Updated Clinical Practice Guidelines for Pediatric GERD

For older, verbal children and adolescents who present with heartburn and/or chest pain, a short-term trial (as long as 4 weeks) of acid suppressants may be used to identify acid reflux as the cause of these symptoms. 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. 5.1 We suggest not to use antacids/alginates for chronic treatment of infants and children with GERD. 3.15 We suggest not to use a trial of PPIs as a diagnostic test for GERD in patients presenting with extraesophageal symptoms. In conclusion, it is uncertain if the use of baclofen for the reduction of signs and symptoms in infants and children with GERD leads to side-effects compared with placebo.

Esophageal healing

5.9 Based on expert opinion, the working group recommends the regular assessment of the ongoing need of long-term acid suppression therapy in infants and children with GERD (Algorithm 2). Determination of the value pH-metry as a diagnostic tool for GERD and to differentiate it from GER is difficult because of lack of a gold standard for comparison. Early pH-metry studies used esophageal manometry, endoscopy, scintigraphy, symptom presence and barium imaging as the gold standard methods to diagnose reflux events.(28, 29, 31) All of these “gold standards” have significant limitations, with high rates of false positivity. The diagnosis of GERD is based primarily on clinical suspicion, which can be strengthened by additional diagnostic investigations that are aimed to quantify and qualify GERD).

The reflux can damage the esophagus, so we try to help parents prevent and reduce GERD symptoms and promote healing through lifestyle changes, but if that doesn’t work, medications that reduce the production of stomach acid are also helpful options,” DiLorenzo explained. 23. DiMarino MC. Drug treatment of gastric acidity. Merck Manual Professional Version.

GERD management in children includes lifestyle changes, pharmacologic therapy, and surgery. Lifestyle changes which may contribute to prevent and improve reflux symptoms in infants have already been discussed in the previous sections. In children and adolescents, lifestyle changes include modification of diet and sleeping position, weight reduction, and smoking cessation [2, 71]. Although usually sufficient to manage physiologic GER, lifestyle changes alone are not effective in the treatment of GERD, which must include pharmacologic therapies and possible surgical intervention for severe, unresponsive cases.

The study design was cross sectional. The study retrospectively included all children who underwent combined multiple intraluminal impedance and pH (pH-MII) monitoring due to gastrointestinal and/or extraesophageal symptoms suggesting gastroesophageal reflux disease at University Children’s Hospital in Belgrade, from July 2012 to July 2016.

Still, significant variation in testing and management occurred both among and within subspecialties. For example, 33% of algorithms incorporated esophageal pH probe tests, 67% included upper gastrointestinal (GI) tests, and 47% comprised small bowel follow-through. In terms of the variation in procedure contraindications, one-third of subspecialists believed ARP was contraindicated in patients with a history of gagging, while 20% indicated they would recommend gastrojejunostomy tubes prior to ARP. The most common adverse experiences in the pediatric study patients were fever, inflammation of the nasal passages and of the upper throat, cough, nasal congestion, vomiting, irritability and diarrhea. Physicians are cautioned to reduce the dose of Axid(R) Oral Solution in any patients with moderate to severe kidney disease.

Effectiveness and safety of proton pump inhibitors in infantile gastroesophageal reflux disease. Infantile gastroesophageal reflux may present with frequent regurgitation or vomiting, postprandial irritability, prolonged feeding or feeding refusal, or back arching.

  • In the present guideline, every effort was made to use the terms GER and GERD strictly as defined.
  • Whether persisting from infancy or of new onset, regurgitation and vomiting are less common in children older than 18 months of age and deserve an instrumental evaluation to diagnose possible GERD or to rule out alternative diagnosis [2].
  • One of the most controversial issues currently around the performance of endoscopy is whether it should be performed while the patient is on or off acid suppression.
  • This entry was posted in Pediatric Gastroenterology Intestinal Disorder and tagged Gastroesophageal Reflux, GERD Clinical Practice Guidelines by gutsandgrowth.

GERD should be suspected in infants with these symptoms, but none of the symptoms are specific to GERD alone. The major role of history and physical examination in the evaluation of purported GERD is to rule out other more worrisome disorders that present with similar symptoms (especially vomiting) and to identify possible complications of GERD.

In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique.

5.3 Based on expert opinion, the working group suggests to use H2RAs in the treatment of reflux related erosive esophagitis in infants and children if PPIs are not available or contra-indicated (Algorithm 2). While increased risk of fractures, dementia, myocardial infarction, and renal disease have been reported in PPI users, no pediatric evidence convincingly documents these risks, and these studies are often confounded by comorbidities found in patients taking PPIs.

Our results highlight the fact that the addition of MII to conventional pH monitoring significantly increases sensitivity of the test in infants and children with suspected GERD. This study showed that the sensitivity of pH-metry alone is especially low in infants, and that it increases with age. Moreover, our findings indicate that 40% of infants and children with an abnormal finding on pH-MII would not be identified by pH-metry alone.

GERD requires treatment to avoid complications like esophageal damage. Efficacy and safety of once-daily esomeprazole for the treatment of gastroesophageal reflux disease in neonatal patients.

The diagnosis of gastroesophageal reflux and GERD should be based primarily on history and physical examination findings because other diagnostic tests have not shown superior accuracy. The results of our study suggested that compared with pH-metry alone, pH-MII had significantly higher detection rate of GERD in all age groups, and especially in infants.

While originally the diagnosis of EoE was made upon the presence of esophageal eosinophils in patients with either a normal pH-metry study or unresponsiveness to an 8 week course of PPI-therapy, recently a subgroup of EoE has emerged that is responsive to PPIs. Therefore, if patients are treated initially with a course of PPIs, esophageal biopsies may not show inflammation and the patient will thereby be misdiagnosed as having non-erosive reflux disease (NERD), hypersensitive esophagus, or may undergo additional unnecessary testing because the initial diagnosis was missed. In light of these concerns, recent guidelines for adults have suggested that patients undergo endoscopy off of acid suppression therapy.(50, 51) The benefit to this approach is that patients will receive a definitive diagnosis at the time of the first endoscopy but the negative side is that patients will need to undergo a second endoscopy to assess for healing after instituting therapy. Prospective studies are clearly needed to determine an algorithm that maximizes diagnostic yield, reduces unnecessary medication and procedure costs, and results in more rapid improvement in outcomes. At this time, there is insufficient prospective data to recommend a single approach, and the pros and cons to both approaches should thus be discussed with patients and their families.

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- October 26, 2015

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