What are the treatment options for gastroesophageal reflux disease (GERD) causing heartburn and indigestion in children less than 2 years old?

Treatment Options for GERD in Children Under 2 Years Old

Conservative management should be the first-line approach for treating GERD in children under 2 years old, with pharmacologic therapy reserved only for confirmed GERD that fails conservative measures. 1

Understanding GERD in Infants

• Gastroesophageal reflux (GER) is a normal physiologic process occurring in approximately 50% of infants daily
• GERD occurs when reflux causes troublesome symptoms or complications including:
  • Feeding refusal
  • Recurrent vomiting
  • Poor weight gain
  • Irritability
  • Sleep disturbance
  • Respiratory symptoms

First-Line Treatment: Conservative Management

Feeding Modifications

• For breastfed infants:

  • Try a 2-4 week maternal elimination diet restricting at least milk and egg 2, 1
  • Reduce feeding volume while increasing frequency 1

• For formula-fed infants:

  • Consider extensively hydrolyzed protein formula 2, 1
  • Try commercially available anti-regurgitant formulas containing processed rice, corn, or potato starch 1
  • Thicken formula with 1 tablespoon rice cereal per ounce (increases caloric density to 34 kcal/oz) 1
  • CAUTION: Avoid thickened formulas in preterm infants due to risk of necrotizing enterocolitis 2, 1

Positioning Strategies

• Keep infant upright for 20-30 minutes after feeding 1
• 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

Second-Line Treatment: Pharmacologic Therapy

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

H2 Receptor Antagonists

• Ranitidine (5-10 mg/kg/day) 1, 3
  • For infants with confirmed GERD
  • LIMITATIONS: Tachyphylaxis within 6 weeks, risk of liver disease and gynecomastia 2, 1

Proton Pump Inhibitors (PPIs)

• For confirmed GERD with erosive esophagitis or severe symptoms 1
• Options include:
  • Omeprazole (0.7-3.3 mg/kg/day) 1
  • Esomeprazole (0.7-3.3 mg/kg/day) 1
• Continue for 8-12 weeks if effective 1
• RISKS: Increased susceptibility to infections, community-acquired pneumonia, gastroenteritis, candidemia 2, 1

Medications NOT Recommended

• Chronic antacid therapy is generally not recommended for treating GERD in children 2, 1
• Prokinetic agents (metoclopramide, domperidone) have unproven efficacy or unfavorable risk profiles 2, 4

When to Consider Surgical Intervention

• Reserved only for cases that fail medical management or have life-threatening complications 2, 1, 5
• Fundoplication is the most common surgical procedure but associated with significant morbidity 2, 1
• Should be avoided before 2-3 years of age if possible 4

Red Flags for Referral to Pediatric Gastroenterology

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

Common Pitfalls to Avoid

1. Overuse of acid suppressants without confirmed GERD diagnosis 1
2. Confusing normal physiologic GER with pathologic GERD requiring medication 1
3. Mistaking cow's milk protein allergy for GERD (they can coexist in 42-58% of infants) 1, 5
4. Relying solely on thickening without implementing other conservative measures 1
5. Using partially hydrolyzed formulas instead of extensively hydrolyzed formulas when treating established allergies 1

Remember that most infants with GER will outgrow their symptoms by 12-18 months of age, making conservative management the most appropriate first-line approach in the majority of cases.