What is the management of Gastroesophageal Reflux Disease (GERD) in children?

Management of Gastroesophageal Reflux Disease (GERD) in Children

Conservative management should be the first-line approach for treating GERD in children, including dietary modifications, positioning strategies, and lifestyle changes, before considering medication. 1

Age-Specific Approach to GERD Management

For Infants (<12 months)

1. Conservative Management (First-Line)

   • Feeding Modifications:

     • Smaller, more frequent feedings
     • Thickening formula with 1 tablespoon rice cereal per ounce
     • Pre-thickened anti-regurgitant formulas 1
     • For breastfed infants: 2-4 week maternal elimination diet of milk and eggs
     • For formula-fed infants: Trial of extensively hydrolyzed protein or amino acid-based formula 1

   • Positioning Strategies:

     • Hold upright for 20-30 minutes after feeding
     • Left side positioning when awake and supervised 1
     • Monitor for improvement in symptoms, weight gain, and growth 1

2. Medication (Only if conservative measures fail after 2-4 weeks)

   • H2-Receptor Antagonists (First-line pharmacologic therapy):

     • Famotidine: 1 mg/kg/day divided twice daily 1
     • Note: Limited by tachyphylaxis within 6 weeks and risks including liver disease 1

   • Proton Pump Inhibitors (Only for severe cases/erosive esophagitis):

     • Limited duration (4-8 weeks)
     • Omeprazole: 0.7-3.3 mg/kg/day
     • Esomeprazole: 0.7-3.3 mg/kg/day 1
     • Note: Not recommended for infants <1 year due to limited efficacy and potential harm 2, 3

For Children (1-11 years)

1. Conservative Management (First-Line)

   • Dietary Modifications:

     • Smaller, more frequent meals
     • Avoid trigger foods (spicy, acidic, fatty foods)
     • Avoid eating within 2-3 hours of bedtime 1

   • Positioning Strategies:

     • Keep upright for 20-30 minutes after meals
     • Elevate head of bed slightly 1

2. Medication (If conservative measures fail after 2-4 weeks)

   • H2-Receptor Antagonists (First-line pharmacologic therapy):

     • Famotidine: 1 mg/kg/day divided twice daily 1

   • Proton Pump Inhibitors (For erosive esophagitis or severe GERD):

     • Lansoprazole: Approved for children 1-11 years for up to 12 weeks for GERD symptoms and healing of EE 2
     • Esomeprazole: Approved for short-term treatment of GERD with erosive esophagitis 3
     • Treatment duration: 8-12 weeks 1

For Adolescents (12-17 years)

• Similar approach to children with adjusted dosing
• Lansoprazole approved for up to 8 weeks for GERD symptoms and healing of EE 2

Treatment Duration and Reassessment

• Reassess after 4-8 weeks of treatment 1
• Consider gradual weaning of medication if symptoms improve 1
• If no improvement, reevaluate diagnosis and consider referral to pediatric gastroenterology 1

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

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 1
• Should be avoided before 2-3 years of age if possible 4

Important Considerations and Pitfalls

1. Distinguish GER from GERD:

   • GER is normal physiologic process occurring in 50-70% of healthy infants, typically resolving by 12 months 1
   • GERD occurs when reflux causes troublesome symptoms or complications 1

2. Avoid overuse of acid suppressants:

   • PPIs should not be used empirically in infants 5
   • Long-term PPI use may increase susceptibility to infections, bone fractures 1, 2
   • In children with proven reflux esophagitis, GERD is not always chronic; trials of therapy withdrawal are warranted 5

3. Consider cow's milk protein allergy:

   • May coexist with GERD in 42-58% of infants 3
   • Symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein 3

4. Prokinetic limitations:

   • Current guidelines conclude insufficient evidence for routine use of prokinetic agents 3
   • Older agents (metoclopramide, bethanechol) are limited by side effects 6

By following this structured approach to GERD management in children, focusing first on conservative measures and progressing to medication only when necessary, most children can achieve symptom relief and avoid unnecessary treatment or complications.