Pediatric Gastroesophageal Reflux
Publication Date: March 1, 2018
Last Updated: March 14, 2022
RECOMMENDATIONS
1. Definitions
1. 1.1: We recommend using the following definitions for GER/GERD for all infants and children.
1. GER: the passage of gastric contents into the esophagus with or without regurgitation and vomiting.
1. GERD: when GER leads to troublesome symptoms and/or complications.
1. Refractory GERD: GERD not responding to optimal treatment after 8 weeks.
(, )
1. GER: the passage of gastric contents into the esophagus with or without regurgitation and vomiting.
1. GERD: when GER leads to troublesome symptoms and/or complications.
1. Refractory GERD: GERD not responding to optimal treatment after 8 weeks.
(, )
6731
2. Red flags
2. 2.1: We recommend to use tables of symptoms and signs that may be associated with gastroesophageal reflux disease (GERD), for alarm symptoms and diagnostic clues to identify an alternative underlying disease which are responsible for the symptoms.
6731
3. Diagnostic interventions for GERD
3. 3.1: We suggest not to use barium contrast studies for the diagnosis of GERD in infants and children.
3. 3.2: We suggest to use barium contrast studies to exclude anatomical abnormalities.
3. 3.3: We suggest not to use ultrasonography for the diagnosis of GERD in infants and children.
3. 3.4: We suggest to use ultrasonography to exclude anatomical abnormalities.
3. 3.5: We suggest not to use esophago-gastro-duodenoscopy to diagnose GERD in infants and children.
3. 3.6: We suggest to use esophago-gastro-duodenoscopy with biopsies to assess complications of GERD, in case an underlying mucosal disease is suspected and prior to escalation of therapy.
3. 3.7: We suggest that salivary pepsin should not be used for the diagnosis of GERD in infants and children.
3. 3.8: We suggest not to use currently available extraesophageal biomarkers for the diagnosis of GERD in infants and children.
3. 3.9: We suggest not to use manometry for the diagnosis of GERD in infants and children.
3. 3.10: We suggest to consider to use manometry when a motility disorder is suspected.
3. 3.11: We suggest scintigraphy should not be used for the diagnosis of GERD in infants and children.
3. 3.12: We suggest not to use transpyloric/jejunal feeding trials for the diagnosis of GERD in infants and children.
3. 3.13: We suggest not to use a trial of PPIs as a diagnostic test for GERD in infants.
3. 3.14: We suggest a 4 to 8 week trial of PPIs for typical symptoms (heartburn, retrosternal or epigastric pain) in children as a diagnostic test for GERD (See Questions 5 and 8 for further therapeutic recommendations).
3. 3.15: We suggest not to use a trial of PPIs as a diagnostic test for GERD in patients presenting with extraesophageal symptoms.
3. 3.16: We suggest, when pH-MII is not available, to consider to use pH-metry only to
1. Correlate persistent troublesome symptoms with acid gastroesophageal reflux events (See also under pH-MII)
2. Clarify the role of acid reflux in the etiology of esophagitis and other signs and symptoms suggestive for GERD.
3. Determine the efficacy of acid suppression therapy.
3. 3.17: We suggest to consider to use pH-MII testing only to
1. Correlate persistent troublesome symptoms with acid and non-acid gastroesophageal reflux events
2. Clarify the role of acid and non-acid reflux in the etiology of esophagitis and other signs and symptoms suggestive for GERD.
3. Determine the efficacy of acid suppression therapy.
4. Differentiate NERD, hypersensitive esophagus and functional heartburn in patients with normal endoscopy.
3. 3.2: We suggest to use barium contrast studies to exclude anatomical abnormalities.
3. 3.3: We suggest not to use ultrasonography for the diagnosis of GERD in infants and children.
3. 3.4: We suggest to use ultrasonography to exclude anatomical abnormalities.
3. 3.5: We suggest not to use esophago-gastro-duodenoscopy to diagnose GERD in infants and children.
3. 3.6: We suggest to use esophago-gastro-duodenoscopy with biopsies to assess complications of GERD, in case an underlying mucosal disease is suspected and prior to escalation of therapy.
3. 3.7: We suggest that salivary pepsin should not be used for the diagnosis of GERD in infants and children.
3. 3.8: We suggest not to use currently available extraesophageal biomarkers for the diagnosis of GERD in infants and children.
3. 3.9: We suggest not to use manometry for the diagnosis of GERD in infants and children.
3. 3.10: We suggest to consider to use manometry when a motility disorder is suspected.
3. 3.11: We suggest scintigraphy should not be used for the diagnosis of GERD in infants and children.
3. 3.12: We suggest not to use transpyloric/jejunal feeding trials for the diagnosis of GERD in infants and children.
3. 3.13: We suggest not to use a trial of PPIs as a diagnostic test for GERD in infants.
3. 3.14: We suggest a 4 to 8 week trial of PPIs for typical symptoms (heartburn, retrosternal or epigastric pain) in children as a diagnostic test for GERD (See Questions 5 and 8 for further therapeutic recommendations).
3. 3.15: We suggest not to use a trial of PPIs as a diagnostic test for GERD in patients presenting with extraesophageal symptoms.
3. 3.16: We suggest, when pH-MII is not available, to consider to use pH-metry only to
1. Correlate persistent troublesome symptoms with acid gastroesophageal reflux events (See also under pH-MII)
2. Clarify the role of acid reflux in the etiology of esophagitis and other signs and symptoms suggestive for GERD.
3. Determine the efficacy of acid suppression therapy.
3. 3.17: We suggest to consider to use pH-MII testing only to
1. Correlate persistent troublesome symptoms with acid and non-acid gastroesophageal reflux events
2. Clarify the role of acid and non-acid reflux in the etiology of esophagitis and other signs and symptoms suggestive for GERD.
3. Determine the efficacy of acid suppression therapy.
4. Differentiate NERD, hypersensitive esophagus and functional heartburn in patients with normal endoscopy.
6731
4. Non-pharmacological treatment
4. 4.1: We suggest use thickened feedings for treating visible regurgitation/vomiting in infants with GERD.
4. 4.2: We suggest to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD.
4. 4.3: We suggest a 2- to 4-week trial of extensively hydrolyzed protein-based (or amino-acid based) formula in infants suspected of GERD after optimal non-pharmacological treatment has failed, or see ESPGHAN 2012 CMPA guidelines) (178).
4. 4.4: We recommend not to use positional therapy (ie, head elevation, lateral and prone positioning) to treat symptoms of GERD in sleeping infants.
4. 4.5: We suggest to consider to use of head elevation or left lateral positioning to treat symptoms of GERD in children.
4. 4.6: We suggest not to use massage therapy to treat infant GERD.
4. 4.7: We suggest not to use currently available lifestyle interventions or complementary treatments such as prebiotics, probiotics, or herbal medications to treat GERD.
4. 4.8: We suggest to inform caregivers and children that excessive body weight is associated with an increased prevalence of GERD.
4. 4.9: We recommend to provide patient/parental education and support as part of the treatment of GERD.
4. 4.2: We suggest to modify feeding volumes and frequency according to age and weight to avoid overfeeding in infants with GERD.
4. 4.3: We suggest a 2- to 4-week trial of extensively hydrolyzed protein-based (or amino-acid based) formula in infants suspected of GERD after optimal non-pharmacological treatment has failed, or see ESPGHAN 2012 CMPA guidelines) (178).
4. 4.4: We recommend not to use positional therapy (ie, head elevation, lateral and prone positioning) to treat symptoms of GERD in sleeping infants.
4. 4.5: We suggest to consider to use of head elevation or left lateral positioning to treat symptoms of GERD in children.
4. 4.6: We suggest not to use massage therapy to treat infant GERD.
4. 4.7: We suggest not to use currently available lifestyle interventions or complementary treatments such as prebiotics, probiotics, or herbal medications to treat GERD.
4. 4.8: We suggest to inform caregivers and children that excessive body weight is associated with an increased prevalence of GERD.
4. 4.9: We recommend to provide patient/parental education and support as part of the treatment of GERD.
6731
5. Pharmacological treatment
5. 5.1: We suggest not to use antacids/alginates for chronic treatment of infants and children with GERD.
5. 5.2: We recommend the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD.
5. 5.3: We suggest to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated.
5. 5.4: We recommend not to use H2RA or PPI for the treatment of crying/distress in otherwise healthy infants.
5. 5.5: We recommend not to use H2RA or PPI for the treatment of visible regurgitation in otherwise healthy infants.
5. 5.6: We recommend a 4- to 8-week course of H2RAs or PPIs for treatment of typical symptoms (ie, heartburn, retrosternal or epigastric pain) in children with GERD.
5. 5.7: We suggest not to use H2RAs or PPIs in patients with extraesophageal symptoms (ie, cough, wheezing, asthma), except in the presence of typical GERD symptoms and/or diagnostic testing suggestive of GERD.
5. 5.8: We recommend evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 to 8 weeks of optimal medical therapy for GERD.
5. 5.9: We recommend the regular assessment of the ongoing need of long-term acid suppression therapy in infants and children with GERD.
5. 5.10: We suggest to consider the use of baclofen prior to surgery in children in whom other pharmacological treatments have failed.
5. 5.11: We suggest not to use domperidone in the treatment of GERD in infants and children.
5. 5.12: We suggest not to use metoclopramide in the treatment of GERD in infants and children.
5. 5.13: We suggest not to use any other prokinetics (ie, erythromycin, bethanechol) as a first-line treatment in infants and children with GERD.
5. 5.2: We recommend the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD.
5. 5.3: We suggest to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated.
5. 5.4: We recommend not to use H2RA or PPI for the treatment of crying/distress in otherwise healthy infants.
5. 5.5: We recommend not to use H2RA or PPI for the treatment of visible regurgitation in otherwise healthy infants.
5. 5.6: We recommend a 4- to 8-week course of H2RAs or PPIs for treatment of typical symptoms (ie, heartburn, retrosternal or epigastric pain) in children with GERD.
5. 5.7: We suggest not to use H2RAs or PPIs in patients with extraesophageal symptoms (ie, cough, wheezing, asthma), except in the presence of typical GERD symptoms and/or diagnostic testing suggestive of GERD.
5. 5.8: We recommend evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 to 8 weeks of optimal medical therapy for GERD.
5. 5.9: We recommend the regular assessment of the ongoing need of long-term acid suppression therapy in infants and children with GERD.
5. 5.10: We suggest to consider the use of baclofen prior to surgery in children in whom other pharmacological treatments have failed.
5. 5.11: We suggest not to use domperidone in the treatment of GERD in infants and children.
5. 5.12: We suggest not to use metoclopramide in the treatment of GERD in infants and children.
5. 5.13: We suggest not to use any other prokinetics (ie, erythromycin, bethanechol) as a first-line treatment in infants and children with GERD.
6731
6. Surgical treatment and new treatment options
6. 6.1: We suggest to consider antireflux surgery, including fundoplication, in infants and children with GERD and:
- life threatening complications such as apneas or BRUE after failure of optimal medical treatment
- symptoms refractory to optimal therapy, after appropriate evaluation to exclude other underlying diseases
- chronic conditions (ie, neurologically impaired, cystic fibrosis) with a significant risk of GERD related complications
- the need for chronic pharmacotherapy for control of signs and/or symptoms of GERD.
6. 6.2: We recommend not to use total esophagogastric disconnection as a first-line surgical treatment in infants and children with GERD refractory to optimal treatment.
6. 6.3: We suggest to consider to use total esophagogastric disconnection as a rescue procedure for neurologically impaired children with a failed fundoplication.
6. 6.4: We suggest to consider the use of transpyloric/jejunal feedings in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication.
6. 6.5: We recommend not to use radiofrequency ablation in infants and children with GERD refractory to optimal treatment.
6. 6.6: We suggest not to use endoscopic full thickness plication in children with GERD refractory to optimal treatment.
- life threatening complications such as apneas or BRUE after failure of optimal medical treatment
- symptoms refractory to optimal therapy, after appropriate evaluation to exclude other underlying diseases
- chronic conditions (ie, neurologically impaired, cystic fibrosis) with a significant risk of GERD related complications
- the need for chronic pharmacotherapy for control of signs and/or symptoms of GERD.
6. 6.2: We recommend not to use total esophagogastric disconnection as a first-line surgical treatment in infants and children with GERD refractory to optimal treatment.
6. 6.3: We suggest to consider to use total esophagogastric disconnection as a rescue procedure for neurologically impaired children with a failed fundoplication.
6. 6.4: We suggest to consider the use of transpyloric/jejunal feedings in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication.
6. 6.5: We recommend not to use radiofrequency ablation in infants and children with GERD refractory to optimal treatment.
6. 6.6: We suggest not to use endoscopic full thickness plication in children with GERD refractory to optimal treatment.
6731
8.: Evaluation of refractory GERD
8.1: We recommend evaluation of treatment efficacy and exclusion of alternative causes of symptoms in infants and children not responding to 4 to 8 weeks of optimal therapy for GERD.
8.2: We recommend referral of infants and children with GERD to the pediatric gastroenterologist if:
- There are alarm signs or symptoms suggesting an underlying gastrointestinal disease
- Patients are refractory to optimal treatment
- Patients cannot be permanently weaned from pharmacological treatment within 6 to 12 months (see 8: additional evaluation should be considered after 4–8 weeks of optimal GERD therapy if clinically indicated).
8.2: We recommend referral of infants and children with GERD to the pediatric gastroenterologist if:
- There are alarm signs or symptoms suggesting an underlying gastrointestinal disease
- Patients are refractory to optimal treatment
- Patients cannot be permanently weaned from pharmacological treatment within 6 to 12 months (see 8: additional evaluation should be considered after 4–8 weeks of optimal GERD therapy if clinically indicated).
6731
Recommendation Grading
Overview
Title
Pediatric Gastroesophageal Reflux
Authoring Organization
Consensus and Physician Experts
Publication Month/Year
March 1, 2018
Last Updated Month/Year
January 22, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Child, Infant
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management, Treatment
Keywords
gastroesophageal reflux disease (GERD), proton pump inhibitor, endoscopy, fundoplication, impedance
Supplemental Methodology Resources
Data Supplement, Data Supplement, Data Supplement, Data Supplement, Data Supplement
Methodology
Number of Source Documents
919
Literature Search Start Date
October 1, 2008
Literature Search End Date
June 1, 2015