eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Gastroesophageal Reflux: Treatment & Medication

Author: Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Coauthor(s): Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: May 13, 2009

Treatment

Medical Care

• Because most cases are functional gastroesophageal reflux (GER), reassurance is the only treatment needed.
• Conservative measures may include upright positioning after feeding, elevating the head of the bed, prone positioning (infants >6 mo), and providing small, frequent feeds thickened with cereal.⁵
• Older children benefit from a diet that avoids tomato and citrus products, fruit juices, peppermint, chocolate, and caffeine-containing beverages. Smaller, more frequent feeds are recommended, as is a relatively lower fat diet because lipid retards gastric emptying. Proper eating habits are encouraged and weight loss and avoidance of alcohol and tobacco are recommended when applicable.
• Prone positioning may be recommended, at least for the first postprandial hour. However, the association of prone positioning with sudden infant death syndrome (SIDS) has brought its use into debate. Observations suggest that SIDS in the prone position is related to either suffocation or rebreathing carbon dioxide and is associated with puffy bedding material. Clearly, the use of the prone position during infancy must be based on a careful risk-to-benefit analysis. When it is advised, only very firm bedding material (no pillows) must be used. Bed elevations offer no added advantage to the prone position, and seated positions are not recommended.
• Thickening of formula provides a therapeutic advantage, particularly when excessive vomiting is associated with suboptimal weight gain. Even for infants with normal weight gain, thickened and reduced volume feedings may reduce the frequency and amount of vomiting episodes, ameliorating the concerns of an anxious caregiver. For formula-fed infants younger than 3 months, thickening is typically achieved by the addition of 1 tablespoon of rice cereal per 2 oz of formula. A recent meta-analysis examined the effect of thickened-feed interventions in gastroesophageal reflux.⁶
• Younger formula-fed infants may benefit from a prethickened, proprietary formula (Enfamil-AR; Mead-Johnson Nutritionals Inc, Evansville, IN). For breast-fed infants, aside from increasing feeding frequency, expressed breast milk may be thickened as described. Also, early introduction of rice cereal feedings (at age 3 mo) may be attempted. Recent work suggests that formula thickening is superior to positioning in promoting weight gain and reducing clinical symptoms in infants with gastroesophageal reflux.⁵
• Results of medical therapy are generally met with a better long-term response, leading to elimination of antisecretory medications (when prescribed) during infancy. This is primarily because normal development of GI motility includes resolution of physiologic gastroesophageal reflux by age 1 year (in most cases by age 6 mo). In mild, uncomplicated cases, more frequent thickened feeds and, in some cases, postprandial prone positioning may yield an excellent therapeutic response. In more severe cases, in addition to dietary management, pharmacologic intervention is directed at reducing gastric acid secretion. As pharmacotherapy has improved, the need for surgical therapy (fundoplication) has markedly decreased. Nevertheless, antireflux surgery remains one of the most common surgical procedures performed during infancy and early childhood.
• Current guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) involve the use of "step-up" and "step-down" therapy, which should be instituted under the guidance of a pediatric gastroenterologist.^7,8  
  • Media file 2 is a diagnostic and therapeutic algorithm to aid in the evaluation and management of gastroesophageal reflux. The diagram outlines the major points addressed in this article.
    
    

    

    Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).

    [ CLOSE WINDOW ]

    

    Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).

  • In the case of pharmacologic intervention, "step-up" therapy involves progression from diet and lifestyle changes to H₂ receptor blockade medications (eg, ranitidine, nizatidine) to proton pump inhibitors (eg, omeprazole, lansoprazole).⁹  Both classes of acid antisecretory have proven safe and effective for both infants and children in reducing gastric acid output.
  • In combination with diet and lifestyle changes, this management guideline should obviate the need for surgery in the vast majority of cases. One important exception, however, may be children with moderate-to-severe neurodevelopmental disabilities who typically manifest both dysphagia and gastroesophageal reflux and are at high risk for aspiration. In these patients, conservative therapy alone may not be sufficient in preventing reflux-associated complications. However, careful monitoring under optimal nonsurgical therapy should be conducted before considering operative intervention.

Surgical Care

The goal of surgery for gastroesophageal reflux disease (GERD) is to reestablish the antireflux barrier, without creating obstruction to the food bolus. In general, the Nissen fundoplication, which is a complete 360° wrap, best controls the symptoms of gastroesophageal reflux;¹⁰ however, it may lead to more episodes of dysphagia (difficulty and discomfort with swallowing) and gas bloat than a partial wrap (see Media file 3).

• The goals of medical therapy in gastroesophageal reflux are to decrease acid secretion and, in many cases, to reduce gastric emptying time. The "step-up" approach described herein is directed at decreasing acid content of the refluxate. However, other components of the refluxate (eg, bile, pepsin, trypsin) may also lead to esophageal mucosal injury, and these gastric fluid components may exert damaging effects even under conditions of gastric alkalinization. Thus, some patients under antisecretory treatment may have normal pH probe studies yet continue to have the symptoms of gastroesophageal reflux.^11,12 In these cases, the development of EEI as a diagnostic tool may prove invaluable.
• When rigorous "step-up" therapy has failed, or when complications of gastroesophageal reflux pose a short or long-term survival risk, the goal of surgical antireflux procedures is to "tighten" the region of the lower esophageal sphincter (LES) and, if possible, reduce hiatal herniation of the stomach (occasionally seen in patients with GERD).
• Surgical treatment of gastroesophageal reflux should be considered for the following patients:
  • Infants and children who have failed "step-up" therapy for gastroesophageal reflux (typically over 12 wk) and those who cannot be weaned off of acid-reducing medications should be considered for surgical treatment.
  • Those with an atypical presentation, especially respiratory, whose symptoms are clearly associated with gastroesophageal reflux (eg, obstructive apnea temporally associated with reflux during pH monitoring) should be considered for surgical treatment. However, a period of medical therapy (including acid blockade) under close monitoring conditions should be attempted in many cases prior to recommending a surgical approach
  • Patients with complications of gastroesophageal reflux, such as aspiration, stricture of the esophagus, or Barrett esophagus should be considered for surgical treatment. Patients with neurologic impairment that requires feeding gastrostomy who are found to have pathologic reflux and remain medication dependent should also be considered for surgery.
  • Patients with chronic reflux and recurrence of anastomotic stricture after repair of esophageal atresia should be considered for surgical treatment.
• Observations related to the possible need for gastrostomy include the following:
  • Small gastric volumes, decreased compliance in infants, and slow gastric emptying rate following the fundoplication procedure may necessitate a gastrostomy procedure to accompany a fundoplication.
  • Patients who are neurologically impaired or who have an inability to tolerate feeds also need an accompanying gastrostomy.
• For those who fail medical therapy, continuous intragastric administration of feeds alone (via nasogastric tube) is another option.¹³ This method is often used in preterm infants who have a significantly greater surgical risk. In these cases, adequate nutritional management, in conjunction with appropriate medical therapy, may permit the infant to "outgrow" reflux while optimizing weight gain.

Consultations

• In addition to pediatric gastroenterological referral, pulmonary consultation may be required to comanage respiratory complications (see Media file 2).
  
  

  

  Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).

  [ CLOSE WINDOW ]

  

  Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).

• Surgical consultation may be required if medical treatment is not successful.

Diet

• In infants, small, frequent feeds are recommended. Also, parents should thicken formula with rice cereal. One tablespoon of dry rice cereal added to 2 oz of milk formula increases the caloric intake to 24 calories per ounce instead of 20 calories per ounce. Feeding volumes should be reduced, in association with increased feeding frequency. For breast-fed infants, early introduction of rice cereal by spoon (at 3-4 mo) may provide a similar thickening effect (expressed breast milk may also be thickened as above). Constipation may be a troublesome consequence of cereal supplementation; however, specific therapy for this problem is not usually required.
• In children, small, frequent meals are also recommended. Greasy and spicy foods, which increase postprandial reflux by increasing gastric distention and slowing gastric emptying, should be avoided. Chocolate, peppermint, tomato products, citrus, and caffeine, which lowers LES pressure, should also be avoided.

Activity

• Appropriate weight management of overweight or obese children is important. Obesity has been cited as a risk factor in the development of gastroesophageal reflux.
• Infants and children diagnosed with gastroesophageal reflux should avoid the seated or the supine position shortly after meals. In addition, sleeping in the prone position has been demonstrated to decrease the frequency of gastroesophageal reflux; however, that same position has been shown to have an association with SIDS.
• Studies that monitored esophageal acid exposure after elevation of the head of the bed showed a decrease in reflux activity in adults. Placing blocks under the head of the bed or placing a foam wedge under the patient's mattress can accomplish this.

Medication

Therapeutic response for gastroesophageal reflux may take up to 2 weeks. If treatment is successful, weight increases and vomiting episodes decrease. Recurrent aspiration pneumonia or apnea is cause for decreased length of medical therapy. Note that the so-called "prokinetic agents" have been omitted from the following drug list. No currently available prokinetic drug (eg, metoclopramide) has been demonstrated to exert a significant influence in the number or frequency of reflux episodes.

Antacids

These agents are used as diagnostic tools to provide symptomatic relief in infants. Associated benefits include symptomatic alleviation of constipation (aluminium antacids) or loose stools (magnesium antacids).

Aluminum hydroxide (ALternaGEL, Amphojel)

Increases gastric pH >4 and inhibits proteolytic activity of pepsin, reducing acid indigestion. Antacids can initially be used in mild cases. No effect on frequency of reflux but decreases its acidity.

Magnesium hydroxide (Phillips Milk of Magnesia)

Used as antacid to relieve indigestion. Also causes osmotic retention of fluid, which distends colon and increases peristaltic activity that provides laxative effect. Forms magnesium chloride in vivo after reacting with stomach hydrochloric acid.

H₂ Receptor Antagonists

Like antacids, these agents do not reduce the frequency of reflux but decrease the amount of acid in the refluxate by inhibiting acid production. All are equipotent when used in equivalent doses. They are most effective in patients with nonerosive esophagitis and are considered the drug of choice in children because of well-established pediatric doses and liquid forms.

Nizatidine (Axid)

Competitively inhibits histamine at the H ₂ receptor of the gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and reduced hydrogen concentrations.

Cimetidine (Tagamet)

Inhibits histamine at H₂ receptors of gastric parietal cells, resulting in reduced amounts of gastric acid secretion, gastric volume, and hydrogen ion concentrations.

Ranitidine (Zantac)

Inhibits histamine stimulation of the H₂ receptor in gastric parietal cells, which reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.

Famotidine (Pepcid)

Competitively inhibits histamine at H₂ receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.

Proton pump inhibitors

These agents are indicated in patients who require complete acid suppression (eg, infants with chronic respiratory disease or neurologic disabilities). Administer with the first meal of the day. Children with nasogastric or gastrostomy tubes may have granules mixed with an acidic juice or suspensions; tubes must then be flushed to prevent blockage.

Lansoprazole (Prevacid)

Suppresses gastric acid secretion by specific inhibition of the (H+, K+)-ATPase enzyme system (ie, proton pump) at the secretory surface of the gastric parietal cell. Blocks the final step of acid production. The effect is dose-related and inhibits both basal and stimulated gastric acid secretion, thus increasing gastric pH. Easy to administer to children because available as cap, PO disintegrating tab, and granules for PO susp.

Omeprazole (Prilosec)

Decreases gastric acid secretion by inhibiting the parietal cell H⁺/K⁺ ATPase pump. Used for the short-term and long-term treatment (4-8 wk to 12 mo) of GERD.

Esomeprazole (Nexium)

S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H⁺/K⁺ -ATPase enzyme system at secretory surface of gastric parietal cells.
Used in severe cases of and patients not responding to H2 antagonist therapy.
Used for up to 4 wk to treat and relieve symptoms of active duodenal ulcers; may be used up to 8 wk to treat all grades of erosive esophagitis.

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