- Chronic abdominal pain
- History of pulmonary aspiration and/or hematemesis
- History of iron deficiency
- Recurrent symptoms
- Failure of empiric therapy
- GI bleeding
- If a feeding tube or reflux surgery (e.g., Nissen fundoplication) is being considered
- Iron deficiency
- Elevate the head while sleeping
- Avoid recumbency for 3 hours after a meal
- No smoking; avoid secondhand smoke
- Sleeping in the left lateral decubitus position
- Avoid fatty meals, foods purported to increase reflux (chocolate, peppermint, onions, garlic, alcohol) and acidic foods (citrus- and tomato-based foods)
- For children utilizing feeding tubes, adjustments in feeding schedule (reducing bolus sizes and limiting feedings given in the recumbent position) may be helpful
Studies have documented resolution of gastroesophageal reflux in malnourished children with CP with combined nutritional and medical interventions (i.e., chronic tube feeds, prokinetic agents, and acid suppression).
Proton pump inhibitors (e.g., lansoprazole, omeprazole):
- Treatment is generally with lansoprazole (Prevacid), (15 mg in children < 30 kg, 30 mg in children > 30 kg), which comes in several different forms including solutabs (available as 15 and 30 mg which dissolve on the child's tongue or can be added to an oral syringe with water), capsules (15 and 30 mg which can be sprinkled on food or swallowed whole), and strawberry packets (15 and 30 mg packets which can be added to water for administration). Treatment of reflux can be augmented by the use of a motility agent (Reglan or low-dose erythromycin), but the clinician must monitor closely for side effects (particularly irritability or dystonia with Reglan).
- If reflux, burping, and gas continue to be a problem, famotidine (Pepcid) may be added on a prn basis (although the efficacy of combination therapy has not been established).
- Common side effects: headache, nausea, stomach pain, diarrhea, and constipation.
- This medication should be avoided or given cautiously if the patient has liver disease or is taking theophylline, digoxin, ampicillin, ketoconazole, iron, or warfarin (Coumadin).
- Dosage: 0.6 - 0.7 mg/kg/dose PO/GT QD. May increase to BID if needed. Administer before meals. For those unable to swallow a pill, the enteric-coated granules may be dumped on food stuff and eaten, but should not be chewed. They may also be given in an acidic beverage. Sometimes parents have had trouble with the granules sticking to the sides of feeding tube. A liquid preparation can be compounded and information about compounding may be obtained from an outpatient pharmacy from a children's hospital: see all Hospitals services providers (62) in our database.
- Common side effects: headache, diarrhea, nausea, and vomiting.
- Induces CYP 450 1A2, so prolongs the half-life of diazepam, phenytoin, and warfarin.
- Lansoprazole (Prevacid):
Acid suppression (H2 blockers, e.g., ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)):
- While many consider proton pump inhibitors to be more effective for treatment of gastroesophageal reflux disease, histamine receptor blockers (e.g., ranitidine) are still an option and may be cheaper if the family is paying out of pocket or a percentage co-pay for medications. These are available as prescription and non-prescription forms, although prescription forms are stronger than non-prescription.
- Dosage is generally twice a day. They can be used on a prn basis, although they take longer to work than antacids.
- When using these agents, monitor for CNS side effects (e.g., sedation, insomnia). Tachyphylaxis may develop with long-term use.
Prokinetics (metoclopropramide, low-dose erythromycin):
- Mechanism of action: Metoclopropramide may mediate its impact through increased lower esophageal sphincter pressure, accelerated of gastric emptying, and increased small bowel peristalsis. However, the data for efficacy of this drug is conflicting and, in general, suggests modest impacts. Metoclopropramide also has centrally acting anti-emetic properties.
- Major Side Effects: May cause significant central nervous system side effects in a large percentage of children, including fatigue, restlessness, tremors, increased tone, extrapyramidal reactions (dystonic, occulogyric crisis), and tardive dyskinesia. Monitor for irritability, sedation, diarrhea, increased emesis/feeding intolerance, and neurological symptoms.
- Dosage: 0.1 to 0.2 mg/kg/dose up to QID PO/GT (maximum dose 0.8mg/kg/24hr). For children eating orally or on bolus feeds, give 30 minutes before feed. For children on continuous feeds, space doses evenly through the feeding time.
- Mechanism of action: Erythromycin may have better efficacy than metoclopramide with regard to increasing gastric motility. However, when used for chronic treatment, tachyphylaxis may develop.
- Major side effects: Safety profile is better than metoclopropramide but development of tachyphylaxis is a concern for long-term efficacy.
- Dosage: 20 mg/kg/day divided into 4 doses.
Medical therapy is not successful in some patients or despite optimal treatment of reflux, the child remains underweight and surgical procedures may be necessary. When medical therapy is not successful, Nissen or other type of fundoplication may be recommended and can be performed laparoscopically in some cases, which shortens hospital and overall recovery time. For children who do not feed orally who are poor surgical candidates, another option is moving the distal end of the feeding tube to the small intestine (i.e., GJ tube or J tube). A referral should be made to gastroenterology if fundoplication and/or tube feedings are being considered.
Health Supervision for Children with Fragile X Syndrome (AAP)
From the American Academy of Pediatrics' AAP Policy site; this 2011 Clinical Report is a revision of the policy originally published in 1996.
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