What are the treatment options for heartburn and indigestion in children?

Treatment Options for Heartburn and Indigestion in Children

Conservative management should be the first-line approach for heartburn and indigestion in children, with medications reserved only for confirmed cases of gastroesophageal reflux disease (GERD) that fail lifestyle modifications. 1

Understanding GER vs. GERD in Children

It's critical to distinguish between:

• Gastroesophageal reflux (GER): Normal physiologic process occurring in approximately 50% of all infants daily 1
• Gastroesophageal reflux disease (GERD): Reflux causing troublesome symptoms or complications including feeding refusal, poor weight gain, irritability, sleep disturbance, respiratory symptoms, and failure to thrive 1

First-Line Treatment: Lifestyle and Feeding Modifications

For Infants:

• Feeding modifications:

  • Reduce feeding volume while increasing frequency
  • Avoid overfeeding
  • For formula-fed infants, consider thickened formulas like Enfamil AR (reduces regurgitation frequency) 1
  • For breastfed infants with suspected milk protein allergy, try 2-4 week maternal elimination diet (restricting at least milk and egg) 1

• Positioning strategies:

  • Hold infant upright for 20-30 minutes after feeding
  • When awake and supervised, place infant on left side to help gas move through digestive system 1
  • IMPORTANT: Always place infant on back for sleep to reduce SIDS risk 1

For Older Children:

• Smaller, more frequent meals
• Avoid eating 2-3 hours before bedtime
• Elevate head of bed
• Avoid trigger foods (spicy, acidic, fatty foods, chocolate)
• Maintain healthy weight

Second-Line Treatment: Pharmacologic Therapy

Medications should be reserved only for confirmed GERD that fails conservative management 1.

H2 Receptor Antagonists

• Options: Ranitidine (5-10 mg/kg/day) or Famotidine (1 mg/kg/day) 1
• Limitations: Tachyphylaxis within 6 weeks, risks including liver disease 1

Proton Pump Inhibitors (PPIs)

• Indications: Erosive esophagitis or severe GERD 1
• Options:
  • Omeprazole (0.7-3.3 mg/kg/day) 1
  • Esomeprazole (0.7-3.3 mg/kg/day) 1
• Duration: 8-12 weeks 1
• Cautions: Increased susceptibility to infections, tubulointerstitial nephritis, Clostridium difficile infection, bone fractures with long-term use 2, 3

When to Refer to Pediatric Gastroenterology

Red flags requiring specialist referral include:

• Bilious vomiting
• Gastrointestinal bleeding
• Consistently forceful vomiting
• Fever or lethargy
• Failure to thrive
• Abdominal tenderness or distension 1

Surgical Intervention

Consider only when:

• Medical therapy fails
• Patient is at severe risk of aspiration
• Life-threatening complications are present 1

Options include:

• Fundoplication (most common): Wraps gastric fundus around distal esophagus
• Total esophagogastric dissociation (rarely used after failed fundoplication) 1

Common Pitfalls to Avoid

1. Overuse of acid suppressants, particularly PPIs, without confirmed GERD diagnosis 1
2. Confusing physiological GER with cow's milk protein allergy, which can lead to inappropriate treatment 1
3. Using partially hydrolyzed formulas to treat established allergy (less effective than extensively hydrolyzed formulas) 1
4. Relying solely on thickening without comprehensive approach including positioning and feeding modifications 1

Monitoring and Follow-up

• Monitor for improvement in symptoms, weight gain, and growth
• Watch for constipation, which can occur with rice cereal thickening
• If symptoms persist despite conservative measures, refer to pediatric gastroenterology 1

Remember that most cases of infant reflux resolve spontaneously with age, typically improving significantly by 3-4 months of age 1. The goal of treatment should always be to minimize symptoms and complications while avoiding unnecessary medication exposure.