What are the treatment options for gastroesophageal reflux disease (GERD) in children?

Treatment Options for Gastroesophageal Reflux Disease (GERD) in Children

For children with GERD, treatment should follow a stepwise approach starting with conservative measures before considering pharmacologic therapy, with surgical options reserved only for severe cases unresponsive to medical management. 1

Initial Conservative Management

Feeding and Dietary Modifications

• For infants:
  • Implement smaller, more frequent feedings to reduce gastric distension 1
  • For formula-fed infants:
    • Thicken formula with 1 tablespoon rice cereal per ounce or use pre-thickened anti-regurgitant formulas 1
    • Consider trial of extensively hydrolyzed protein or amino acid-based formula (2-4 weeks) 1
  • For breastfed infants:
    • Try 2-4 week maternal elimination diet of milk and eggs 1
    • Alginates may be tried 2

Positional Therapy

• Keep child upright for 20-30 minutes after meals 1
• Avoid eating within 2-3 hours of bedtime 1
• Elevate the head of the bed slightly 1

Dietary Adjustments for Older Children

• Avoid trigger foods that worsen reflux (spicy, acidic, and fatty foods) 1, 3
• Avoid large meals 3
• Maintain regular meal patterns 3

Pharmacologic Therapy

Medications should only be used when:

1. Conservative measures have failed after 2-4 weeks of consistent implementation
2. The child has confirmed GERD with troublesome symptoms affecting quality of life
3. There are complications such as esophagitis, poor weight gain, or significant sleep disturbances 1

First-Line Pharmacologic Options

• H2-Receptor Antagonists:
  • Recommended as first-line pharmacologic therapy 1
  • Famotidine: 1 mg/kg/day divided twice daily 1
  • Ranitidine: 5-10 mg/kg/day 1
  • Limitation: Tachyphylaxis within 6 weeks and risks including liver disease 1

Second-Line Pharmacologic Options

• Proton Pump Inhibitors (PPIs):
  • Should be used for a limited duration (4-8 weeks) for severe cases or erosive esophagitis only 2, 1
  • Should not be used solely for chronic cough or respiratory symptoms associated with reflux 2, 1
  • Options include:
    • Omeprazole: 0.7-3.3 mg/kg/day 1, 4
    • Esomeprazole: 0.7-3.3 mg/kg/day 1
  • FDA approved for children with erosive esophagitis (Esomeprazole is approved for infants aged 1-12 months) 5

Important Medication Considerations

• PPIs carry risks including:
  • Increased susceptibility to infections 1
  • Clostridium difficile infection 4, 6
  • Bone fractures with long-term use 4, 6
  • Kidney problems (tubulointerstitial nephritis) 4
  • Certain types of lupus erythematosus 4

Monitoring and Follow-up

• 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
• Monitor for improvement in symptoms, weight gain, and growth 1
• Watch for constipation with rice cereal thickening 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 surgical procedure) - wraps gastric fundus around distal esophagus to increase lower esophageal sphincter pressure 1
• Total esophagogastric dissociation (for severe cases) 1

Special Considerations

• Cow's milk protein allergy overlaps with GERD in 42-58% of infants 5
• For these infants, symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein 5
• "Happy spitters" (infants with physiologic GER without complications) require no intervention beyond parental reassurance 5

Treatment Algorithm

1. Start with conservative measures for 2-4 weeks
2. If no improvement and symptoms affect quality of life, add H2-receptor antagonist
3. If still no improvement after 4 weeks, consider PPI for 4-8 weeks (only for erosive esophagitis or severe symptoms)
4. Reassess after treatment period and wean medication if improved
5. Consider surgical options only for severe, refractory cases

Remember that 70-85% of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95% of infants by 1 year of age 5.