How to diagnose and manage gastric pain due to acidity in a child?

Diagnosing and Managing Gastric Pain Due to Acidity in Children

For a child presenting with gastric pain attributed to acidity, the diagnosis should be written as "Gastroesophageal Reflux Disease (GERD)" only when reflux causes troublesome symptoms or complications; otherwise, document it as "Gastroesophageal Reflux (GER)" or "Functional Dyspepsia" if no pathologic reflux is confirmed. 1

Distinguishing Between Physiologic Reflux and Pathologic Disease

The critical first step is determining whether the child has simple GER (physiologic) versus GERD (pathologic disease requiring treatment):

• GERD diagnosis requires reflux causing troublesome symptoms or complications including poor weight gain, feeding refusal, significant irritability, respiratory symptoms, or signs of esophagitis 1
• Simple GER involves spitting up or throat-clearing without troublesome symptoms and does not meet GERD criteria 2
• History and physical examination alone are sufficient for diagnosis in most cases without diagnostic testing 2

Warning Signs Requiring Immediate Attention

Document these "red flags" if present, as they indicate serious pathology beyond simple acidity:

• Bilious vomiting, GI bleeding, hematemesis, or hematochezia 2
• Consistently forceful or projectile vomiting 2, 1
• Weight loss or poor weight gain 1
• Fever, lethargy, abdominal tenderness or distension 2
• Choking or gagging with feeds, feeding refusal 1

If any warning signs are present, the diagnosis shifts from simple GERD to potential surgical abdomen, peptic ulcer disease, or other serious conditions requiring urgent evaluation 3, 4

Diagnostic Approach by Age and Presentation

For Infants (Under 2 Years)

• Diagnosis is primarily clinical based on symptoms; routine diagnostic testing is not indicated 2, 1
• Consider cow's milk protein allergy as it co-exists with GERD in 42-58% of cases 1, 5
• Document whether symptoms are troublesome enough to warrant GERD diagnosis versus physiologic GER 2

For Children 2-16 Years

• Symptomatic GERD can be diagnosed when heartburn, regurgitation, or epigastric pain occurs without alarm symptoms 2, 6
• Peptic ulcer disease or gastritis should be considered in the differential, particularly if pain has specific patterns (nocturnal pain, pain relieved by eating) 4, 7
• Upper endoscopy with biopsy is indicated only if symptoms persist despite 4-8 weeks of appropriate therapy 1, 8

When to Perform Diagnostic Testing

Avoid routine testing in most cases, but consider specific studies when:

• Upper endoscopy with biopsy is the primary method to establish GERD-related esophageal injury and exclude other conditions like eosinophilic esophagitis 2, 8
• pH monitoring or combined pH/impedance may be considered for recurrent symptoms or to establish temporal relationship between symptoms and reflux 2
• Upper GI series should NOT be routinely performed for GERD diagnosis as it is too brief to rule out pathologic reflux and has high false-positive rates 2

Treatment Algorithm: Conservative First, Medications Only When Necessary

First-Line: Conservative Management (2-4 Weeks)

Implement these evidence-based lifestyle modifications before any medication:

• Reduce feeding volume while increasing frequency to avoid overfeeding 1, 5
• Hold infant upright after feeding for 10-20 minutes 2, 5
• Ensure frequent burping during feeds 1
• Consider thickened formula (commercially available) to decrease regurgitation frequency 2, 1
• Trial 2-4 week maternal elimination diet (milk and egg) for breastfed infants 1, 5

Pharmacologic Therapy: Use With Extreme Caution

Acid suppression therapy should be avoided in most pediatric patients due to significant safety concerns:

• Do NOT routinely prescribe proton pump inhibitors or H2 receptor antagonists, as they increase risk of pneumonia, gastroenteritis, candidemia, and necrotizing enterocolitis 2, 1, 5
• If pharmacologic therapy is deemed necessary after failed conservative measures, consider a 2-week trial of PPI with continuation for 8-12 weeks total if symptoms improve 1
• Dosing for omeprazole in children 2-16 years: 10 mg once daily for weight 10-20 kg; 20 mg once daily for weight >20 kg 6

When Medications Are Appropriate

Acid suppression is justified only when:

• Erosive esophagitis is confirmed on endoscopy 8
• Pathologic reflux is documented on pH monitoring 8
• Conservative measures have failed for 4-8 weeks and symptoms significantly impact quality of life 1, 8

Documentation Recommendations

Write the diagnosis based on your clinical assessment:

1. "Gastroesophageal Reflux (GER)" - for physiologic reflux without troublesome symptoms
2. "Gastroesophageal Reflux Disease (GERD)" - when reflux causes troublesome symptoms or complications
3. "Suspected Peptic Ulcer Disease" or "Gastritis" - if pain pattern suggests these (nocturnal pain, specific food triggers) 4, 7
4. "Functional Dyspepsia" - if symptoms persist but objective testing shows no pathologic reflux or mucosal injury 2

Common Pitfalls to Avoid

• Do not diagnose GERD based solely on spitting up - this is physiologic GER in most infants 2
• Do not order upper GI series routinely - it has poor sensitivity and specificity for GERD 2
• Do not prescribe acid suppression empirically without first attempting conservative measures for 2-4 weeks 1, 5
• Do not continue PPI therapy indefinitely without confirming diagnosis via endoscopy if long-term treatment is planned 2