1. Distinguishing between physiologic gastroesophageal reflux (GER) and pathologic gastroesophageal reflux disease (GERD) is key to managing regurgitation symptoms in children.
2. Lifestyle modifications are the first-line therapy in both infants and older children, with refractory symptoms then managed with pharmacologic agents—or surgery in severe cases.
Study Rundown: GER is a topic of discussion at more than two-thirds of pediatrician visits for infants. Distinguishing between GER and GERD is thus important for effective pediatric care. This American Academy of Pediatrics (AAP) clinical guideline expands upon previous guidelines by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Physiologic GER in infants is defined as painless regurgitation that does not affect growth. These infants, known as ‘happy spitters,’ should be managed conservatively with parental education, reassurance, and thickening of formula. Most cases resolve by 18 months of age. GERD is instead manifested by symptoms like weight loss, irritability, and back arching with or refusal of feeds. In such cases, a laboratory workup and upper GI series should be considered, and treatment is with lifestyle modification, medication, or for intractable cases, surgery. Older children with GERD may be managed with an empiric proton pump inhibitor (PPI) trial.
Relevant Reading: Pediatric gastroesophageal reflux clinical practice guidelines
In-Depth [clinical guideline]: This AAP clinical guideline provides a framework for approaching GER and GERD. Physiologic GER in infants (painless regurgitation without weight loss) should be managed conservatively with parental education, reassurance, and thickening of formula; it will usually resolve by 18 months. Concerning symptoms such as weight loss prompt a work-up for GERD. Lifestyle changes for infants with GERD include thickening formula, reducing feeding volume while increasing frequency, upright positioning with feeds, and avoidance of environmental tobacco smoke. As GERD symptoms often mimic a milk protein allergy, restricting milk and egg intake in breastfeeding mothers and using hydrolyzed protein- or amino acid-based formulas are suggested. These measures resolve symptoms in 24%. Pharmacologic therapy can be considered in infants, though side effects need careful management. Older children with GERD should cease smoking, lose weight if overweight, and avoid alcohol, chocolate, caffeine, and spicy foods. They can be given an empiric trial of a PPI, similar to adults. For refractory or life-threatening symptoms, surgery may be beneficial.
By Neha Joshi and Devika Bhushan
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