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

Treatment Options for Infant Gastroesophageal Reflux Disease (GERD)

Lifestyle modifications should be the first-line treatment for infant GERD, including feeding changes and positioning therapy, before considering pharmacologic intervention. 1

Distinguishing GER from GERD

• Gastroesophageal reflux (GER) is a normal physiologic process occurring in healthy infants, with regurgitation affecting approximately 40% of infants, peaking at 4 months and typically resolving by 12 months of age 2
• GERD occurs when reflux causes troublesome symptoms (feeding refusal, irritability, sleep disturbance) or complications (poor weight gain, esophagitis, respiratory symptoms) 1, 3

First-Line Management: Lifestyle Modifications

Feeding Changes

• For breastfed infants:

  • Implement a 2-4 week trial of maternal exclusion diet that restricts at least milk and egg 1
  • This is particularly important as cow's milk protein allergy can mimic or coexist with GERD in 42-58% of infants 3

• For formula-fed infants:

  • Consider switching to extensively hydrolyzed protein or amino acid-based formula 1
  • Reduce feeding volume while increasing feeding frequency 1
  • Use thickened feedings by either:
    • Adding up to 1 tablespoon of dry rice cereal per 1 oz of formula 1
    • Switching to commercially available anti-regurgitant formulas containing processed rice, corn, potato starch, guar gum, or locust bean gum 1

Caution: Thickened feedings are contraindicated in preterm infants due to risk of necrotizing enterocolitis 1

Positioning Therapy

• Keep infants in completely upright position when awake 1
• Important safety note: Prone positioning should only be considered when the infant is observed and awake due to SIDS risk 1

Second-Line Management: Pharmacologic Therapy

Medications should be reserved for infants with confirmed GERD who fail to respond to conservative measures 1.

Acid Suppressants

• Histamine-2 Receptor Antagonists (H2RAs):

  • Ranitidine: 5-10 mg/kg/day divided in 2-3 doses (FDA approved for ages 1 month-16 years) 1
  • Famotidine: 1 mg/kg/day divided in 2 doses (FDA approved for ages 1-16 years) 1
  • Limitation: Can cause tachyphylaxis within 6 weeks and may increase risk of liver disease 1

• Proton Pump Inhibitors (PPIs):

  • Omeprazole: 0.7-3.3 mg/kg/day (FDA approved for ages 2-16 years) 1
  • Lansoprazole: 0.7-3 mg/kg/day (FDA approved for ages 1-17 years) 1
  • Esomeprazole: 0.7-3.3 mg/kg/day (FDA approved for ages 1-17 years) 1
  • Note: Esomeprazole is specifically approved for short-term treatment of GERD with erosive esophagitis in infants aged 1-12 months 3

Important caution: There is significant concern about overprescription of acid suppressants, particularly PPIs 1. Evidence suggests acid suppression may be a risk factor for community-acquired pneumonia, gastroenteritis, candidemia, and necrotizing enterocolitis in preterm infants 1

Duration of Treatment

• Evaluate treatment efficacy after 4-8 weeks of optimal therapy 1
• If symptoms resolve but recur after stopping treatment, consider restarting medication 1

Third-Line Management: Surgical Intervention

• Fundoplication (wrapping gastric fundus around distal esophagus) should be reserved for:
  • Children with intractable symptoms unresponsive to medical therapy 1, 3
  • Patients at risk for life-threatening complications of GERD 1
  • Note: Surgical procedures are associated with significant morbidity and should be considered only after thorough evaluation to exclude other etiologies 1, 3

Special Considerations

• Upper endoscopy with esophageal biopsy is indicated in patients who:

  • Fail to respond to pharmacologic therapy 1
  • Present with alarm symptoms (poor weight gain, unexplained anemia, fecal occult blood, recurrent pneumonia, hematemesis) 1

• Approximately 25% of infants younger than 1 year will have histologic evidence of esophageal inflammation 1

• Always consider and rule out other conditions that can mimic GERD symptoms, including cow's milk protein allergy, neurologic disorders, constipation, and infection 3