Several medications may be used to treat GERD in infants and children. The 2 major classes of pharmacologic agents for treatment of GERD are acid suppressants and prokinetic agents ( Table 4 ). Growing evidence that demonstrates the former to be more effective than the latter has led to an increased use of acid suppressants to manage suspected GERD in pediatric patients 4 , 39 ; however, there is also significant concern for the overprescription of acid suppressants, particularly proton pump inhibitors (PPIs), and it is important to understand the new guidelines for medication indications.
To date, no single symptom or cluster of symptoms can reliably be used to diagnose esophagitis or other complications of GERD in children or to predict which patients are most likely to respond to therapy. 21 Nonetheless, a number of GERD symptom questionnaires have been validated and may be useful in the detection and surveillance of GERD in affected children of all ages. Kleinman et al developed a questionnaire for infants that was validated for documentation and monitoring of parent-reported GERD symptoms. 30 Another questionnaire by Størdal et al 32 for pediatric patients 7 to 16 years of age compared favorably with results of pH monitoring. As yet another example, the GERD Symptom Questionnaire developed by Deal et al 33 appears valid for differentiating children with GERD from healthy controls but has not been compared with objective standards, such as pH monitoring or endoscopic findings.
Gastroesophageal reflux strictures typically occur in the mid-esophagus to distal esophagus. Patients present with dysphagia to solid meals and vomiting of nondigested foods. As a rule, the presence of any esophageal stricture is an indication that the patient needs surgical consultation and treatment (usually surgical fundoplication). When patients present with dysphagia, barium esophagraphy is indicated to evaluate for possible stricture formation. In these cases, especially when associated with food impaction, eosinophilic esophagitis must be ruled out prior to attempting any mechanical dilatation of the narrowed esophageal region.
H2RAs represent a major class of medications that has completely revolutionized the treatment of GERD in children. H2RAs decrease the secretion of acid by inhibiting the histamine-2 receptor on the gastric parietal cell. Expert opinion suggests little clinical difference between the various formulations of H2RAs. Randomized placebo-controlled pediatric clinical trials have shown that cimetidine and nizatidine are news superior to placebo for the treatment of erosive esophagitis in children. 52 , 53 Pharmacokinetic studies in school-aged children suggest that gastric pH begins to increase within 30 minutes of administration of an H2RA and reaches peak plasma concentrations 2.5 hours after dosing. The acid-inhibiting effects of H2RAs last for approximately 6 hours, so H2RAs are quite effective if administered 2 or 3 times a day.