Pediatric erosive esophagitis maintenance: finally, some level 1 evidence!

In children, as in adults, gastroesophageal reflux disease (GERD), particularly erosive esophagitis, is now believed to be a chronic disease, probably requiring lifelong maintenance therapy. However, this assumption has not received adequate clinical testing, and the provocative article by Boccia et al. in this issue of the Journal challenges it. The strengths of this exceptional pediatric study lie in its prospective, controlled, randomized character, and in its relatively long duration of prospective follow-up. Weaknesses of the study include its limited power and lack of prior validation of outcome measures. The conclusions of the study are applicable only to children without chronic neurologic, respiratory, or congenital esophageal abnormalities, the children for whom chronic proton pump inhibitors (PPIs) are most often required. The study's provocative results might be explained by the fundamental lack of GERD chronicity in otherwise healthy children, combined with absence of the PPI dependence that can be produced when PPIs are used chronically for chronic disease.