What is the role of conservative and pharmacologic therapy in the treatment of pediatric gastroesophageal reflux disease (GERD)?

Updated: Mar 14, 2019
  • Author: Steven M Schwarz, MD, FAAP, FACN, AGAF; Chief Editor: Carmen Cuffari, MD  more...
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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.

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