Published: Apr 29, 2013 | Updated: Apr 29, 2013
By Cole Petrochko , Staff Writer, MedPage Today

Action Points

• Pediatricians should differentiate between gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) before determining a course of treatment for infants, children, and teens, according to new American Academy of Pediatrics guidelines.
• Point out that lifestyle changes are recommended as a first-line therapy, while more intensive treatments are recommended for those with intractable symptoms or life-threatening GERD-related complications.

Pediatricians should differentiate between gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) before determining a course of treatment for infants, children, and teens, according to new guidelines from the American Academy of Pediatrics (AAP).

Making the appropriate diagnosis will identify patients who can be treated with lifestyle changes alone or those who require more intensive therapies, according to Jenifer Lightdale, MD, MPH, of Boston Children’s Hospital, David Gremse, MD, of the University of South Alabama Health System in Mobile, and colleagues from the AAP section on gastroenterology, hepatology, and nutrition.

Among patients with either condition, lifestyle changes — such as modifying maternal diets in breastfeeding mothers or avoiding spicy foods in older children — are recommended as a first-line therapy, while more intensive treatments are recommended for those with intractable symptoms or life-threatening GERD-related complications, they wrote online in Pediatrics.

GER is common to more than two-thirds of infants who are otherwise healthy and “is considered a normal physiologic process that occurs several times a day in healthy infants, children, and adults,” they wrote.

The condition is “generally associated with transient relaxations of the lower esophageal sphincter independent of swallowing, which permits gastric contents to enter the esophagus,” they explained.

While GER is short lived and can cause few to no symptoms in healthy adults, GERD is characterized by mucosal injury on upper endoscopy and can result in vomiting, poor weight gain, dysphagia, abdominal or substernal/retrosternal pain, and esophagitis.

Symptoms of GERD can also include cough, laryngitis, and, in infants, wheezing, as well as dental erosion, pharyngitis, sinusitis, and recurrent otitis media.

Infants may present with feeding refusal, recurrent vomiting, poor weight gain, irritability, sleep disturbance, and respiratory symptoms.

One major issue with treating GERD, noted Jose Garza, MD, of Cincinnati Children’s Hospital Medical Center, is that “there is no gold standard to diagnose it.”

“The definition of gastroesophageal reflux disease is when gastric contents reflux into the esophagus and cause troublesome symptoms,” he told MedPage Today, noting that there is no single symptom profile and that symptoms vary from person to person and by age.

The new guidelines cautioned that certain pediatric patient populations may be at elevated risk for GERD and GERD-related complications, including patients with neurologic impairment, obesity, history of esophageal atresia, hiatal hernia, achalasia, chronic respiratory disorders, and history of lung transplantation, as well as preterm infants.

Though history and physical examination may make diagnosis of GER possible without diagnostic testing, “no single symptom or cluster of symptoms can reliably be used to diagnose esophagitis or other complications of GERD in children or to predict which patients are most likely to respond to therapy,” they cautioned, adding that there is “no single test that can rule it in or out.”

To diagnose GERD, healthcare professionals should use tests in a thoughtful and serial manner. Possible tests are:

• Upper gastrointestinal tract contrast radiography
• Continuous intraluminal esophageal pH monitoring
• Multiple intraluminal impedance
• Gastroesophageal scintigraphy scans for reflux of solids or liquids labeled with technetium-99m
• Endoscopy or esophageal biopsy

In patients with GER and GERD, the new guidelines offer several disease management recommendations.

As a first-line treatment, infants and older children can engage lifestyle modification.

In infants, this may include changes in feeding volume or feeding time. Mothers who are breastfeeding should consider changing their own diet. Those who are using formula should change to a protein hydrolysate formula thickened with 1 tablespoon of rice cereal per ounce.

Positioning therapy is another option. This can include keeping an infant upright or prone during feeding. The authors cautioned that semisupine positioning can exacerbate GER and should be avoided during and after feeding.

For children and teens, lifestyle recommendations were closer to those made in adults, and included avoidance of caffeine, chocolate, alcohol, and spicy foods. The authors also noted a prior study that showed postprandial chewing of sugarless gum helped decrease reflux episodes.

Another treatment option the authors noted was pharmacotherapeutic agents, such as acid suppressants and prokinetic agents. However, antacid and acid suppressant therapy may carry safety risks when used as a chronic treatment, and some agents have not been tested in pediatric populations.

Other possible drug therapies included H2RAs, which may result in rapidly reduced efficacy over time, and proton pump inhibitors (PPI), which require specific timing for dosing in treatment.

The authors also noted that prokinetic agents may carry an adverse event profile that outweighs the risks of therapy.

Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD.

Surgical interventions, such as fundoplication, or wrapping the gastric fundus around the distal esophagus, “may not produce optimum clinical results,” and may result in vomiting, rumination, gastroparesis, and eosinophilic esophagitis, and should only be considered if PPI therapy is ineffective.

They concluded that best practice among pediatric patients involves identifying those at risk for GERD complications and informing parents of nonphysiologic GER patients not at risk for complications to avoid extraneous diagnostic procedures and therapies.