Managing GERD in Children with Asthma with H2 receptor antagonists (H2RAs): Indian Paediatricians' Perspectives
Gastroesophageal reflux disease (GERD) symptoms extend beyond typical esophageal symptoms such as heartburn and regurgitation, with asthma emerging as one of the most common and clinically significant extra-esophageal manifestations in children. Epidemiological data suggest that nearly 80% of asthma patients also experience these GERD symptoms. Given this overlap, there is a need for acid-reducing medications (ARMs) like H2 receptor antagonists (H2RAs) when symptomatic reflux of GERD occurs.
GERD and asthma tend to trigger each other, although the exact pathophysiological explanation remains unclear. Two theories have been proposed to explain GERD-induced bronchoconstriction: the Reflux Theory, in which reflux has a direct effect on the lungs, and the Reflex Theory, suggesting that esophageal reflux stimulates bronchoconstriction via vagal nerves. Asthma may contribute to reflux through mechanisms such as an increased gastroesophageal pressure gradient from increased negative intrathoracic pressure during inspiration due to airflow obstruction. Additionally, asthma medications like β-adrenergic agonists, theophylline, and high doses of oral corticosteroids may exacerbate reflux.
For the management of confirmed GERD in children with asthma, ARMs are used like H2RAs and proton pump inhibitors (PPIs). Although PPIs are prescribed frequently, they are associated with adverse effects, including a higher risk of symptomatic respiratory infections, and studies have generally not shown improvement in asthma outcomes with their use. One trial conducted by the American Lung Association Asthma Clinical Research Centres, PPI therapy showed no benefit in asthma patients without concomitant reflux symptoms, with no improvement observed in asthma attack rates, asthma symptoms, nocturnal awakenings, quality of life, or lung function. Also, the Global Initiative for Asthma (GINA) 2024 Report advises that ARM therapy should not be used for poorly controlled asthma unless symptomatic reflux is also present.
Given the adverse effects linked to PPIs, H2RAs may represent a safer option for managing GERD in asthmatic children. Their use and safety in this context have been supported by the EMPACIP study, in which a panel of 24 pediatric specialists from India developed comprehensive recommendations on ARM use. These recommendations, published in the May 2025 issue of Cureus, include specific guidance on GERD management in children with asthma, as outlined below:
2. ARM therapy should be reserved for asthmatic children with symptomatic GERD
3. No strong evidence supports routine PPI use for symptomatic GERD in asthmatic children
4. H2RAs (ranitidine, famotidine) may be a safer alternative for GERD management in asthmatic children.
Association Between GERD and Asthma in Pediatric Patients
Dr. A. V. Ravishankar, Consultant Pediatrician, M. K. Hospital and Kauvery Hospital, Chennai, India an expert from the panel of review paper, said - “Gastroesophageal reflux disease (GERD) is far more common in children with asthma (20–80%) than in the general pediatric population (10 -20%). The association is bidirectional - GERD can trigger or worsen wheezing, cough, and nocturnal attacks and asthma can worsen reflux due to increased abdominal pressure from coughing or bronchodilator-related relaxation of lower esophageal sphincter (LES). Even small amounts of refluxed material reaching the lungs can mimic or worsen asthma.
GERD should be suspected when asthma begins after age 3yrs, symptoms worsen at night, after meals, or when lying down, response to asthma medicines is poor, or when there are associated signs like throat clearing, hoarseness, or recurrent pneumonia.”
Challenges in Diagnosing GERD in Children with Asthma
Dr Subhashis Roy, Consultant Pediatrician, Columbia Asia Hospital, Salt Lake Kolkata, another expert from the review paper said, “Diagnosing GERD in children with asthma is challenging because these conditions often coexist, and it is difficult to determine how much GERD contributes to asthma severity. GERD cannot be diagnosed through simple blood or urine tests, and available investigations like multichannel impedance studies are invasive. In practice, diagnosis is often based on symptoms and a trial of PPIs or H2 blockers—if both GERD and asthma symptoms improve, a GERD contribution is suspected. Asthma and GERD frequently go together, and asthma medications such as steroids and bronchodilators can further increase the risk of reflux.”
Indications for ARMs in Children and Preference Between H2RAs and PPIs
Dr Mukesh Sanklecha, Consultant Pediatrician at Bombay Hospital Institute of Medical Sciences, one more panel expert from the review paper said – “In asthma, even though pathophysiology suggests that reflux should worsen asthma and asthma should worsen reflux, the literature is not very robust. Acid-reducing therapy is considered only when the child has clear GERD symptoms, such as recurrent vomiting in infants or heartburn in older children. Treating GERD helps relieve reflux symptoms, but does not reliably improve asthma on its own. However, in difficult or poorly controlled asthma where reflux also exists, a trial of acid suppression may be reasonable to see if asthma control improves. Regarding medication choice, H2RAs act faster, while PPIs provide stronger acid suppression, so either can be used depending on the clinical need. In resistant asthma with coexisting reflux, acid suppression may be added as supportive therapy.”
This study reiterates cautious application, particularly of PPIs, and the targeted use of H2RAs, aiming to promote the safe and effective use of ARMs in children.
- 1. Evidence-Based Review by a Multidisciplinary Team of Pediatricians on the Use of Gastric Acid-Reducing Medications in Children: Indian Perspectives Cureus 17-
