Live from the GI Conference: Reflux Update

The field of medicine is always changing as researchers explore new theories and
treatments. During the NASPGHAN conference (www.naspghan.org) sessions this weekend,I have been learning as much as possible about recent developments in the study of Gastroesophageal Reflux Disease (GERD).

GERD is now viewed as a chronic childhood health condition. Keep in mind that most
babies have Gastroesophageal Reflux (GER), a common condition of infancy that resolves without tests, medicine or treatment during the first year of life. Research studies have documented the effectiveness of Proton Pump Inhibitor (PPI) medications (examples of brand names include Prevacid, Prilosec and Nexium) and H2 blocker medication (examples of brand names include Zantac and Pepcid) in reducing acid and healing the esophagus of children with GERD. Further, there is often excellent improvementin respiratory symptoms as well as a reduction in irritability and swallowing problems.

Unfortunately, some children continue to have uncomfortable symptoms despite medication to block acid. I frequently hear from parents who report significant symptoms and pain despite treatment that includes a strong medication. It is frustrating to doctors, parents and children when the pH probe test is normal (showing average or normal amounts of acid in the stomach), indicating
complete “control” of the acid. Yet, the pain and discomfort march on. There is some evidence that children with a normal pH probe and failure to respond to PPI treatment may have Eosinophilic Esophagitis, a condition that may mimic GERD. There was a great deal of discussion about Eosinophilic Esophagitis at the conference this weekend and I will provide more in depth information in the near future.

Researchers are using more advanced testing methods (Bravo pH monitoring and Impedance testing) to monitor acid reflux (backwashing of acidic stomach contents) and non acid reflux (backwashing that is not acidic) events. Preliminary research demonstrates that young babies and babies born prematurely have more non acid reflux events than older children. Studies using the more advanced testing demonstrate that PPI medications block the acid but it does not stop reflux episodes characterized by food coming up after a meal. Researchers are wondering if non acid reflux is causing the persistent symptoms even when acid reflux is controlled.

We know that the basic mechanism of childhood GERD is not too much acid but Transient Lower Esophageal Sphincter Relaxation (TLESR) and decreased pressure in the Lower Esophageal Sphincter (LES). So what do these fancy terms mean? Quite simply, the movement of food through the esophagus is affected by the coordination of nerves and muscles.When there is a lack of coordination in the contractions and relaxation of the muscles, the food fails to move through the esophagus properly. A doctor may use the term poor motility to describe the condition. The food and acid move in the wrong direction and expose the sensitive lining of the esophagus to acid, resulting in damage. Research is targeting the role of motility, acid reflux and non acid reflux in the management of GERD. New motility medicines suitable for children are needed since the present medications have not been proven to be very effective and have worrisome side effects.

We have certainly come a long way from the time when we thought all babies had colic, a benign condition. Then we thought reflux was rare in infants and children. Now we know that GERD is common, is on the increase and researchers are becoming more refined in assessment and treatment approaches based on excellent research and discovery.