Treatment of Gastroesophageal Reflux Disease in Children

Gastroesophageal reflux (GER) is the physiologic process of gastric contents transferring upward, past the lower esophageal sphincter (LES), and into the esophagus. GER occurs naturally in more than 25% of infants, peaks at approximately 3 to 4 months of age, and usually self-resolves with time without pathologic consequences. When reflux symptoms become severe or complications such as esophagitis, refusal to eat, or weight loss develop, GER progresses to gastroesophageal reflux disease (GERD). Intractable GERD occurs when symptoms or complications of GERD persist despite optimal medical treatment. The prevalence of GERD is less than 5% in early school-aged children and approximately 10% in children older than 10 years.

GERD is an umbrella term for a spectrum of manifestations that can be classified into categories based on symptoms, endoscopic findings, reflux monitoring, and underlying pathophysiology. The 4 major subtypes of GERD are 1) erosive reflux disease, 2) nonerosive esophageal reflux disease, 3) reflux hypersensitivity, and 4) functional heartburn. Functional heartburn is the most prevalent phenotype in children. Identifying a patient’s distinct GERD phenotype aids in selection of more effective treatment. GERD management should be based on the best available evidence, consistent with practice guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

Nutritional management is the mainstay of nonpharmacologic treatment of GER in infants younger than 1 year. The initial approach involves …