- Gastroesophageal Reflux Disease
- Regurgitation is common for infants
- Peak age: 4 months old
- Onset may occur before 8 weeks of age
- Regurgitation in 40% of infants with most feedings
- Spitting Up more than 4 times per day occurs in 25% of infants
- Resolution by age 10 to 14 months
- Persists in 5% of infants
- Peak age: 4 months old
- Pediatric Reflux persists in some children
- Ages 3-9 years old: 2-7% Prevalence
- Prevalence gradually declines until age 12 years, then peaks again after age 16 years old
- Empiric prophylaxis of Preterm Infants may not be warranted
- Antireflux medications evaluated in very Low Birth Weight Infants
- Not associated with a difference in growth or neurodevelopment
- Malcolm (2008) Pediatrics 121(1): 22-7 [PubMed]
- Mild physiologic Gastroesophageal Reflux (spitting-up) is an expected condition
- Best treated conservatively (e.g. upright for feeds)
- No evidence for significant cardiopulmonary complications
- No increased risk of chronic lung disease, recurrent aspiration
-
Gastroesophageal Reflux disease is more severe than physiologic spitting-up
- Associated with complications such as respiratory symptoms and growth restriction
- Mechanism
- Postprandial gastric distention associated with Delayed Gastric Emptying
- Exacerbated by large volume feedings
- Transient reflexive Lower Esophageal Sphincter (LES) relaxation (response to increased pressure)
- Exacerbated by factors that increase gastric pressure (e.g. crying)
- Prematurity
- Esophageal disorders
- Esophageal atresia with repair
- Transesophageal fistula
- Congenital Hiatal Hernia
- Cardiopulmonary disease
- Neurodevelopmental disorders
- Medications
- Reflux
- Precipitating factors
- Frequent, large volume feedings
- Supine position
- Typical findings
- Effortless Spitting Up 1-2 mouthfuls (under age 1)
- Irritability may be present, but typically asymptomatic
- Findings absent in simple reflux (differentiates from GERD)
- No significant gastrointestinal, respiratory or neurologic findings
- Symptoms and Signs
- Uncommon
- Hematemesis
- Poor growth or poor weight gain
- Anemia
- Esophageal Stricture
- Respiratory disease
- Recurrent Pneumonia
- Chronic Cough
- Wheezing or Stridor
- Apnea or Cyanosis
- Barrett's Esophagus
- Rare
- Protein loss
- Sandifer Syndrome
- Lateral Head Tilt with contralateral chin rotation
- Torticollis or neck tilting in infants
- Distinguish from Movement Disorders (refer for evaluation)
- Gastroesophageal Reflux Disease (GERD)
- Approach
- Constitutional
- Poor weight gain, weight loss or Failure to Thrive
- Gastrointestinal
- Cardiopulmonary
- Chest Pain or Epigastric Pain
- Asthma
- Chronic Cough, Wheezing, Stridor or Hoarseness
- Recurrent respiratory disease (e.g. Otitis Media, Aspiration Pneumonia)
- Brief Resolved Unexplained Event (BRUE, apnea, Cyanosis)
- Neurologic
- Dystonic neck Posture in infants (Sandifer Syndrome)
- Growth measurements
- Plot height and weight on growth curve
- Evaluate for Failure to Thrive
- Head and Neck Exam
-
Lung Exam
- Wheezing
- Respiratory distress
- Abdominal exam
- Hepatosplenomegaly
- Abdominal Distention or tenderness
- Palpable abdominal mass
-
Neurologic Exam
- Neurodevelopmental abnormalities
- Common Alternative Causes
- Viral Gastroenteritis
- Cow's Milk Allergy
- Hiatal Hernia
- Infantile Colic
- Nongastrointestinal Infection
- Rumination Syndrome
- Recently swallowed food is regurgitated, chewed and re-swallowed
- Less common Alternative Causes
- Persistent or Recurrent Fever
- Gastrointestinal
- Bilious Vomiting (e.g. Intestinal Obstruction)
- Forceful Vomiting (e.g. Pyloric Stenosis)
- Vomiting onset after 6 months (or persists or increases at 12-18 months)
- Abdominal Pain, Abdominal Distention or palpable mass
- Hepatosplenomegaly
- Chronic Diarrhea
- Hematemesis or other Gastrointestinal Bleeding
- Neurologic
- Lethargy
- Bulging Fontanelle
- Seizures
- Developmental Delay
- Microcephaly or Macrocephaly
- Rapidly increasing Head Circumference (>1 cm/week, possible Increased Intracranial Pressure)
- Indications
- Not generally indicated in most cases
- Obtain in severe and refactory cases that fail empiric management or demonstrate alarm, red flags
- Endoscopy
- Most sensitive test for Barrett's Esophagus
- Can also identify gastric outlet obstruction
- pH Probe (24 hour)
- Gold standard for Reflux diagnosis (esp. multichannel intraluminal impedance testing)
- Variable Test Sensitivity (41-81%), invasive and expensive
- pH probe placed in distal Esophagus
- pH below 4.0 suggests reflux
- Abnormal if esophageal pH <4 for more than 7% of the time
- Specific indications only
- Correlate reflux with respiratory symptoms
- Barium Swallow (Upper GI)
- Poor sensitivity and Specificity for GERD
- Not recommended for GERD evaluation unless anatomic abnormalities are suspected
- Very good for identifying underlying anatomic conditions
- Hiatal Hernia
- Pyloric Stenosis
- Malrotation
- Esophageal Webs and strictures
- Tracheoesophageal fistula
- Achalasia
- Poor sensitivity and Specificity for GERD
- Milk study
- Good to assess gastric emptying
- Fair for identifying Reflux
- Manometry
- Can assess lower esophageal sphincter and mechanisms of Swallowing
- Not recommended in GERD evaluation unless other indications (e.g. postoperative reflux surgery)
-
Abdominal Ultrasound
- Evaluates Pyloric Stenosis
- May identify Hiatal Hernia
- Step 1 Conservative Management
- Indications
- Physiologic Reflux
- Normal weight gain
- Interventions in infants
- Smaller, more frequent feedings
- Thickened Feedings (most evidence)
- Avoid xantham gum (e.g. SimplyThick) due to risk of Necrotizing Enterocolitis
- Rice cereal up to 1 tablespoon per ounce formula
- Rice cereal may cause excessive weight gain, Abdominal Pain and stool changes
- Arsenic contamination has been found in some rice cereal formulations
- Positioning
- Danny Sling
- Due to safe sleep guidelines to prevent SIDS, optimal position changes are not recommended
- Minimize seated position
- May worsen reflux
- Increases intra-abdominal pressure
- Consider trial of formula change to extensively hydrolyzed formula (if refractory to other conservative measures)
- Identifies Cow's Milk Allergy
- Trial of casein hydrolysate formula for 2-4 weeks
- Consider changes in maternal diet in Breast fed infants
- Dairy elimination (including casein and whey Protein avoidance)
- May also avoid other common triggers (wheat, soy, egg)
- Interventions in older children and adolescents
- See Gastroesophageal Reflux for lifestyle management
- Upright for 2-3 hours after eating
- Avoid Caffeine
- Elevate the head of the bed
- Target 64 ounces non-caffeinated fluid per day
- Step 2 Evaluate for Pathologic Reflux
- Indications
- Persistent regurgitation despite management in Step 1 for 2-4 weeks
- Poor weight gain
- Signs of Esophagitis or respiratory symptoms (see GERD related findings as above)
- Evaluation
- Consider differential diagnosis (see above)
- Consider Upper GI Study
- Trial of acid suppression
- Approach
- Start with initial trial for 4 weeks (and continue for 2-3 months if effective)
- Precautions
- Avoid acid suppression when reflux is effortless, painless and does not impact growth
- Acid suppression is overutilized in Pediatric GERD and has significant associated risks
- Risk of Necrotizing Enterocolitis in preterm and Low Birth Weight Infants
- Associated with increased risk of Pneumonia and gastrointestinal infections
- Microbiome alterations on acid suppression risk of allergy, Asthma and Obesity
- Increased risk of Pediatric Fractures
- References
- H2 Receptor Blockers (e.g. Famotidine, Cimetidine)
- See H2 Blockers for dosing
- Famotidine
- Age <3 months: 0.5 mg/kg daily for age
- Age >3 months: 0.5 mg/kg (up to 40 mg) twice daily
- Cimetidine (300 mg/ml oral solution)
- For age <12 years (use adult dose of 400-800 mg twice daily for age >12 years)
- Newborns
- Dose: 5-10 mg/kg/day divided every 8-12 hours
- Infants
- Dose: 10-20 mg/kg/day divided every 6-12 hours
- Doses up to 20-40 mg/kg/day may be needed in GERD
- Children <12 years old
- Dose: 20-40 mg/kg/day divided every 6 hours
- Nizatidine (15 mg/ml suspension)
- For age 6 months to 11 years old (use adult dose of 150 twice daily for age >=12 years)
- Dose: 5-10 mg/kg/day divided every 12 hours
- Doses up to 10-20 mg/kg/day may be needed in GERD
- Proton Pump Inhibitors (e.g. Prevacid, Prilosec, Aciphex)
- See Proton Pump Inhibitors for additional dosing and adverse effects
- Esomeprazole
- Capsule contents sprinkled on food
- Weight 3 to 5 kg
- Give 2.5 mg orally daily for up to 6 weeks
- Weight 5 to 7.5 kg
- Give 5 mg orally daily for up to 6 weeks
- Weight 7.5 to 20 kg
- Give 10 mg orally daily for up to 6 weeks
- Weight >20 kg and age <11 years
- Give 20 mg orally daily for up to 8 weeks
- Age <12 to 17 years
- Take 20 to 40 mg orally daily for up to 8 weeks
- Lansoprazole
- May be compounded into liquid for dosing in infants
- May sprinkle opened capsule onto food or into juice
- Available in a disintegrating tablet
- Weight <10 kg (and age 3-12 months)
- Dose: 7.5 mg twice daily or 15 mg daily
- Dose: 1 mg/kg/day (0.5 to 1.6 mg/kg)
- May use up to 2 mg/kg/day in GERD
- Weight 10 to 30 kg (age 1 to 11 years)
- Dose: 15 mg orally daily for up to 12 weeks
- Weight >30 kg (age 12 to 17 years)
- Dose: 30 mg orally daily for up to 12 weeks
- Omeprazole
- May sprinkle opened capsule onto applesauce or acidic liquid
- Infants
- Give 0.7 mg/kg orally daily
- Doses up to 1-4 mg/kg/day may be needed in GERD
- Weight 5-10 kg (and age >1 year old)
- Give 5 mg orally daily
- Weight 10-20 kg
- Give 10 mg orally daily
- Weight >20 kg
- Give 20 mg orally daily
- Pantoprazole
- Weight <15 kg (off-label)
- Give 0.5 to 1 mg/kg/day
- Doses up to 1-2 mg/kg/day may be needed in GERD
- Weight 15 to 40 kg
- Give 20 mg orally daily for up to 8 weeks
- Weight >=40 kg
- Give 40 mg orally daily for up to 8 weeks
- Weight <15 kg (off-label)
- Approach
- Other measures to consider (avoid in most cases, consult gastroenterology)
- Prokinetics
- Metoclopramide (Reglan) 1 mg/ml oral solution
- Dose: 0.1 to 0.2 mg/kg/dose three to four times daily
- Risk of Extrapyramidal Effects, Dystonic Reaction, drowsiness
- Not recommended due to adverse effects in over one third of patients
- Erythromycin (EES) 200 mg/ml
- Dose 1.5 to 12.5 mg/kg every 6-8 hours
- Very expensive, no proven efficacy, no established doses in GERD
- Not recommended
- Metoclopramide (Reglan) 1 mg/ml oral solution
- Other gastrointestinal agents
- Antacid solutions (Magnesium Hydroxide, aluminum hydroxide)
- Magnesium Hydroxide only has been FDA approved in infants
- Not recommended <12 years old
- Risk of Milk Alkali Syndrome
- Magnesium Alginate with Simethicone
- Weight <5 kg: 2.5 ml three times daily
- Weight >=5 kg: 5 ml three times daily
- Sucralfate (Carafate)
- Dose 40-80 mg/kg/day divided every 6 hours
- No established dosing or efficacy in Pediatric Reflux
- Antacid solutions (Magnesium Hydroxide, aluminum hydroxide)
- Prokinetics
- Follow-up: Evaluate efficacy after 2-3 weeks
- Interventions effective: Continue for 2-3 months
- Interventions not effective: See Step 3 below
- Step 3 Refractory Reflux
- Indications
- Failed management in Step 2
- Evaluation
- Pediatric Gastroenterology Consultation
- Consider further studies
- pH probe for 24 hours
- Endoscopy
- Interventions for medically Intractable disease
- Pulmonary aspiration
- Chronic Bronchitis
- Bronchiectasis
- Antono (2025) Am Fam Physician 111(1): 62-72 [PubMed]
- Baird (2015) Am Fam Physician 92(8): 705-14 [PubMed]
- Boyle (1989) Gastroenterol Clin North Am 18:315-337 [PubMed]
- Faubion (1998) Mayo Clin Proc 73:166-73 [PubMed]
- Gauer (2014) Am Fam Physician 90(4): 244-51 [PubMed]
- Jung (2001) Am Fam Physician 64(11):1853-60 [PubMed]
- Orenstein (1999) Pediatr Rev 20:24-8 [PubMed]
- Tsou (1998) Otolaryngol Clin North Am 31:419-34 [PubMed]