title: Nocturnal acid breakthrough in children with reflux esophagitis taking proton pump inhibitors.
abstract: OBJECTIVE
  We aimed to determine if nocturnal acid breakthrough occurs in children receiving proton pump inhibitors for reflux esophagitis, and to compare the healing of esophagitis in children with nocturnal acid breakthrough receiving proton pump inhibitors +/- ranitidine.
  
  
  METHODS
  This is a prospective, double-blind study. Endoscopic and histologic esophagitis were scored 0-4 and 0-3, respectively. Patients were treated with a proton pump inhibitor twice daily and esophagogastric pH monitoring was performed at week 3. Patients with nocturnal acid breakthrough were randomized. One group received ranitidine and the other received placebo at bedtime in addition to proton pump inhibitor therapy. Endoscopy was performed on all patients (with pH monitoring on patients with nocturnal acid breakthrough) during the 17th week of therapy.
  
  
  RESULTS
  We enrolled 18 patients, ages 1 to 13 years (mean = 10.3 years). Mean baseline endoscopic and histologic scores were 3.1 +/- 1.4 and 1.8 +/- 0.7, respectively. Mean dose of proton pump inhibitor was 1.3 mg/kg +/- 0.6. Nocturnal acid breakthrough was documented in 16/18 (89%) patients. Seven patients received ranitidine and 9 received placebo. The reflux index improved: mean of 14.3 at baseline, 2.0 at week 3 (P = 0.0001), and 5.1 at week 17 (P = 0.09). Nocturnal acid breakthrough persisted in 9/12 (75%) patients, 3 of whom received ranitidine at bedtime. Esophagitis improved in all patients following therapy: mean endoscopy and histology scores were 1.6 +/- 1.8 (P = 0.0020) and 0.8 +/- 0.9 (P = 0.0013), respectively. Symptoms significantly improved from a mean score of 2.0 at baseline to 0.4 at week 17 (P = 0.0001).
  
  
  CONCLUSIONS
  Nocturnal acid breakthrough is common in pediatric patients treated with proton pump inhibitors. Reflux index remains normal in spite of nocturnal acid breakthrough. Symptoms and esophagitis continued to improve during therapy in spite of nocturnal acid breakthrough. There appears to be no additional benefit to supplementation with ranitidine at bedtime.
authors.affiliation: Division of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, 702 Barnhill Drive, Indianapolis, IN 46202, USA. mdelrosa@iupui.edu
authors.forename: Marian D
authors.initials: MD
authors.lastname: Pfefferkorn
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Croffie
authors.forename: Sandeep K
authors.initials: SK
authors.lastname: Gupta
authors.forename: Jean P
authors.initials: JP
authors.lastname: Molleston
authors.forename: George J
authors.initials: GJ
authors.lastname: Eckert
authors.forename: Mark R
authors.initials: MR
authors.lastname: Corkins
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Fitzgerald
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002940:Circadian Rhythm; D004311:Double-Blind Method; D004357:Drug Synergism; D004942:Esophagitis, Peptic / Q000188:drug therapy* / Q000473:pathology; D005260:Female; D005744:Gastric Acid / Q000378:metabolism*; D006635:Histamine H2 Antagonists / Q000627:therapeutic use*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007223:Infant; D008297:Male; D011446:Prospective Studies; D054328:Proton Pump Inhibitors; D011899:Ranitidine / Q000627:therapeutic use*; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors; D011899:Ranitidine