Gastroesophageal Reflux Disease (GERD) Management

Introduction to GERD

Gastroesophageal reflux disease (GERD) is a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach (esophagus), as defined by the American College of Chest Physicians 1
Treatment for GERD should not be used when there are no GI clinical features of GERD, as recommended by the American College of Chest Physicians 2

Consider endoscopy to assess for erosive esophagitis for ongoing symptoms despite therapy 1
Consider pH monitoring to confirm GERD diagnosis if long-term PPI therapy is being considered 1
Red flags for referral to pediatric gastroenterology include bilious vomiting, gastrointestinal bleeding, consistently forceful vomiting, fever or lethargy, failure to thrive, and abdominal tenderness or distension, as well as newborn gurgling with respiratory distress, cyanosis or color changes, persistent gurgling with feeding difficulties, gurgling associated with projectile or bilious vomiting, and gurgling with hematemesis or blood in stool, as recommended by the American Academy of Pediatrics and the American College of Radiology 3, 4, 5, 6

The American College of Gastroenterology recommends a 4-8 week trial of single-dose proton pump inhibitor (PPI) therapy along with lifestyle and dietary modifications, with medication tapered to the lowest effective dose after symptom improvement 1
Take PPI 30-60 minutes before a meal for optimal effect 1
If inadequate response after 4-8 weeks, consider increasing to twice daily dosing or switching to a more potent PPI 1
The American Academy of Pediatrics recommends Proton Pump Inhibitors (PPIs) for a limited duration (4-8 weeks) for severe cases or erosive esophagitis only, with a strength of evidence based on moderate-quality trials 7
Medication options include H2 Receptor Antagonists (e.g., Famotidine 1 mg/kg/day or Ranitidine 5-10 mg/kg/day), although limited by tachyphylaxis within 6 weeks and risks including liver disease and gynecomastia 8, 3
Using PPIs indefinitely without attempting to taper to lowest effective dose is not recommended 1

Avoid meals within 3 hours of bedtime 1
Elevate the head of the bed for nighttime symptoms 1
Implementing smaller, more frequent meals can help reduce gastric distension in children with acid reflux 7
Avoiding trigger foods that may worsen reflux, such as spicy, acidic, and fatty foods, is recommended for children with acid reflux 7
For formula-fed infants, consider thickening formula with 1 tablespoon rice cereal per ounce, which increases energy density to 34 kcal/oz, as recommended by the American Academy of Pediatrics 8
The American Academy of Pediatrics suggests trying commercially available pre-thickened anti-regurgitant formulas for formula-fed infants 8
For breastfed infants, a 2-4 week maternal elimination diet of milk and eggs can be tried, and for formula-fed infants, a trial of extensively hydrolyzed protein or amino acid-based formula can be considered 8, 3, 9, 10

Patient education should cover GERD mechanisms and the physiological nature of reflux 1
Patient education should cover the importance of weight management if applicable 1
Patient education should cover the role of the brain-gut axis in symptom perception 1
Patient education should cover realistic expectations regarding treatment response 1

Reassess symptoms after the 4-8 week PPI trial 1
If symptoms improve, taper to lowest effective PPI dose 1
If symptoms don't respond adequately to the PPI trial, consider further evaluation 1
If alarm symptoms develop (e.g., weight loss, dysphagia, hematemesis), seek immediate medical attention 1
Reassessing the child after 4-8 weeks of treatment and considering gradual weaning of medication if symptoms improve is recommended 7
If no improvement is seen, reevaluating the diagnosis and considering referral to pediatric gastroenterology is necessary 7
Infants with GER or GERD should be monitored for improvement in symptoms, weight gain, and growth, and watched for constipation, which can occur with rice cereal thickening 8, 3

Consider potential overlap with other conditions that can mimic or exacerbate GERD symptoms, such as anxiety or stress-induced symptoms 1
For infants with cow's milk protein allergy, extensively hydrolyzed formula is a first-line option, with casein-based extensively hydrolyzed formulas recommended, and can be well tolerated by 80-90% of infants with cow's milk protein allergy, according to the American Academy of Allergy, Asthma, and Immunology 11
Amino acid-based formula is recommended for severe cases or when extensively hydrolyzed formula is not tolerated, and is indicated for infants who fail to respond to extensively hydrolyzed formulas, with approximately 10-20% of infants with cow's milk protein allergy requiring an amino acid-based formula 11
The American Academy of Pediatrics recommends continued breastfeeding as the primary recommendation for infants with reflux, as breast milk is optimal for these patients 12, 13

Consider surgical intervention when medical therapy fails, patient is at severe risk of aspiration, or life-threatening complications are present, with options including Fundoplication or Total esophagogastric dissociation, as recommended by the American Academy of Pediatrics and the American Academy of Family Physicians 8, 3
Fundoplication is the most common surgical procedure, which wraps gastric fundus around distal esophagus, increases lower esophageal sphincter pressure, but is associated with significant morbidity, as recommended by the American Academy of Pediatrics 8