Managing GERD in Pediatric Patients

Introduction

Gastroesophageal reflux disease (GERD) in children requires an individualized treatment approach that balances effectiveness and cost. Although GERD is common in infants, most cases are physiological and resolve over time. Distinguish between gastroesophageal reflux (GER) and GERD, focusing interventions on children who exhibit significant symptoms or complications.

Management Approach

General Management

• Reassure and Educate Parents: Emphasize that infant GER is generally benign and does not increase the risk of sudden infant death syndrome (SIDS). Offer guidance on recognizing normal versus problematic symptoms.
• Modify Feeding Practices: Suggest small, frequent feedings for infants, which can help reduce reflux episodes.
• Encourage Burping: Advise parents to burp infants regularly during and after feeding.
• Consider Thickened Feeds: Mix one tablespoon of cereal per ounce of formula. This strategy may reduce regurgitation but does not prevent GER.
• Recommend Proper Positioning: Instruct caregivers to keep infants upright post-feeding. For older children, head elevation during sleep can be beneficial. Discourage prone positioning due to SIDS risk.

Medication Therapy

First-Line Medications: H2 Blockers

• Ranitidine (PO) - "Removed from market"
  • < 1 month: 6 mg/kg/day divided TID.
  • ≥ 1 month–16 years: 5–10 mg/kg/day divided BID–TID (max 300 mg/day).
  • Adults: 150 mg BID or 300 mg nightly.
• Famotidine (PO)
  • < 3 months: 0.5 mg/kg daily.
  • 3 months–1 year: 0.5 mg/kg BID.
  • 1–12 years: 1 mg/kg/day divided BID (max 80 mg/day).
  • ≥ 12 years: 20 mg BID.

Second-Line Medications: Proton Pump Inhibitors (PPIs)

• PPIs for Severe GERD: More effective than H2 blockers for acid suppression; consider for refractory GERD or mucosal injury.
  • Omeprazole (PO):
    • < 1 year: 1–2 mg/kg/day (daily or divided BID); may not improve clinical symptoms.
    • > 1 year: 1–2 mg/kg/day up to adult dose.
  • Lansoprazole (PO):
    • < 1 year: 0.4–1.8 mg/kg/day.
    • 1–11 years: 7.5 mg/day (<10 kg); 15 mg daily up to BID. (10–30 kg)
    • > 30 kg: 30 mg daily up to BID.
• Side Effects: Monitor for headache, abdominal pain, diarrhea, risk of infections (e.g., C. difficile), and potential osteopenia in long-term use. Balance risks versus benefits.

Adjunct Therapy: Prokinetics

• Use Prokinetics Cautiously: May aid severe GERD cases, especially with hypomotility, but generally not recommended as routine therapy.
  • Erythromycin (PO): 3–4 mg/kg/dose BID–TID for prokinetic effect.
  • Metoclopramide (PO): Reserved for select cases, but beware of side effects like tardive dyskinesia.

Antacids and Mucosal Protectants

• Antacids: Provide temporary relief but require multiple dosing and may cause diarrhea or aluminum toxicity. Also, monitor for malabsorption of other medications.
• Sucralfate (Gastrofait, Carafate): Use in cases of erosive esophagitis; maximally effective at pH 4 and on mucosal lesions.

Take-home points

1. Reassure parents that GER in infants is usually benign and not linked to sudden infant death syndrome.
2. Advise small, frequent feedings and proper positioning after meals to reduce reflux episodes.
3. Initiate H2 blockers as first-line therapy for children with persistent GERD symptoms, adjusting doses by age.
4. Consider PPIs for severe cases, especially for mucosal injury or when H2 blockers are insufficient.
5. Use prokinetics cautiously, and reserve them for severe GERD cases due to potential side effects.

References

Keywords: Pediatric GERD treatment, Infant reflux management, GERD medications for children, H2 blockers vs. PPIs in pediatrics, Pediatric gastroesophageal reflux, Reflux positioning for infants, Thickened feeds for GER, GERD symptoms in children, Parental reassurance for GERD