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• Acid suppression in children with asthma and gastro-oesophageal reflux: more evidence is needed
  Jitendra Kumar Sahu
  Published on: 9 January 2022

• Published on: 9 January 2022

  Acid suppression in children with asthma and gastro-oesophageal reflux: more evidence is needed

  • Jitendra Kumar Sahu, Junior Resident
  • Other Contributors:
    • Rakesh Lodha

  Dear Editor,

  We read with interest the recent article by Stordal et al. on acid suppression in children in with asthma and gastro-oesophageal reflux disease.[1] The authors concluded omeprazole treatment did not improve asthma symptoms or lung function in children with asthma and gastro-oesophageal reflux disease.

  Since Kennedy.[2] first reported the association between gastro-oesophageal reflux and lung di...

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  Dear Editor,

  We read with interest the recent article by Stordal et al. on acid suppression in children in with asthma and gastro-oesophageal reflux disease.[1] The authors concluded omeprazole treatment did not improve asthma symptoms or lung function in children with asthma and gastro-oesophageal reflux disease.

  Since Kennedy.[2] first reported the association between gastro-oesophageal reflux and lung disease 43 years ago, a number of publications have reported its’ strong association with asthma; prevalence ranging from 34% to 89%.[3] If acid suppression is really achieved in the current study, why was there a negative result?[1] We believe there are important potential limitations in the study.

  There are concerns about the management of the study subjects. The severity of asthma was classified as the GINA guidelines.[4] According to the authors, 31 children had persistent asthma (steps 2 and 3) and seven had episodic asthma. Yet, 34 patients were administered daily-inhaled steroids (indicated for steps 2 and beyond as per GINA guidelines). Similarly, long acting bronchodilators are indicated for use in moderate and severe persistent asthma (steps 3 and 4). However, these drugs were used in 22 children while there were only 17 children with moderate persistent asthma in the study.[1] From this it appears that the study subjects were over-treated.

  To evaluate the effect of acid suppression on symptom control in children with asthma and gastro-oesophageal reflux, it is desirable to enrol children with asthma who have symptoms attributable to gastro-oesophageal reflux. The diagnosis of gastro-oesophageal reflux disease by a 24-hour pH study and documentation of reflux index alone is not enough. The quality of study may have been improved by simultaneously measurement of proximal and distal oesophageal pH using dual probes, correlation of pH changes with episodes of cough and asthma exacerbation, measurement of peak expiratory flow rate and forced expiratory volume in the first second during or immediately after a reflux episode.[5]

  Authors did not enrol children with ‘difficult to control’ asthma. In clinical practice, the important question to address is ‘whether therapy for gastro-oesophageal reflux improves asthma symptom control in children with difficult asthma and reflux disease? Previous studies showed reflux is reportedly more common in poorly controlled patients than in well-controlled patients[6,7] suggesting that reflux may be responsible for poor control.

  The duration of acid suppression was too short to show a predictable improvement in asthma. Longer period of suppression is essential for proper assessment of clinical parameters (i.e. changes in asthma medication, reduction in method dosage, number of exacerbations and seasonal variation).

  In addition, it is not clear whether any anti-reflux measures were used in the study subjects such as prokinetics and lifestyle modifications. These may be important as preventing reflux may in itself lead to symptom control as has been seen with surgical treatment.[8]

  A major flaw in the study design, also mentioned by the authors, was the small sample size. With such small sample size the possibility of type II error cannot be excluded. The authors may provide more details of the sample size calculation.

  Clinicians should interpret this study with caution. The study does not mean that acid suppression should not be used in children with asthma and gastro-oesophageal reflux disease. In absence of robust evidence against use of acid suppression, it could be tried in any child with difficult to control asthma associated with gastro-oesophageal reflux disease, along with other medical measures.

  References:

  1. Stordal K, Johannesdottir GB, Bentsen BS, et al. Acid suppression does not change respiratory symptoms in children with asthma and gastro- oesophageal reflux disease. Arch Dis Child 2005; 90: 956-60.

  2. Kennedy, JH. `Silent' gastro esophageal reflux: an important but little known cause of pulmonary complications. Dis Chest.1962; 42: 42-45.

  3. Harding SM, Richter JE.The role of gastro esophageal reflux in chronic cough and asthma. Chest 1997; 111: 1389-1402.

  4. Von Mutius E. Presentation of new GINA guidelines for paediatrics. The Global Initiative on Asthma. Clin Exp Allergy 2000; 30 (suppl 1): 6–10.

  5. Mathew J L, Singh M, and Mittal S K. Gastro-oesophageal reflux and bronchial asthma: current status and future directions. Postgrad Med J 2004; 80: 701 - 705.

  6. Chopra K , Matta SK, Madan N, et al. Association of gastro esophageal reflux (GER) with bronchial asthma. Indian Pediatr 1995; 32: 1083–86.

  7. Khoshoo V, Le T, Haydel RM Jr, Landry L, et al. Role of gastro esophageal reflux in older children with persistent asthma. Chest 2003; 123: 1008-13.

  8. Kiljander TO, Salomaa ER, Hietanen EK, et al. Gastroesophageal reflux and bronchial responsiveness: correlation and the effect of fundoplication. Respiration 2002; 69: 434–9.

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  Conflict of Interest:
  None declared.

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