BNF for Children 2011-2012

36 1.1.1 Antacids and simeticone BNFC 2011–20121 Gastro-intestinal systemwithout treatment between 12 and 18 months of age.Older children with gastro-oesophageal reflux diseasemay have heartburn, acid regurgitation and dysphagia.Oesophageal inflammation (oesophagitis), ulceration orstricture formation may develop in early childhood;gastro-oesophageal reflux disease may also be associatedwith chronic respiratory disorders includingasthma.Parents and carers of neonates and infants should bereassured that most symptoms of uncomplicated gastrooesophagealreflux resolve without treatment. Anincrease in the frequency and a decrease in the volumeof feeds may reduce symptoms. A feed thickener or prethickenedformula feed (Appendix 2) can be used on theadvice of a dietician. If necessary, a suitable alginatecontainingpreparation (section 1.1.2) can be usedinstead of thickened feeds.Older children should be advised about life-stylechanges such as weight reduction if overweight, andthe avoidance of alcohol and smoking. An alginatecontainingantacid (section 1.1.2) can be used to relievesymptoms.Children who do not respond to these measures or whohave problems such as respiratory disorders or suspectedoesophagitis need to be referred to hospital.On the advice of a paediatrician, a histamine H 2 -receptor antagonist (section 1.3.1) can be used torelieve symptoms of gastro-oesophageal reflux disease,promote mucosal healing and permit reduction in antacidconsumption. A proton pump inhibitor (section1.3.5) can be used for the treatment of moderate, nonerosiveoesophagitis that is unresponsive to an H 2-receptor antagonist. Endoscopically confirmed erosive,ulcerative, or stricturing disease in children is usuallytreated with a proton pump inhibitor. Reassessment isnecessary if symptoms persist despite 4–6 weeks oftreatment; long-term use of an H 2 -receptor antagonistor proton pump inhibitor should not be undertakenwithout full assessment of the underlying condition.For endoscopically confirmed erosive, ulcerative, orstricturing disease, the proton pump inhibitor usuallyneeds to be maintained at the minimum effective dose.Motility stimulants (section 1.2), such as domperidoneor erythromycin may improve gastro-oesophagealsphincter contraction and accelerate gastric emptying.Evidence for the long-term efficacy of motilitystimulants in the management of gastro-oesophagealreflux in children is unconvincing.For advice on specialised formula feeds, see section9.4.2.Antacids (usually containing aluminium or magnesiumcompounds) can be used for short-term relief of intermittentsymptoms of ulcer dyspepsia and non-erosivegastro-oesophageal reflux (see section 1.1) in children;they are also used in functional (non-ulcer) dyspepsia,but the evidence of benefit is uncertain.Aluminium- and magnesium-containing antacids,being relatively insoluble in water, are long-acting ifretained in the stomach. Magnesium-containingantacids tend to be laxative whereas aluminium-containingantacids may be constipating; antacids containingboth magnesium and aluminium may reduce thesecolonic side-effects. Aluminium-containing antacidsshould not be used in children with renal impairment,or in neonates and infants because accumulation maylead to increased plasma-aluminium concentrations.Complexes such as hydrotalcite confer no specialadvantage.Calcium-containing antacids can induce rebound acidsecretion; with modest doses the clinical significance ofthis is doubtful, but prolonged high doses also causehypercalcaemia and alkalosis.Simeticone (activated dimeticone) is used to treatinfantile colic, but the evidence of benefit is uncertain.Simeticone is added to an antacid as an antifoamingagent to relieve flatulence; such preparations may alsobe useful for the relief of hiccup in palliative care (seePrescribing in Palliative Care, p. 19).Alginates act as mucosal protectants in gastro-oesophagealreflux disease (section 1.1.2). The amount ofadditional ingredient or antacid in individual preparationsvaries widely, as does their sodium content, so thatpreparations may not be freely interchangeable.Hepatic impairment In children with fluid retention,avoid antacids containing large amounts of sodium.Avoid antacids that cause constipation because thiscan precipitate coma. Avoid antacids containingmagnesium salts in hepatic coma if there is a risk ofrenal failure.Renal impairment In children with fluid retention,avoid antacids containing large amounts of sodium.There is a risk of accumulation and aluminium toxicitywith antacids containing aluminium salts. Absorption ofaluminium from aluminium salts is increased by citrates,which are contained in many effervescent preparations(such as effervescent analgesics). Antacids containingmagnesium salts should be avoided or used at a reduceddose because there is an increased risk of toxicity.Interactions Antacids should preferably not be takenat the same time as other drugs since they may impairabsorption. Antacids may also damage enteric coatingsdesigned to prevent dissolution in the stomach. See alsoAppendix 1 (antacids, calcium salts).Low Na +The words ‘low Na + ’ added after some preparationsindicate a sodium content of less than 1 mmol pertablet or 10-mL dose.1.1.1 Antacids and simeticoneAluminium- and magnesiumcontainingantacidsALUMINIUM HYDROXIDECautions see notes above; interactions: Appendix 1(antacids)Contra-indications hypophosphataemia; neonatesand infantsHepatic impairment see notes aboveRenal impairment see notes aboveSide-effects see notes above