Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children

 


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Am Fam Physician. 2015 Oct 15;92(8):705-717.

  Patient information: See related handout on gastroesophageal reflux in infants and children, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Gastroesophageal reflux is defined as the passage of stomach contents into the esophagus with or without accompanied regurgitation (spitting up) and vomiting. It is a normal physiologic process that occurs throughout the day in infants and less often in children and adolescents. Gastroesophageal reflux disease (GERD) is reflux that causes troublesome symptoms or leads to medical complications. The diagnoses of gastroesophageal reflux and GERD are based on the history and physical examination. Diagnostic tests, such as endoscopy, barium study, multiple intraluminal impedance, and pH monitoring, are reserved for when there are atypical symptoms, warning signs, doubts about the diagnosis, or suspected complications or treatment failure. In infants, most regurgitation resolves by 12 months of age and does not require treatment. Reflux in infants may be treated with body position changes while awake, lower-volume feedings, thickening agents (i.e., rice cereal), antiregurgitant formula, extensively hydrolyzed or amino acid formulas, and, in breastfed infants, eliminating cow's milk and eggs from the mother's diet. Lifestyle changes to treat reflux in children and adolescents include sleeping position changes; weight loss; and avoiding smoking, alcohol, and late evening meals. Histamine H2 receptor antagonists and proton pump inhibitors are the principal medical therapies for GERD. They are effective in infants, based on low-quality evidence, and in children and adolescents, based on low- to moderate-quality evidence. Surgical treatment is available, but should be considered only when medical therapy is unsuccessful or is not tolerated.

Gastroesophageal reflux in children is the passage of stomach contents into the esophagus. It is a normal physiologic process, occurring throughout the day in infants and less often in children and adolescents, typically after meals. It may be asymptomatic or cause mild, nontroubling symptoms such as regurgitation or occasional vomiting. Regurgitation (spitting up) is the passive movement of stomach contents into the pharynx or mouth. Vomiting is the forceful movement of stomach contents through the mouth by autonomic and voluntary muscle contractions, sometimes triggered by reflux.13

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnosis of gastroesophageal reflux and GERD should be based primarily on history and physical examination findings because other diagnostic tests have not shown superior accuracy.

C

24, 27

Conservative treatments are the first-line strategies for most infants, older children, and adolescents with reflux and GERD.

C

24

A trial of extensively hydrolyzed or amino acid formula in formula-fed infants, or maternal dietary modification in breastfed infants, is warranted when reflux is presumed to be caused by an allergy to cow's milk protein.

C

2, 4, 19

Histamine H2 receptor antagonists are an option for acid suppression therapy in infants and children with GERD.

B

2, 3, 52, 56, 57

Proton pump inhibitors are reasonable treatment options for GERD in older children and adolescents, but their use in infants is questionable because of a lack of proven effectiveness.

B

2, 3, 50, 52, 53, 57


GERD = gastroesophageal reflux disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnosis of gastroesophageal reflux and GERD should be based primarily on history and physical examination findings because other diagnostic tests have not shown superior accuracy.

C

24, 27

Conservative treatments are the first-line strategies for most infants, older children, and adolescents with reflux and GERD.

C

24

A trial of extensively hydrolyzed or amino acid formula in formula-fed infants, or maternal dietary modification in breastfed infants, is warranted when reflux is presumed to be caused by an allergy to cow's milk protein.

C

2, 4, 19

Histamine H2 receptor antagonists are an option for acid suppression therapy in infants and children with GERD.

B

2, 3, 52, 56, 57

Proton pump inhibitors are reasonable treatment options for GERD in older children and adolescents, but their use in infants is questionable because of a lack of proven effectiveness.

B

2, 3, 50, 52, 53, 57


GERD = gastroesophageal reflux disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN GASTROENTEROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation

The Authors

show all author info

DREW C. BAIRD, MD, is the associate program director at the Family Medicine Residency Program at Carl R. Darnall Army Medical Center, Fort Hood, Tex....

DAUSEN J. HARKER, MD, is a family physician in Fort Hood. At the time the article was submitted, he was the research director for the Family Medicine Residency Program at Carl R. Darnall Army Medical Center.

AARON S. KARMES, DO, is a family physician in Fort Bragg, N.C. At the time the article was submitted, he was chief resident at the Family Medicine Residency Program at Carl R. Darnall Army Medical Center.

Address correspondence to Drew C. Baird, MD, Family Medicine Residency Center, Carl R. Darnall Army Medical Center, Fort Hood, TX 76544 (e-mail: drew.c.baird.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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