What are the treatment options for pediatric patients with Gastroesophageal Reflux Disease (GERD)?

Treatment Options for Pediatric Gastroesophageal Reflux Disease (GERD)

Lifestyle modifications should be emphasized as first-line therapy for both GER and GERD in pediatric patients, while medications are explicitly indicated only for patients with GERD, not for those with uncomplicated physiologic reflux. 1

Distinguishing GER from GERD

• Gastroesophageal reflux (GER) is the physiologic passage of gastric contents into the esophagus, occurring in more than two-thirds of otherwise healthy infants 1
• GERD is defined as reflux associated with troublesome symptoms or complications that affect quality of life 1
• Proper distinction between GER and GERD is crucial as treatment approaches differ significantly 1

Treatment Algorithm for Infants (<12 months)

First-Line: Lifestyle Modifications

• Feeding changes:

  • For breastfed infants: 2-4 week trial of maternal exclusion diet restricting at least milk and egg 1
  • For formula-fed infants: Trial of extensively hydrolyzed protein or amino acid-based formula 1
  • Thickened feedings: Adding up to 1 tablespoon dry rice cereal per 1 oz of formula or using commercially thickened formulas (caution: increases caloric density to 34 kcal/oz) 1
  • Reduce feeding volume while increasing frequency 1

• Positioning:

  • Keep infants in completely upright position when awake 1
  • Avoid prone positioning during sleep due to SIDS risk (only acceptable if infant is observed and awake) 1
  • Avoid seated positions 1

• Environmental factors:

  • Avoid exposure to environmental tobacco smoke 1

Second-Line: Pharmacologic Therapy (for confirmed GERD only)

• Acid suppressants:

  • H2-receptor antagonists (H2RAs):

    • Ranitidine: 5-10 mg/kg/day divided in 2-3 doses (FDA approved for ages 1 month-16 years) 1, 2
    • Famotidine: 1 mg/kg/day divided in 2 doses (FDA approved for ages 1-16 years) 1

  • Proton pump inhibitors (PPIs):

    • Lansoprazole: 0.7-3 mg/kg/day (FDA approved for ages 1-17 years) 1, 3
    • Esomeprazole: 0.7-3.3 mg/kg/day (FDA approved for ages 1-17 years) 1
    • Omeprazole: 0.7-3.3 mg/kg/day (FDA approved for ages 2-16 years) 1

• Important caution: Lansoprazole was not effective in infants with GERD less than one year of age in controlled studies 3

Treatment Algorithm for Children (>12 months) and Adolescents

First-Line: Lifestyle Modifications

• Prone positioning (beneficial in children older than 1 year) 1
• Weight loss if overweight 4
• Head of bed elevation 4
• Dietary modifications to avoid trigger foods 5

Second-Line: Pharmacologic Therapy (for GERD)

• Antacids:

  • Limited evidence for on-demand use in children 1
  • Generally seen as a relatively benign approach 1

• H2-receptor antagonists:

  • Ranitidine: 5-10 mg/kg/day divided in 2-3 doses 1, 2
  • Famotidine: 1 mg/kg/day divided in 2 doses 1
  • Cimetidine: 30-40 mg/kg/day divided in 4 doses (FDA approved for ≥16 years) 1

• Proton pump inhibitors:

  • Lansoprazole: 0.7-3 mg/kg/day 1, 3
  • Esomeprazole: 0.7-3.3 mg/kg/day 1
  • Omeprazole: 0.7-3.3 mg/kg/day 1
  • Rabeprazole: 20 mg daily (for ages 12-17 years) 1

Third-Line: Surgical Therapy

• Reserved for children with intractable symptoms unresponsive to medical therapy or at risk for life-threatening complications of GERD 1
• Nissen fundoplication is the most common surgical procedure 6

Special Considerations

• Milk protein allergy: Can mimic GERD in 42-58% of infants; symptoms typically decrease within 2-4 weeks after elimination of cow's milk protein 6

• Duration of treatment:

  • For erosive esophagitis in children who do not heal with 8 weeks of PPI therapy, an additional 8-week course may be considered 3
  • Controlled studies for maintenance therapy with PPIs do not extend beyond 12 months 3

• Caution regarding medication use:

  • Growing concern about overprescription of acid suppressants, particularly PPIs 1
  • PPIs should only be used for confirmed GERD, not for physiologic GER 1, 7
  • Esomeprazole is approved for short-term treatment of GERD with erosive esophagitis in infants aged 1-12 months 6

• Diagnostic evaluation:

  • Upper endoscopy with esophageal biopsy is indicated in patients with GERD who fail to respond to pharmacologic therapy 1
  • Also indicated as part of initial management if symptoms include poor weight gain, unexplained anemia, fecal occult blood, recurrent pneumonia, or hematemesis 1

Remember that conservative measures should be pursued before considering more invasive testing or aggressive pharmacologic therapy in pediatric patients with suspected GERD. 1, 7