Management of pediatric gastroesophageal reflux disease

Gastroesophageal reflux, defined as passage of gastric contents into the esophagus, is normal and occurs in 66% of healthy infants. Gastroesophageal reflux disease (GERD), defined as reflux associated with worrisome symptoms or complications, is far less common and must be differentiated from simple gastroesophageal reflux (GER) when making decisions about further testing and treatment. A primary emphasis of the American Academy of Pediatrics guidelines is for clinicians to decrease unnecessary diagnostic testing and pharmacologic treatment by distinguishing between GER, which requires relatively mild or no treatment at all, and GERD, which may require more careful intervention.

Clinical presentation

Symptoms associated with GER vary by age group. In infants (younger than 1 year of age), common symptoms include spitting up and vomiting. In school-age children, symptoms may include regurgitation and vomiting. In older children and adults, symptoms include the feeling of "heartburn" and foul-tasting belches. GERD on the other hand has additional symptoms and consequences. GERD symptoms are classified as esophageal or extraesophageal. Esophageal symptoms include poor weight gain, persistent vomiting, dysphagia, severe pain, and esophagitis. Extraesophageal manifestations include respiratory symptoms including cough, laryngitis, pneumonia, wheezing, and dental erosions. In infants less than age 1, the most common presentations of GERD include feeding refusal, poor weight gain, persistent irritability, and sleep disturbances, arching of the back, choking, and respiratory symptoms. In children aged 1-5 years, common symptoms include feeding refusal, vomiting, regurgitation, and abdominal pain. In older children and adolescents, the most common symptoms of GERD include abdominal pain (heartburn), recurrent vomiting, dysphagia, asthma, dental erosions, recurrent pneumonia, and chronic cough.

Diagnostic testing

Diagnostic testing usually is not necessary to make a diagnosis of either GER or GERD. A careful history and physical exam suffice. The diagnostic choices for evaluation of pediatric GERD include upper GI contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy. None of these tests are sufficiently sensitive or specific to serve as a reliable test for GERD. Upper GI series are too short in duration to adequately rule out reflux, and, since reflux can occur normally, the observation of reflux on an upper GI test can lead to false-positive interpretations of the test. Esophageal pH monitoring is also flawed because of similar issues in that there is not a clear cut-off point in changes in esophageal pH that distinguish GER from GERD. Upper endoscopy allows visualization of injury to the esophageal mucosa, but recent data suggest that 25% of infants younger than 1 year have histologic evidence of esophageal inflammation, so the test again suffers from both false-positive and false-negative results. The decision for further diagnostic testing and/or evaluation by specialists is generally determined by failure to respond to pharmacologic treatment or the need to determine with more certainty the diagnosis because of severe consequences of GERD including poor weight gain, unexplained anemia, positive fecal occult blood, recurrent pneumonia, or hematemesis.

Management

Management of GER and GERD should always begin conservatively with lifestyle modifications. Lifestyle modifications in older children and adults include weight loss, as well as avoidance of food triggers such as caffeine, chocolate, alcohol, and spicy foods. Lifestyle modifications vary based on the age of the child. In infants who have uncomplicated GER or GERD, the following treatments can be considered:

• Reducing the volume of feeds and increasing the frequency of feeding.

• Maternal dietary restriction of egg and milk in breastfed children and changing of formula to a non–milk-based formula in bottle-fed infants, because mild protein allergy may mimic GERD. The guidelines reference one study where simply changing to protein hydrolysate formula thickened with 1 tablespoon of rice per 1 ounce of formula, avoiding overfeeding, and emphasizing correct feeding position led to a 24% rate of resolution of symptoms over 2 weeks.

• Formula thickening with 1 tablespoon of rice cereal per 1 ounce of formula. This technique should be recommended to full term infants only, because of an association between thickened feedings and necrotizing enterocolitis in preterm infants. In addition, it is important to realize that thickening a 20 kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the caloric density to 34 kcal/oz. There are commercially available thickened formulas that do not add excess calories per ounce.

• Positioning recommendations include keeping infant upright or placing them prone while supervised and awake. Recently, studies have shown that the semisupine position (such as in a car seat) exacerbates GER and should be avoided in infants especially after feeding.

Pharmacotherapeutic agents are the next line of treatment. The guidelines express concern about overprescription of medications for pediatric GERD and emphasize that medications should be reserved to treat GERD in infants and children who did not respond to lifestyle modifications or who have significant complications of GERD. It is important to understand that medications should not be recommended to healthy children with GER. When medications are chosen the following points should be considered:

• Histamine₂ receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.

• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.

• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.

The bottom line

Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.

Reference

J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.

Gastroesophageal reflux, defined as passage of gastric contents into the esophagus, is normal and occurs in 66% of healthy infants. Gastroesophageal reflux disease (GERD), defined as reflux associated with worrisome symptoms or complications, is far less common and must be differentiated from simple gastroesophageal reflux (GER) when making decisions about further testing and treatment. A primary emphasis of the American Academy of Pediatrics guidelines is for clinicians to decrease unnecessary diagnostic testing and pharmacologic treatment by distinguishing between GER, which requires relatively mild or no treatment at all, and GERD, which may require more careful intervention.

Clinical presentation

Symptoms associated with GER vary by age group. In infants (younger than 1 year of age), common symptoms include spitting up and vomiting. In school-age children, symptoms may include regurgitation and vomiting. In older children and adults, symptoms include the feeling of "heartburn" and foul-tasting belches. GERD on the other hand has additional symptoms and consequences. GERD symptoms are classified as esophageal or extraesophageal. Esophageal symptoms include poor weight gain, persistent vomiting, dysphagia, severe pain, and esophagitis. Extraesophageal manifestations include respiratory symptoms including cough, laryngitis, pneumonia, wheezing, and dental erosions. In infants less than age 1, the most common presentations of GERD include feeding refusal, poor weight gain, persistent irritability, and sleep disturbances, arching of the back, choking, and respiratory symptoms. In children aged 1-5 years, common symptoms include feeding refusal, vomiting, regurgitation, and abdominal pain. In older children and adolescents, the most common symptoms of GERD include abdominal pain (heartburn), recurrent vomiting, dysphagia, asthma, dental erosions, recurrent pneumonia, and chronic cough.

Diagnostic testing

Diagnostic testing usually is not necessary to make a diagnosis of either GER or GERD. A careful history and physical exam suffice. The diagnostic choices for evaluation of pediatric GERD include upper GI contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy. None of these tests are sufficiently sensitive or specific to serve as a reliable test for GERD. Upper GI series are too short in duration to adequately rule out reflux, and, since reflux can occur normally, the observation of reflux on an upper GI test can lead to false-positive interpretations of the test. Esophageal pH monitoring is also flawed because of similar issues in that there is not a clear cut-off point in changes in esophageal pH that distinguish GER from GERD. Upper endoscopy allows visualization of injury to the esophageal mucosa, but recent data suggest that 25% of infants younger than 1 year have histologic evidence of esophageal inflammation, so the test again suffers from both false-positive and false-negative results. The decision for further diagnostic testing and/or evaluation by specialists is generally determined by failure to respond to pharmacologic treatment or the need to determine with more certainty the diagnosis because of severe consequences of GERD including poor weight gain, unexplained anemia, positive fecal occult blood, recurrent pneumonia, or hematemesis.

Management

Management of GER and GERD should always begin conservatively with lifestyle modifications. Lifestyle modifications in older children and adults include weight loss, as well as avoidance of food triggers such as caffeine, chocolate, alcohol, and spicy foods. Lifestyle modifications vary based on the age of the child. In infants who have uncomplicated GER or GERD, the following treatments can be considered:

• Reducing the volume of feeds and increasing the frequency of feeding.

• Maternal dietary restriction of egg and milk in breastfed children and changing of formula to a non–milk-based formula in bottle-fed infants, because mild protein allergy may mimic GERD. The guidelines reference one study where simply changing to protein hydrolysate formula thickened with 1 tablespoon of rice per 1 ounce of formula, avoiding overfeeding, and emphasizing correct feeding position led to a 24% rate of resolution of symptoms over 2 weeks.

• Formula thickening with 1 tablespoon of rice cereal per 1 ounce of formula. This technique should be recommended to full term infants only, because of an association between thickened feedings and necrotizing enterocolitis in preterm infants. In addition, it is important to realize that thickening a 20 kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the caloric density to 34 kcal/oz. There are commercially available thickened formulas that do not add excess calories per ounce.

• Positioning recommendations include keeping infant upright or placing them prone while supervised and awake. Recently, studies have shown that the semisupine position (such as in a car seat) exacerbates GER and should be avoided in infants especially after feeding.

Pharmacotherapeutic agents are the next line of treatment. The guidelines express concern about overprescription of medications for pediatric GERD and emphasize that medications should be reserved to treat GERD in infants and children who did not respond to lifestyle modifications or who have significant complications of GERD. It is important to understand that medications should not be recommended to healthy children with GER. When medications are chosen the following points should be considered:

• Histamine₂ receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.

• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.

• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.

The bottom line

Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.

Reference

J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.

Gastroesophageal reflux, defined as passage of gastric contents into the esophagus, is normal and occurs in 66% of healthy infants. Gastroesophageal reflux disease (GERD), defined as reflux associated with worrisome symptoms or complications, is far less common and must be differentiated from simple gastroesophageal reflux (GER) when making decisions about further testing and treatment. A primary emphasis of the American Academy of Pediatrics guidelines is for clinicians to decrease unnecessary diagnostic testing and pharmacologic treatment by distinguishing between GER, which requires relatively mild or no treatment at all, and GERD, which may require more careful intervention.

Clinical presentation

Symptoms associated with GER vary by age group. In infants (younger than 1 year of age), common symptoms include spitting up and vomiting. In school-age children, symptoms may include regurgitation and vomiting. In older children and adults, symptoms include the feeling of "heartburn" and foul-tasting belches. GERD on the other hand has additional symptoms and consequences. GERD symptoms are classified as esophageal or extraesophageal. Esophageal symptoms include poor weight gain, persistent vomiting, dysphagia, severe pain, and esophagitis. Extraesophageal manifestations include respiratory symptoms including cough, laryngitis, pneumonia, wheezing, and dental erosions. In infants less than age 1, the most common presentations of GERD include feeding refusal, poor weight gain, persistent irritability, and sleep disturbances, arching of the back, choking, and respiratory symptoms. In children aged 1-5 years, common symptoms include feeding refusal, vomiting, regurgitation, and abdominal pain. In older children and adolescents, the most common symptoms of GERD include abdominal pain (heartburn), recurrent vomiting, dysphagia, asthma, dental erosions, recurrent pneumonia, and chronic cough.

Diagnostic testing

Diagnostic testing usually is not necessary to make a diagnosis of either GER or GERD. A careful history and physical exam suffice. The diagnostic choices for evaluation of pediatric GERD include upper GI contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy. None of these tests are sufficiently sensitive or specific to serve as a reliable test for GERD. Upper GI series are too short in duration to adequately rule out reflux, and, since reflux can occur normally, the observation of reflux on an upper GI test can lead to false-positive interpretations of the test. Esophageal pH monitoring is also flawed because of similar issues in that there is not a clear cut-off point in changes in esophageal pH that distinguish GER from GERD. Upper endoscopy allows visualization of injury to the esophageal mucosa, but recent data suggest that 25% of infants younger than 1 year have histologic evidence of esophageal inflammation, so the test again suffers from both false-positive and false-negative results. The decision for further diagnostic testing and/or evaluation by specialists is generally determined by failure to respond to pharmacologic treatment or the need to determine with more certainty the diagnosis because of severe consequences of GERD including poor weight gain, unexplained anemia, positive fecal occult blood, recurrent pneumonia, or hematemesis.

Management

Management of GER and GERD should always begin conservatively with lifestyle modifications. Lifestyle modifications in older children and adults include weight loss, as well as avoidance of food triggers such as caffeine, chocolate, alcohol, and spicy foods. Lifestyle modifications vary based on the age of the child. In infants who have uncomplicated GER or GERD, the following treatments can be considered:

• Reducing the volume of feeds and increasing the frequency of feeding.

• Maternal dietary restriction of egg and milk in breastfed children and changing of formula to a non–milk-based formula in bottle-fed infants, because mild protein allergy may mimic GERD. The guidelines reference one study where simply changing to protein hydrolysate formula thickened with 1 tablespoon of rice per 1 ounce of formula, avoiding overfeeding, and emphasizing correct feeding position led to a 24% rate of resolution of symptoms over 2 weeks.

• Formula thickening with 1 tablespoon of rice cereal per 1 ounce of formula. This technique should be recommended to full term infants only, because of an association between thickened feedings and necrotizing enterocolitis in preterm infants. In addition, it is important to realize that thickening a 20 kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the caloric density to 34 kcal/oz. There are commercially available thickened formulas that do not add excess calories per ounce.

• Positioning recommendations include keeping infant upright or placing them prone while supervised and awake. Recently, studies have shown that the semisupine position (such as in a car seat) exacerbates GER and should be avoided in infants especially after feeding.

Pharmacotherapeutic agents are the next line of treatment. The guidelines express concern about overprescription of medications for pediatric GERD and emphasize that medications should be reserved to treat GERD in infants and children who did not respond to lifestyle modifications or who have significant complications of GERD. It is important to understand that medications should not be recommended to healthy children with GER. When medications are chosen the following points should be considered:

• Histamine₂ receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.

• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.

• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.

The bottom line

Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.

Reference

J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.