when supine. This upward migration of acid, sometimes referred to as an "acid film", likely contributes to mucosal pathology in the region of the squamocolumnar junction. Furthermore, movement of the acid pocket itself to a supradiaphragmatic location with hiatus hernia increases the propensity for acid reflux by all conventional mechanisms. Consequently, the acid pocket is an attractive target for GERD therapy. It may be targeted in a global way with proton pump inhibitors that attenuate acid pocket development, or with alginate/antacid combinations that colocalize with the acid pocket and displace it distally, thereby demonstrating the potential for selective targeting of the acid pocket in GERD.
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Affiliation(s)
- Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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20
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Corvaglia L, Monari C, Martini S, Aceti A, Faldella G. Pharmacological therapy of gastroesophageal reflux in preterm infants. Gastroenterol Res Pract 2013; 2013:714564. [PMID: 23878533 PMCID: PMC3710644 DOI: 10.1155/2013/714564] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 05/22/2013] [Accepted: 06/12/2013] [Indexed: 02/07/2023] Open
Abstract
Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.
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Affiliation(s)
- Luigi Corvaglia
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
| | - Caterina Monari
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Silvia Martini
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Arianna Aceti
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Giacomo Faldella
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
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21
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Erdeve O, Atasay B, Arsan S, Türmen T. Authors' Response. J Clin Pharmacol 2012. [DOI: 10.1177/0091270011401738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Malcolm WF, Cotten CM. Metoclopramide, H2 blockers, and proton pump inhibitors: pharmacotherapy for gastroesophageal reflux in neonates. Clin Perinatol 2012; 39:99-109. [PMID: 22341540 DOI: 10.1016/j.clp.2011.12.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pharmacotherapy for gastroesophageal reflux (GER) in neonates, aimed at interfering with this physiologic process and potentially reducing the negative sequelae that providers often attribute to GER, consists primarily of drugs that increase the viscosity of feeds, reduce stomach acidity, or improve gut motility. Medications used to treat clinical signs thought to be from GER, such as apnea, bradycardia, or feeding intolerance, are among the most commonly prescribed medications in neonatal intensive care units in the United States, despite the lack of evidence of safety and efficacy in this population.
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Affiliation(s)
- William F Malcolm
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University, Durham, NC, USA
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23
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Corvaglia L, Spizzichino M, Zama D, Aceti A, Mariani E, Legnani E, Faldella G. Sodium Alginate (Gaviscon®) does not reduce apnoeas related to gastro-oesophageal reflux in preterm infants. Early Hum Dev 2011; 87:775-8. [PMID: 21696897 DOI: 10.1016/j.earlhumdev.2011.05.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/30/2011] [Accepted: 05/31/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Apnoea of prematurity (AOP) frequently recurs in preterm infants. We have previously shown that a significant but variable proportion of AOP is induced by gastro-oesophageal reflux (GOR). AIM The aim of this study is to evaluate the efficacy of sodium alginate in reducing the frequency of GOR-related AOP. SUBJECTS Twenty-eight preterm infants with AOP were studied by a six-hour recording of combined multichannel intraluminal impedance and pH monitoring and polysomnography, including two three-hour postprandial periods: sodium alginate was given after one single meal named as drug-given (DG) meal, while the other as drug-free (DF). RESULTS During 165h of registration, 715 apnoeas were recorded, 368 after-DG and 347 after-DF (p=.99); furthermore, 851 GOR episodes were detected, 315 after-DG and 536 after-DF (p=.001). No differences in the number of AOP were found between DG and DF. A significant reduction in the number of acid GORs and in acid exposure was found during DG, while the administration of sodium alginate didn't influence non-acid GOR indexes. The frequency of GOR-related apnoeas didn't differ between DG and DF. DISCUSSION Sodium alginate doesn't reduce the total number of AOP nor GOR-related apnoeas. On the other hand, it reduces acid GOR features, while it had no effect on non-acid GOR indexes.
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Affiliation(s)
- Luigi Corvaglia
- Neonatology and Neonatal Intensive Care Unit-S. Orsola-Malpighi Hospital-University of Bologna, Via Massarenti 11, 40138 Bologna, Italy.
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Kwiatek MA, Roman S, Fareeduddin A, Pandolfino JE, Kahrilas PJ. An alginate-antacid formulation (Gaviscon Double Action Liquid) can eliminate or displace the postprandial 'acid pocket' in symptomatic GERD patients. Aliment Pharmacol Ther 2011; 34:59-66. [PMID: 21535446 PMCID: PMC3612878 DOI: 10.1111/j.1365-2036.2011.04678.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recently, an 'acid pocket' has been described in the proximal stomach, particularly evident postprandially in GERD patients, when heartburn is common. By creating a low density gel 'raft' that floats on top of gastric contents, alginate-antacid formulations may neutralise the 'acid pocket'. AIM To assess the ability of a commercial high-concentration alginate-antacid formulation to neutralize and/or displace the acid pocket in GERD patients. METHODS The 'acid pocket' was studied in ten symptomatic GERD patients. Measurements were made using concurrent stepwise pH pull-throughs, high resolution manometry and fluoroscopy in a semi-recumbent posture. Each subject was studied in three conditions: fasted, 20 min after consuming a high-fat meal and 20 min later after a 20 mL oral dose of an alginate-antacid formulation (Gaviscon Double Action Liquid, Reckitt Benckiser Healthcare, Hull, UK). The relative position of pH transition points (pH >4) to the EGJ high-pressure zone was analysed. RESULTS Most patients (8/10) exhibited an acidified segment extending from the proximal stomach into the EGJ when fasted that persisted postprandially. Gaviscon neutralised the acidified segment in six of the eight subjects shifting the pH transition point significantly away from the EGJ. The length and pressure of the EGJ high-pressure zone were minimally affected. CONCLUSIONS Gaviscon can eliminate or displace the 'acid pocket' in GERD patients. Considering that EGJ length was unchanged throughout, this effect was likely attributable to the alginate 'raft' displacing gastric contents away from the EGJ. These findings suggest the alginate-antacid formulation to be an appropriately targeted postprandial GERD therapy.
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Affiliation(s)
- M A Kwiatek
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 St. Clair Street, Chicago, IL 60611-2951, USA.
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Erdeve O, Atasay B, Arsan S, Türmen T. Efficacy and safety of sodium alginate for GERD in preterm infants. Aliment Pharmacol Ther 2011; 33:981-2; author reply 982-3. [PMID: 21434951 DOI: 10.1111/j.1365-2036.2011.04591.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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