Therapy for gastroesophageal reflux disease: more is not necessarily better

Pediatric erosive esophagitis maintenance: finally, some level 1 evidence!

In children, as in adults, gastroesophageal reflux disease (GERD), particularly erosive esophagitis, is now believed to be a chronic disease, probably requiring lifelong maintenance therapy. However, this assumption has not received adequate clinical testing, and the provocative article by Boccia et al. in this issue of the Journal challenges it. The strengths of this exceptional pediatric study lie in its prospective, controlled, randomized character, and in its relatively long duration of prospective follow-up. Weaknesses of the study include its limited power and lack of prior validation of outcome measures. The conclusions of the study are applicable only to children without chronic neurologic, respiratory, or congenital esophageal abnormalities, the children for whom chronic proton pump inhibitors (PPIs) are most often required. The study's provocative results might be explained by the fundamental lack of GERD chronicity in otherwise healthy children, combined with absence of the PPI dependence that can be produced when PPIs are used chronically for chronic disease.

Review article: diagnosis and management of night-time reflux

Symptoms of gastro-oesophageal reflux disease (GERD) range from mild to severe and, when they occur during night-time hours, can interfere with sleep patterns and reduce overall quality of life. The clinical presentation of GERD is characterized by oesophageal as well as supra-oesophageal symptoms, including otolaryngologic and pulmonary complications. However, GERD may be overlooked as the cause of a patient's supra-oesophageal symptoms because these complaints can occur in the absence of oesophageal symptoms or endoscopic changes. The role of available tools used for GERD diagnosis, including endoscopy, oesophageal pH monitoring and an empirical course of proton pump inhibitor therapy, is discussed. Interventions available to achieve the therapeutic goals of symptom relief and prevention include specific lifestyle modifications and over-the-counter as well as prescription pharmacological agents. Patient-initiated, as-needed treatment may not be the best choice for managing persistent night-time reflux because it requires patient arousal from sleep. Proton pump inhibitor therapy remains the treatment of choice for patients with more severe symptoms and those with erosive oesophagitis. Few studies have specifically evaluated the role of pharmacological agents in the management of night-time reflux and comparisons are difficult due to the variability in study design and endpoints assessed.