Management of GER in Children- The AAP Guidelines
The link below provides the full article from the journal “Pediatrics” titled: Gastroesophageal Reflux: Management Guidance for the Pediatrician”.
This is a well done summary and reference work, on this most common of clinical problems. These new guidelines emphasize weight loss as the crucial warning sign indicating something needs to be done, and that physiologic GER (gastroesophageal reflux) without pain and that doesn’t affect growth is likely “normal”. We know that GER in infants (that spitty infant) is present in 50% around the 4-6 month age range, and by a year, it’s only there in 5-10%. In the 1-5 age range, add symptoms of spitting up, poor appetite, not wanting to eat and abdominal discomfort to that list of GER symptoms.
We tend to worry more and consider this process GERD (the D stands for disease), when an infant is not growing or shows severe pain, and when older children fail to grow or actually complain of heartburn, epigastric pain, pain that wakes them at night, difficulty eating, and sour burps.
What to do bout this? If you are breast feeding, it’s definitely worth cutting out certain foods from mom’s diet. Remove dairy and eggs to begin and try to give more frequent smaller feeds. If breast feeding, you might feed one side every 1-2 hours instead of both every 3-4 hours, or if you are already feeding one side due to large supply, you may have to cut down the time of each feeding to reduce the volume, but feed more often. For formula fed babies, it may be best to try an extensively hydrolyzed or amino acid-based formula along with smaller, more frequent feeding. Thickening the formula by adding 1 tablespoon of dry rice cereal per ounce of formula increases the density to 34 kcal/ounce and is not recommended for premature infants due to increased risk of NEC (necrotizing enterocolitis). Similar caution is needed if thickening formula with Simplythick.
Infants may do better if kept more upright during and after feeds and some even do better if prone (on their tummies), which is not recommended for the very young infant who is supposed to sleep on their back to reduce SIDS risk. For older school age and beyond, weight loss if they are overweight, can help and avoiding tobacco and alcohol also helps.
There are three main classes of medication that might be used in the severe GERD cases that don’t respond to the above measures and are causing growth failure or significant distress.
1. Antacids- not recommended on a chronic basis due to possible aluminum toxicity or calcium induced milk-alkali syndrome (hypercalcemia, alkalosis, renal failure).
2. Histamine- 2-receptor antagonists – also not to be used for over 6 weeks and cimetadine has been linked to liver disease so there is concern about the others.
3. PPI’s (Proton Pump Inhibitors)- generally the safest for long term use with the least side effects. For infants, it’s not clear that they are better than placebo for irritability.
Omeprazole, Lansoprazole and Esomeprazole have FDA approval for over age 1 and I know they are “go to drugs” in the NICU for premies who need treatment.
Side effects can also include headaches, diarrhea, constipation, nausea, and with all methods of suppressing stomach acid, there are reports of pneumonia, gastroenteritis, candidemia, and NEC in premature infants.
I was pleased to read that GERD is not as closely associated to asthma as previously thought. I have found the practice of the allergists reflexively placing all wheezing or asthma patients on GERD medications to be usually without benefit.
I agree with the summary statement, that “pediatric best practice involves both identifying children at risk for complications of GERD and reassuring parents of patients with physiologic GERD who are not at risk for complications to avoid unnecessary diagnostic or pharmacological therapy”.