How do you treat gastroesophageal reflux disease (GERD) in children?

Treatment of Heartburn in Children

Start with lifestyle modifications for 2-4 weeks before considering medications, and if pharmacologic therapy becomes necessary, use proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs) at the lowest effective dose for the shortest duration (4-8 weeks), avoiding overtreatment in "happy spitters" who are growing well. 1, 2

Initial Assessment: Distinguish Physiologic Reflux from GERD

Recognize the "happy spitter" - infants with effortless, painless regurgitation who are growing normally have physiologic gastroesophageal reflux (GER), not GERD, and require only parental reassurance and education, not medication 3, 4. About 70-85% of infants have regurgitation within the first 2 months of life, and this resolves spontaneously in 95% by 1 year of age 4.

Warning signs requiring intervention include:

• Poor weight gain or weight loss 3, 2
• Feeding refusal or significant irritability 4
• Recurrent pneumonia or respiratory symptoms 2, 5
• Hematemesis or blood in stool 2
• Choking, gagging, or coughing with feedings 4

First-Line: Lifestyle and Feeding Modifications (2-4 weeks)

For Infants

Dietary modifications based on feeding type:

• Breastfed infants: Maternal elimination of cow's milk and egg proteins for 2-4 weeks, as cow's milk protein allergy mimics GERD in 42-58% of cases 2, 4
• Formula-fed infants: Trial of extensively hydrolyzed protein or amino acid-based formula for 2-4 weeks 2, 4

Feeding adjustments:

• Reduce feeding volume while increasing frequency to minimize gastric distension 1, 2
• Thickened feedings with up to 1 tablespoon of dry rice cereal per ounce of formula can reduce regurgitation 3, 2
• Critical warning: Never use SimplyThick in preterm infants (<37 weeks gestation) due to necrotizing enterocolitis risk 3
• Consider commercially available antiregurgitant formulas containing processed rice, corn, or potato starch 3

Positioning strategies:

• Keep infants completely upright for at least 30 minutes after meals 1, 2
• Prone positioning is beneficial only when infant is awake and observed due to sudden infant death syndrome risk in sleeping infants 3, 1

For Older Children (>1 year)

Lifestyle modifications:

• Weight loss if overweight or obese 1, 2
• Avoid trigger foods: spicy foods, chocolate, caffeine, acidic foods 1, 2
• Avoid eating within 2-3 hours before bedtime 1
• Elevate head of bed 1, 2
• Encourage chewing sugarless gum after meals to increase saliva production 1, 2
• Avoid tobacco smoke exposure 1
• For adolescents: avoid smoking and alcohol 2

Second-Line: Pharmacologic Therapy (if symptoms persist after 2-4 weeks)

Medication Selection Algorithm

For mild symptoms:

• Start with H2 receptor antagonists (H2RAs) for 4 weeks 2
• Ranitidine: 5-10 mg/kg/day divided in 2-3 doses (FDA approved for ages 1 month-16 years) 3, 2
• Famotidine: 1 mg/kg/day divided in 2 doses 3, 2
• Limitation: Tachyphylaxis develops within 6 weeks of H2RA initiation 2, 5

For moderate to severe symptoms or erosive esophagitis:

• Use proton pump inhibitors (PPIs) as first-line therapy 1, 2
• Omeprazole: 0.7-3.3 mg/kg/day, given 30 minutes before meals 2, 6
• Lansoprazole: 0.7-3 mg/kg/day 2
• Esomeprazole: 0.7-3.3 mg/kg/day (FDA approved for infants 1-12 months with erosive esophagitis) 2, 4
• Treatment duration: 4-8 weeks initially 1, 2, 6
• If symptoms improve, continue for total of 8-12 weeks 3, 5

Critical Safety Warnings for Acid Suppressants

PPIs increase risk of:

• Community-acquired pneumonia and gastroenteritis 1, 2, 5
• Necrotizing enterocolitis in preterm infants 5
• Candidemia 1
• Bone fractures with prolonged use (>1 year) 6
• Tubulointerstitial nephritis 6
• Clostridium difficile infection 6
• Certain types of lupus erythematosus 6

H2RAs may cause:

• Liver disease 1, 2
• Gynecomastia, particularly with cimetidine 1, 2

Antacids:

• May provide on-demand symptom relief but are not recommended for chronic therapy due to potential risks 1, 2

Prokinetic Agents: Not Recommended

Avoid routine use of prokinetic agents (e.g., metoclopramide) as there is insufficient evidence to justify their use, and they have not been proven effective for symptom control 3, 7

Monitoring and Reassessment (4-8 weeks)

Evaluate treatment response after 4-8 weeks of optimal therapy 1, 2, 5:

• If symptoms improve: Continue PPI for total of 8-12 weeks, then attempt discontinuation 3, 5
• If symptoms persist: Consider alternative diagnoses rather than blindly escalating therapy 2, 5
• If relapse occurs: Refer to pediatric gastroenterology 3

Indications for referral to pediatric gastroenterology:

• Failure to respond to optimal medical therapy after 4-8 weeks 1, 2, 5
• Warning signs present (poor weight gain, recurrent pneumonia, hematemesis) 2, 5
• Need for upper endoscopy with esophageal biopsy to confirm diagnosis or evaluate complications 1, 5

Diagnostic Testing: When to Consider

Upper endoscopy with esophageal biopsy is indicated for:

• Atypical symptoms or warning signs 2, 5
• Suspected complications (erosive esophagitis, stricture, Barrett's esophagus) 5
• Treatment failure after 4-8 weeks of optimal therapy 2, 5
• To exclude conditions mimicking GERD (eosinophilic esophagitis, infectious esophagitis) 5
• Approximately 25% of infants under 1 year have histologic esophageal inflammation not detectable without biopsy 5

24-hour pH monitoring or pH/impedance testing:

• Quantifies reflux episodes and establishes temporal relationship between symptoms and reflux 5
• Reserved for unclear diagnoses or treatment failures 8

Surgical Intervention: Highly Selective

Fundoplication is reserved only for:

• Failed optimal medical therapy after 8-12 weeks 5
• Severe risk of aspiration of gastric contents 5
• Confirmed GERD-related complications (recurrent pneumonia, failure to thrive) 5
• Life-threatening complications unresponsive to medical therapy 4

Common Pitfalls to Avoid

Do not overtreat "happy spitters" - the most common error is prescribing acid suppressants to infants with physiologic reflux who are growing well 3, 1. This exposes them to unnecessary risks without benefit.

Do not use acid suppression for chronic cough alone without other GERD symptoms, as evidence does not support this practice 2

Do not continue PPIs beyond 12 months without clear indication, as long-term use increases serious adverse events including bone fractures and infections 1, 6

Do not ignore cow's milk protein allergy - always trial dietary protein elimination before escalating to medications, as up to 58% of suspected GERD cases are actually food allergy 2, 4