Most pediatric surgeons advocate for routine acid suppression after repair of congenital esophageal atresia. However, there is conflicting data on this. Should proton pumps be prescribed routinely? For how long? What are the endpoints?
As the incidence of reflux in children with EA/TEF is high, (close to 75% )J Pediatr Surg. 2015;50(7):1099–103, the usage of antireflux (PPI) is part of standard recommendation. J Pediatr. 2010;156(5):755–60.
As the chance of asymptomatic complications (cyanotic spells, aspiration, etc) are high atleast for 1 year is as per Espghan/ Naspghan [J Pediatr Gastroenterol Nutr. 2016;63(5):550–70]
Current guidelines based on expert opinion recommend GERD be treated with PPI as long as necessary and based on surveillance findings [Curr Gastroenterol Rep 19, 4 (2017)]
Those are expert opinions and my current treatment protocol. But PPIs also have downsides, and the data on the prevention of strictures is conflicting.
The positive message is possibly the use of PPI until the first year of age [J Pediatr. 2021 Jan;228:155-163.e1.].
The smallest comfort is that only about 22% require surgical intervention for GER among EA / TEF children [Eur J Pediatr Surg. 2016 Dec;26(6):476-480]
The PPIs are not protective for strictures [Eur J Pediatr Surg. 2017 Feb;27(1):50-55, Pediatr Surg Int. 2018 May;34(5):491-497]
Barring few [Pediatr Int. 2015 Jun;57(3):461-4.], there is pessimism over usage of antireflux medications in stricture prevention.
I routinely give it until 1 year of age. Then discharge the PPI and 1 month later do an endoscopy with biopsies. If the biopsies show anything more than minimal inflammation, I restart the PPIs for another year and repeat the procedure.
Proton pump inhibitors (PPI) treatment does not prevent the formation of anastomotic strictures and appears to be over-prescribed in children with airway symptoms because of tracheomalacia. This suggests that PPI treatment could be prescribed more selectively. Close monitoring and long-term follow-up, however, of these vulnerable patients in specialized multidisciplinary clinics is imperative. https://pubmed.ncbi.nlm.nih.gov/30889131/
Check https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5899117/
Also check https://link.springer.com/article/10.1007/s13318-020-00630-8
https://pubmed.ncbi.nlm.nih.gov/30889131/
More rational prescription practices are warranted as per the aforesaid article on the issue.
Use of PPI should be restricted to 1 year or till resolution of GER ( whichever is shorter). Such patients have high incidence of reflux ( which can be due to mobilisation of lower pouch) ; and this causes microaspirations and hence pneumonitis... Another rescue is early solidification of feeds.
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