What is the recommended treatment for gastroesophageal reflux disease (GERD) in a teenager?

Treatment of Gastroesophageal Reflux Disease (GERD) in Teenagers

For teenagers with GERD, a stepwise approach starting with lifestyle modifications followed by an 8-12 week course of proton pump inhibitors (PPIs) is the recommended first-line treatment, with surgery reserved only for cases that are truly refractory to medical management. 1

Diagnostic Considerations

Before initiating treatment, it's important to correctly diagnose GERD in teenagers, who typically present with:

• Heartburn
• Regurgitation
• Dysphagia
• Chest pain
• Extraesophageal symptoms (chronic cough, hoarseness)

Key diagnostic tools include:

• 24-hour MII-pH monitoring (most accurate tool for GERD diagnosis)
• Upper endoscopy with biopsy (to assess for esophagitis and exclude other conditions)
• Barium swallow (to evaluate anatomy)

Treatment Algorithm

Step 1: Lifestyle Modifications (First-line)

• Weight loss if overweight or obese
• Dietary changes:
  • Avoid trigger foods: fatty/fried foods, spicy foods, acidic foods (tomatoes, citrus), chocolate
  • Avoid carbonated beverages
  • Avoid large meals before bedtime (eat at least 3 hours before lying down)
• Positional therapy: Elevate head of bed 6-8 inches
• Smoking cessation and alcohol avoidance
• Chewing sugarless gum after meals (increases saliva production) 1, 2

Step 2: Pharmacologic Therapy (If symptoms persist)

1. Proton Pump Inhibitors (PPIs):

   • First-line medication therapy
   • Recommended dosing:
     • Initial 2-week trial
     • If effective, continue for 8-12 weeks total
     • Administer approximately 30 minutes before meals
   • Options include lansoprazole (15-30mg daily based on weight) 3
   • Monitor for improvement in symptoms at 2 weeks

2. H2 Receptor Antagonists:

   • Alternative if PPIs not tolerated
   • Less effective than PPIs
   • Limited by tachyphylaxis (decreased effectiveness after 6 weeks)
   • Potential side effects: increased risk of liver disease, gynecomastia 1

3. Antacids:

   • For occasional breakthrough symptoms only
   • Not recommended for chronic therapy due to side effects 1

4. Prokinetic Agents:

   • Not recommended as routine therapy due to significant adverse effects
   • Side effects include drowsiness, restlessness, and extrapyramidal reactions
   • Insufficient evidence supports their routine use in pediatric GERD 1

Step 3: Management of Refractory GERD

If symptoms persist despite 8-12 weeks of optimal PPI therapy and lifestyle modifications:

1. Reassess diagnosis:

   • Consider other conditions that mimic GERD (eosinophilic esophagitis, functional dyspepsia)
   • Repeat endoscopy with biopsies
   • Consider impedance-pH testing while on PPI therapy 4

2. Surgical Options (for truly refractory cases only):

   • Laparoscopic fundoplication: Preferred surgical approach
   • Reserved for patients with:
     • Documented GERD refractory to optimal medical therapy
     • Risk of life-threatening complications
   • Significant morbidity; careful patient selection required 1

Monitoring and Follow-up

• Assess response after 2 weeks of PPI therapy
• If symptoms improve, continue for total 8-12 weeks
• After completion of therapy, attempt to discontinue or reduce medication
• If relapse occurs, consider referral to pediatric gastroenterologist 1

Important Caveats

1. PPI overuse concerns: There is growing concern about inappropriate prescription of PPIs in pediatric populations. PPIs should be used only when clearly indicated for GERD, not for non-specific symptoms 1

2. PPI side effects: Long-term PPI use may increase risk of community-acquired pneumonia, gastroenteritis, and other infections 1

3. Surgical considerations: Before considering surgery, ensure accurate diagnosis and rule out conditions that could persist after surgery (eosinophilic esophagitis, motility disorders) 1

4. Adolescent-specific concerns: Teenagers may have poor adherence to lifestyle modifications and medications. Emphasize the importance of consistency with both for optimal outcomes 1

5. Medication timing: PPIs are most effective when taken approximately 30 minutes before meals 1