What is the treatment for Gastroesophageal Reflux Disease (GERD) in a pediatric patient?

From the Guidelines

The treatment of GERD in a 10-year-old should begin with lifestyle modifications before considering medication, as recommended by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines 1. These modifications include:

• Elevating the head of the bed
• Avoiding meals 2-3 hours before bedtime
• Limiting fatty foods, chocolate, caffeine, and acidic foods
• Maintaining a healthy weight If symptoms persist, medication therapy can be initiated with proton pump inhibitors (PPIs) as first-line treatment. For a 10-year-old, omeprazole at 10-20 mg once daily or lansoprazole at 15-30 mg once daily for 8-12 weeks is typically recommended, as supported by studies demonstrating the efficacy of PPIs in children with GERD 1. H2 receptor antagonists like ranitidine (5-10 mg/kg/day divided twice daily) can be used for milder cases or as adjunct therapy. Antacids may provide temporary relief but should not be used as primary treatment in children. Treatment effectiveness should be assessed after 4-8 weeks, and medication should be tapered to the lowest effective dose once symptoms improve. It is essential to note that PPIs are generally well-tolerated in children, but their long-term use requires caution, and the potential risks and benefits should be carefully considered, as highlighted in recent guidelines 1. If symptoms are severe, persist despite treatment, or include warning signs like weight loss, dysphagia, or hematemesis, referral to a pediatric gastroenterologist is warranted. PPIs work by blocking acid production in the stomach, while lifestyle changes help reduce acid reflux episodes by improving gastric emptying and decreasing pressure on the lower esophageal sphincter. In addition to these recommendations, it is crucial to differentiate between GER and GERD, as children with GERD may benefit from further evaluation and treatment, whereas conservative recommendations are more appropriate for those with uncomplicated physiologic reflux, as emphasized in the guidelines 1.

From the FDA Drug Label

One year to 11 years of age In an uncontrolled, open-label, US multicenter study, 66 pediatric patients (one year to 11 years of age) with GERD were assigned, based on body weight, to receive an initial dose of either lansoprazole 15 mg daily if ≤30 kg or lansoprazole 30 mg daily if greater than 30 kg administered for eight to 12 weeks The lansoprazole dose was increased (up to 30 mg twice daily) in 24 of 66 pediatric patients after two or more weeks of treatment if they remained symptomatic. At baseline 85% of patients had mild to moderate overall GERD symptoms (assessed by investigator interview), 58% had non-erosive GERD and 42% had erosive esophagitis (assessed by endoscopy) After eight to 12 weeks of lansoprazole treatment, the intent-to-treat analysis demonstrated an approximate 50% reduction in frequency and severity of GERD symptoms. Twenty one of 27 erosive esophagitis patients were healed at eight weeks and 100% of patients were healed at 12 weeks by endoscopy

For a 10-year-old patient with GERD, the recommended treatment is lansoprazole. The initial dose should be based on body weight:

• 15 mg daily if the patient weighs ≤30 kg
• 30 mg daily if the patient weighs >30 kg The dose can be increased up to 30 mg twice daily if the patient remains symptomatic after two or more weeks of treatment. The expected outcome is a reduction in frequency and severity of GERD symptoms, with approximately 50% of patients experiencing improvement after 8-12 weeks of treatment. Healing rates for erosive esophagitis are also expected, with 21 out of 27 patients healed at 8 weeks and 100% healed at 12 weeks. 2

From the Research

Treatment Options for GERD in a 10-Year-Old

• The treatment of gastroesophageal reflux disease (GERD) in children can be managed through various methods, including pharmacologic, lifestyle, surgical, and endoscopic management 3.
• For pediatric patients, the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GERD, which includes recommendations for evaluation, initial treatment, follow-up management, and indications for consultation by a specialist 4.

Pharmacologic Treatment

• Proton pump inhibitors (PPIs) are considered the medical treatment of choice for GERD, although concerns have been raised about their long-term use and potential adverse events 3.
• PPIs have been shown to be effective in healing reflux esophagitis and relieving symptoms in adults and children 5, 6.
• Histamine(2) receptor antagonists (H2RAs) can also be used to treat GERD, but their effectiveness is generally lower than that of PPIs 7, 6.

Lifestyle Modifications

• Lifestyle modifications, such as dietary changes and weight loss, can also be effective in managing GERD symptoms 3.
• However, the specific lifestyle modifications recommended for pediatric patients with GERD are not well-established in the provided studies.

Surgical and Endoscopic Interventions

• Surgical and endoscopic interventions may be considered for patients with severe GERD or those who do not respond to medical therapy 3.
• However, the use of these interventions in pediatric patients is not well-established in the provided studies.