Treatment of eerd: The objectives in the treatment of PLPR are to
(1) heal any mucosal damage.
(2) to relieve symptoms, and
(3) to prevent recurrence. Management of pediatric reflux remains a challenge. This is because it is often difficult or even impossible to differentiate between physiological reflux and pathological reflux, that is, reflux causing complications. Current studies of treatment in the pediatric population are limited. There are no randomized controlled trials to evaluate the efficacy of antireflux therapy in children. The lack of trials can be explained by the difficulty in defining what constitutes PLPR. There are also no universally accepted and validated reflux scores for pediatric laryngeal signs. Obtaining ethical approval for studies is, therefore, difficult to justify. In addition, many of the drugs, especially the proton pump inhibitors (PPIs), which are the most effective antacids, are not licensed for use in children in several countries, including the United Kingdom and United States .( Meyer TK,et al ,2004)
Empirical treatment with PPIs, a common practice in the United Kingdom for adults with suspected laryngopharyngeal reflux, is therefore difficult to justify in the pediatric population. Conservative management such as dietary and lifestyle bbehavioralQ modifications may be successful. In many cases of PLPR, appropriate positioning of the sleeping child with elevation of the head of the bed, milk thickening, and fasting before bedtime are simple and often curative measures .( Hassall E. et al , 2005)
Reflux increases the risk of stenosis in animal models and is assumed to account for a significant number of failed laryngotracheal reconstruction attempts. The North Carolina Group recommends prophylactic treatment in every patient undergoing surgery, during which laryngeal mucosal disruption is anticipated. On the other hand, Zalzal et al found no direct correlation between reflux treatment and outcomes after laryngotracheal reconstruction. Drug therapy is probably the most successful treatment modality for PLPR and can include a combination of lifestyle changes with an antacid and/or a histamine-2 receptor antagonist. One would predict that the use of PPIs as part of a step-down therapy, as recommended in the treatment of adult GERD, would have similar effects in PLPR. This, however, cannot be proven until PPIs are licensed for use in children. Experience indicates that the most common error in prescribing PPI is underdosing. If the diagnosis is GERD and there is not a great response to PPIs, then the possible explanation would be an insufficient dose .( Chang A,et al ,2005) However, in PLPR, the data are inconclusive and studies focusing on adequate dosing in pediatric patients are lacking. Some centers will use PPIs in a few selected cases. In the United States, at present, only 2 PPIs are licensed for use in children, omeprazole and lasoprazole, but none is licensed for use of infants younger than 1 year. A recent Cochrane review of antireflux treatment for prolonged nonspecific cough in children and adults— a symptom that can be reflux related in up to 40% of cases— has confirmed what we had already suspected: there is insufficient evidence to definitely conclude that GERD treatment with PPI is beneficial for cough associated with GERD in adults. The pediatric data are even more inconclusive, and more double-blind, randomized, controlled, parallel-design studies are needed . Surgical intervention is reserved for patients in whom medical therapy has failed or symptoms are life-threatening. Antireflux surgery has considerable appeal especially if it achieves its goals, that is, cure of symptoms and avoid the need for long-term medication. However, most recent data document high rates of failure with morbidity and mortality . Children without respiratory symptoms tend to have better surgical outcomes. More randomized controlled trials are needed to assess results of antireflux surgery in atypical pediatric reflux. Candidates for surgery should have a definite diagnosis and should try prolonged and aggressive PPI treatment before being considered for fundoplication. .( Chang A,et al ,2005)