Pediatric Gastroesophageal Reflux Surgery Guidelines

Updated: May 01, 2020
  • Author: Tom Jaksic, MD, PhD; Chief Editor: Robert K Minkes, MD, PhD  more...
  • Print
Guidelines

NASPGHAN/ESPGHAN Guidelines for Treatment of Pediatric GERD

In 2018, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) issued updated clinical guidelines for the management of gastroesophageal reflux disease (GERD) in infants and children. [68]

Guidelines for nonpharmacologic treatment of GERD include the following:

  • It is suggested to use thickened feedings for visible regurgitation or vomiting in infants
  • It is suggested to modify feeding volume and frequency by age and weight to avoid overfeeding in infants
  • It is suggested to make a 2- to 4-week trial of extensively hydrolyzed protein (or amino)-based formula in infants with suspected GERD after failed optimal nonpharmacologic treatment
  • It is recommended not to use positional therapy to treat GERD symptoms in sleeping infants
  • It is suggested to consider head elevation or left lateral positioning to treat GERD symptoms in children
  • It is suggested not to use massage therapy for treatment in infants
  • It is suggested not to use current lifestyle interventions or complementary modalities for treatment
  • It is suggested to inform caregivers and children regarding the association between excessive body weight and increased prevalence of GERD
  • It is recommended to provide education to patients and parents as part of treatment

Guidelines for pharmacologic treatment of GERD include the following:

  • It is suggested not to use antacids or alginates for long-term treatment
  • It is recommended to use proton pump inhibitors (PPIs) as first-line treatment of reflux-related erosive esophagitis
  • It is suggested to use histamine-2 receptor antagonists (H2RAs) to treat reflux-associated erosive esophagitits if PPIs are unavailable or contraindicated
  • It is recommended not to use H2RAs or PPIs to treat crying or distress in otherwise healthy infants
  • It is recommended not to use H2RAs or PPIs to treat visible regurgitation in otherwise healthy infants
  • It is recommended to institute a 4- to 8-week course of H2RAs or PPIs to treat typical GERD symptoms
  • It is suggested not to use H2RAs or PPIs to treat extraesophageal symptoms unless typical GERD symptoms are present or diagnostic testing suggests GERD
  • It is recommended to evaluate treatment efficacy and exclude alternative causes of symptoms if patients do not respond to 4-8 weeks of optimal medical therapy
  • It is recommended to carry out regular assessment of the ongoing requirement for long-term acid-suppressing therapy
  • It is suggested to consider baclofen before surgery for children in whom other pharmacologic therapy has failed
  • It is suggested not to use domperidone to treat GERD
  • It is suggested not to use metoclopramide to treat GERD
  • It is suggested not to use any other prokinetics (eg, erythromycin or bethanechol) as first-line treatment

Guidelines for surgical treatment of and newer treatment options for GERD include the following:

  • It is suggested to consider antireflux surgery in pediatric GERD patients who have (a) life-threatening complications after failed optimal medical therapy, (b) symptoms refractory to optimal therapy after evaluation to exclude other underlying diseases, (c) chronic conditions with a significant risk of GERD-related complications, or (d) a need for long-term pharmacotherapy to control signs or symptoms
  • It is recommended not to use total esophagogastric disconnection as first-line surgical treatment in infants
  • It is suggested to consider total esophagogastric disconnection as as a rescue measure for neurologically impaired children after failure of fundoplication
  • It is suggested  to consider transpyloric/jejunal feeding as an alternative to fundoplication in the treatment of GERD that is refractory to optimal treatment
  • It is recommended  not to use radiofrequency ablation (RFA) in the treatment of GERD that is refractory to optimal treatment
  • It is suggested not to use endoscopic full-thickness plication in the treatment of children with GERD that is refractory to optimal treatment