Treatment Options for Pediatric Gastroesophageal Reflux Disease (GERD)

Introduction to Pediatric GERD

The American Academy of Pediatrics recommends that 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, 2, 3

Gastroesophageal reflux (GER) is the physiologic passage of gastric contents into the esophagus, occurring in more than two-thirds of otherwise healthy infants 4
GERD is defined as reflux associated with troublesome symptoms or complications that affect quality of life 5, 6
Proper distinction between GER and GERD is crucial as treatment approaches differ significantly 4, 7

For breastfed infants, a 2-4 week trial of maternal exclusion diet restricting at least milk and egg is recommended 1, 2
For formula-fed infants, a trial of extensively hydrolyzed protein or amino acid-based formula is recommended 2
Thickened feedings, such as adding up to 1 tablespoon dry rice cereal per 1 oz of formula, can be used to reduce reflux symptoms 3, 8
Reducing feeding volume while increasing frequency can also help alleviate symptoms 2
Keeping infants in a completely upright position when awake and avoiding prone positioning during sleep can help reduce reflux symptoms 3, 8
Avoiding exposure to environmental tobacco smoke is also recommended 1

Acid suppressants, such as H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), can be used to treat confirmed GERD in infants 3, 8
H2RAs, such as ranitidine and famotidine, can be used at specific dosages 8
PPIs, such as lansoprazole, esomeprazole, and omeprazole, can be used at specific dosages 8

Prone positioning can be beneficial in children older than 1 year 8
Antacids can be used for on-demand relief in children, but evidence is limited 3, 8
H2-receptor antagonists, such as ranitidine and famotidine, can be used at specific dosages 8
Proton pump inhibitors, such as lansoprazole, esomeprazole, and omeprazole, can be used at specific dosages 8

Upper endoscopy with esophageal biopsy is indicated in patients with GERD who fail to respond to pharmacologic therapy or have certain symptoms, such as poor weight gain or unexplained anemia 1
Conservative measures should be pursued before considering more invasive testing or aggressive pharmacologic therapy in pediatric patients with suspected GERD 1
The American Academy of Pediatrics recommends that PPIs should only be used for confirmed GERD, not for physiologic GER 5, 8