Pediatric Gastroesophageal Reflux Treatment & Management

Conservative and pharmacologic therapy

Conservative measures in treating gastroesophageal reflux may include upright positioning after feeding, elevating the head of the bed, prone positioning (infants >6mo), and providing small, frequent feeds thickened with cereal. ^[1] In more severe cases, in addition to dietary management, pharmacologic intervention directed at reducing gastric acid secretion can be employed.

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).

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.

About two thirds of otherwise healthy infants spit up because of their physiology ("happy spitters"); these infants have simple gastroesophageal reflux (GER) rather than true gastroesophageal reflux disease (GERD), which is characterized by troublesome symptoms or complications (eg, irritability, weight loss, refusing to eat, coughing, or wheezing). ^{[12, 13]} Many cases of the former are inappropriately treated with proton pump inhibitors (PPIs).

According to the guidelines of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, infants with uncomplicated physiologic GER should be treated not with medication but with modest lifestyle changes; medications should be reserved for infants with GERD. ^[13] The most aggressive treatments, including surgery, should be reserved for children whe have intractable symptoms or are at risk for life-threatening complications. Older children and adolescents should be counseled to adopt recommended dietary changes.

Surgery

Surgery is required in only a very small minority of patients with gastroesophageal reflux. Indeed, 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.

Intragastric feeding

For patients who fail medical therapy, continuous intragastric administration of feeds alone (via nasogastric tube) may be used as an alternative to surgery. ^[2] 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 gastroenterologic referral, pulmonary consultation may be required so that respiratory complications can be comanaged. Surgical consultation may be required if medical treatment is not successful.

The diagram below presents a diagnostic and therapeutic algorithm to aid in the evaluation and management of gastroesophageal reflux.

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

View Media Gallery

Infants and children diagnosed with gastroesophageal reflux should avoid the seated or the supine position shortly after meals.

Prone positioning may be recommended for the patient, at least for the first postprandial hour. Sleeping in the prone position has been demonstrated to decrease the frequency of gastroesophageal reflux. 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 of 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.

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.

Thickening an infant’s formula provides a therapeutic advantage against gastroesophageal reflux, 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. ^[14] For formula-fed infants older than 3 months, thickening is typically achieved by the addition of 1 tablespoon of rice cereal per 2 oz of formula.

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. In addition, early introduction of rice cereal feedings (at age 3 mo) may be attempted. Research suggests that formula thickening is superior to positioning in promoting weight gain and reducing clinical symptoms in infants with gastroesophageal reflux. ^[1]

In children, small, frequent meals are also recommended. Greasy and spicy foods, which encourage 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.

Guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) discuss the use of step-up and step-down therapies, which should be instituted under the guidance of a pediatric gastroenterologist. ^{[15, 16]}

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). ^[17] Both classes of acid antisecretory agents have proven safe and effective for infants and children in reducing gastric acid output.

The proton-pump inhibitor rabeprazole sodium is now approved by the US Food and Drug Administration (FDA) for the treatment of GERD in pediatric patients aged 1-11 years. ^{[18, 19]} This agent was already indicated for (1) treatment of adults with GERD and duodenal ulcers, (2) eradication of Helicobacter pylori in adults, and (3) short-term treatment of symptomatic gastroesophageal reflux in adolescents (≥12 years).

In combination with diet and lifestyle changes, this management guideline should render surgery unnecessary 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 GERD and are at high risk for aspiration. In these patients, conservative therapy alone may not be sufficient for preventing reflux-associated complications. However, careful monitoring under optimal nonsurgical therapy should be conducted before operative intervention is considered.

The goals of medical therapy in gastroesophageal reflux are to decrease acid secretion and, in many cases, to reduce gastric emptying time. The previously described step-up approach 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. 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 and yet continue to have the symptoms of gastroesophageal reflux. ^{[20, 21]} In these cases, the development of EEI as a diagnostic tool may prove invaluable.

When rigorous step-up therapy has failed or when the 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 LES and, if possible, to reduce hiatal herniation of the stomach (occasionally seen in patients with GERD).

To summarize, 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 who remain medication dependent should 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 a 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

The goal of surgery for patients with GERD is to reestablish the antireflux barrier without creating obstruction to the food bolus. In general, the Nissen fundoplication (shown in the image below), which is a complete 360° wrap, best controls the symptoms of gastroesophageal reflux. ^[22] However, this technique may lead to more episodes of dysphagia (swallowing difficulty and discomfort) and gas bloat than would a partial wrap.

Illustration of the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360-degree wrap).

View Media Gallery

Before operative intervention, patients should be evaluated with a thorough history and physical examination and the results of medical treatment (nonoperative therapy) should be well documented. In infants and young children, performing an upper GI series (upper GI contrast study) prior to the performance of fundoplication is advisable in order to rule out other possible pathologies that may be causing emesis.