Gastroesophageal Reflux: Management Guidance for the Pediatrician

Abstract

Recent comprehensive guidelines developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition define the common entities of gastroesophageal reflux (GER) as the physiologic passage of gastric contents into the esophagus and gastroesophageal reflux disease (GERD) as reflux associated with troublesome symptoms or complications. The ability to distinguish between GER and GERD is increasingly important to implement best practices in the management of acid reflux in patients across all pediatric age groups, as children with GERD may benefit from further evaluation and treatment, whereas conservative recommendations are the only indicated therapy in those with uncomplicated physiologic reflux. This clinical report endorses the rigorously developed, well-referenced North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines and likewise emphasizes important concepts for the general pediatrician. A key issue is distinguishing between clinical manifestations of GER and GERD in term infants, children, and adolescents to identify patients who can be managed with conservative treatment by the pediatrician and to refer patients who require consultation with the gastroenterologist. Accordingly, the evidence basis presented by the guidelines for diagnostic approaches as well as treatments is discussed. Lifestyle changes are emphasized as first-line therapy in both GER and GERD, whereas medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. Recent black box warnings from the US Food and Drug Administration are discussed, and caution is underlined when using promoters of gastric emptying and motility. Finally, attention is paid to increasing evidence of inappropriate prescriptions for proton pump inhibitors in the pediatric population.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

“…Therefore, gastroesophageal scintigraphy is not recommended in the routine evaluation of pediatric patients with GER symptoms or a lowerrisk BRUE. 97 Multiple intraluminal impedance (MII) is useful for detecting both acidic and nonacidic reflux, thereby providing a more detailed picture of esophageal events than pH monitoring. Combined pH/MII testing is evolving into the test of choice to detect temporal relationships between specific symptoms and the reflux of both acid and nonacid gastric contents.…”

Proton pump inhibitors: from CYP2C19 pharmacogenetics to precision medicine

“…Additionally, the guidelines do not recognize the involvement of pharmacogenetic factors in PPI metabolism. Similarly, the current North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) treatment guidelines support PPI dose increase for children with refractory GERD prior to esophageal pH testing [105]. Adopting a genotype-guided program for dosing of PPIs would allow clinicians to find individualized doses for patients and strike the balance between failed PPI therapy due to inadequate doses or adverse events as a result of empirical overprescribing approaches [106].…”

Review shows that parental reassurance and nutritional advice help to optimise the management of functional gastrointestinal disorders in infants

“…However, to provide proper parental education, we need to clarify the interaction between physiological changes during the maturation of the GI tract, the natural evolution of the specific disorder and the parental coping mechanisms. For example, contributory factors for reflux and regurgitation include feeding large amounts of liquid over a short period of time, a short intra‐abdominal oesophagus, an obtuse angle of His, feeding in horizontal position and the position of the infant after feeding 17.…”