Treatment for pediatric GERD depends on the severity of the condition. Doctors will almost always advise parents, children, and teens to start with simple lifestyle changes. For example:. These medications include:. You may want to focus on helping your child make lifestyle modifications. You may also want your child to try herbal remedies.
Some parents feel that herbal remedies may be helpful, but the effectiveness of remedies is unproven and the long-term consequences for children taking them are unknown. Doctors rarely consider surgery as a treatment for pediatric GERD.
Gastroesophageal reflux disease GERD is a chronic condition that affects the digestive system. While most people have heartburn or indigestion from…. Acid reflux can lead to a sore throat. Learn how to treat acid reflux to prevent more damaging complications. The terms heartburn, acid reflux, and GERD are often used interchangeably.
They actually have very different meanings. Water brash is a symptom of GERD. Learn about acid brash and other symptoms of GERD, what causes acid reflux, and how to treat it.
For Patients. Contact the Aerodigestive Center How is GERD in children diagnosed? Endoscopy : This procedure involves the use of a thin and lighted tube placed through the nose or mouth into the esophagus to "see" inside the esophagus. Upper GI gastrointestinal endoscopy : In this test, a flexible tube is placed from the mouth into the stomach.
This allows visualization and sampling biopsies of the different organs to see if there is underlying inflammation or a reason for the GERD symptoms.
Lying down or bending over after a meal can also lead to heartburn. Children younger than age 12 will often have different GERD symptoms. They will have a dry cough, asthma symptoms, or trouble swallowing. GERD symptoms may seem like other health problems.
Make sure your child sees his or her healthcare provider for a diagnosis. Your child's healthcare provider will do a physical exam and take a health history. Other tests may include:. It will also depend on how severe the condition is. In many cases, diet and lifestyle changes can help to ease GERD. Here are some tips to better manage GERD symptoms.
Your child's provider may prescribe medicines to help with reflux. There are medicines that help reduce the amount of acid the stomach makes. This reduces the heartburn linked to reflux. These medicines may include:. The provider may prescribe another type of medicine that helps the stomach empty faster. Calorie supplements. If this is the case, your child's healthcare provider may suggest:.
Tube feedings. In some cases tube feedings may be recommended. Some babies with reflux have other conditions that make them tired. These include congenital heart disease or being born too early premature. These babies often get sleepy after they eat or drink a little. Other babies vomit after having a normal amount of formula. These babies do better if they are constantly fed a small amount of milk.
In both of these cases, tube feedings may be suggested. Formula or breastmilk is given through a tube that is placed in the nose. This is called a nasogastric tube. The tube is then put through the food pipe or esophagus, and into the stomach.
Your baby can have a tube feeding in addition to a bottle feeding. Or a tube feeding may be done instead of a bottle feeding. There are also tubes that can be used to go around, or bypass, the stomach. These are called nasoduodenal tubes. In severe cases of reflux, surgery called fundoplication may be done. This is often done as a laparoscopic surgery.
This method has less pain and a faster recovery time. A small tube with a camera on the end is placed into one of the incisions to look inside. The surgical tools are put through the other incisions. Functional heartburn occurs in patients with esophageal symptoms heartburn or chest pain who also lack the objective evidence of reflux and who do not have evidence that symptoms are triggered by reflux episodes.
Excessive body weight is associated with an increased prevalence of GERD. Distressed infants are a special group of patients. Many infants with overt GERD are distressed and cry a lot because not only esophagitis but also esophageal dilatation caused by reflux regurgitated milk , may cause discomfort and pain. Infants with GERD often present inconsolable crying and overt regurgitation or vomiting.
The role of occult GERD in children presenting with chronic respiratory symptoms needs further evaluation. The length of the esophagus in an infant is about 10 cm and can only contain about 5 ml of liquid. In other words, it is difficult to understand how a minimal volume of reflux that restricts itself to a couple of centimeters can cause so much distress and pain.
These techniques may investigate reflux for a very limited time and mainly during the postprandial period. An upper gastrointestinal GI barium contrast study is mainly helpful to detect GI malformations and it can be useful in the diagnosis of hiatal hernia, malrotation, pyloric stenosis, duodenal web, duodenal stenosis, antral web, esophageal narrowing, Schatzki's ring, achalasia, esophageal stricture, and esophageal extrinsic compression.
Persistent symptoms after anti-reflux surgery are another indication [ 7 , 8 ]. Ultrasonography is not indicated for GERD diagnosis as the results are clearly investigator-dependent. The correlation between esophageal wall thickness and esophagitis is also poor. Besides demonstrating tracer that refluxes into the esophagus, scintigraphy evaluates gastric emptying and may also show pulmonary aspiration [ 12 ]. Erosive esophagitis is defined as visible breaks in the esophageal mucosa.
There is no specific symptom of esophagitis. These findings indicate that a biopsy without the hallmarks of esophagitis or the absence of macroscopic lesions does not rule out the presence of GERD. Thus, there is insufficient evidence to support the use of endoscopy with or without biopsy for the diagnosis of GERD in infants and children.
However, endoscopy of the upper GI tract is useful to evaluate the mucosa in the presence of alarm symptoms or signs, such as hematemesis, dysphagia, or failure to thrive or anemia; to detect complications of GERD, such as erosive esophagitis, strictures, and Barrett's esophagus; or to diagnose conditions that might mimic GERD, such as eosinophilic esophagitis.
GERD may exist despite the normal endoscopic appearance of the esophageal mucosa and the absence of histological abnormalities. The correlation between esophagitis and acid exposure time on pH-monitoring is quite poor, particularly in infants. The area under the curve is a pH-metry parameter that considers the acidity of the reflux episodes and was shown to correlate with esophagitis but has lost appeal in recent years and is no longer reported in commercially-available pH-metry reports [ 16 ].
Biomarkers, such as salivary pepsin, have not been shown to be useful to diagnose GERD. Pepsin can be found in the mouth of almost one-third of control patients [ 17 ]. Moreover, no relation was found between salivary pepsin positivity, extra-esophageal symptoms, quality of life scores, or inflammation on bronchoscopy or esophagogastroduodenoscopy [ 21 ].
Middle ear fluid analysis showed no association between pepsin and reflux symptoms [ 23 ]. Bile salts, pepsin, and lipid-filled macrophages in BAL fluids have been studied to demonstrate gastric aspiration secondary to reflux as a cause of chronic respiratory disease but were not useful [ 18 , 21 , 24 , 25 ].
When pulmonary aspiration is obvious, the biomarkers are positive. Also, when GERD is obvious because of the presence of classic symptoms, such as vomiting, these biomarkers are positive. However, they are not helpful in other patient groups and cannot be recommended for children with chronic respiratory diseases without GERD symptoms.
The reason for this might simply be that chronic respiratory disease caused by GERD is seldom in the absence of GER symptoms in neurologically-normal children. Manometry or motility studies do, of course, not measure reflux, but may be useful by demonstrating the etiology of GERD. High-resolution esophageal manometry may be helpful to diagnose rumination syndrome [ 26 , 27 ].
High-resolution manometry can also highlight esophageal motility disorders in those who present with symptoms similar to GERD. Since none of the trials in infants showed a better symptom reduction than placebo, regardless of the duration of the trial, the administration of PPIs cannot be recommended for infants as a diagnostic test [ 28 ]. The best improvement of symptoms in children occurs during the first 2 to 4 weeks [ 29 , 30 , 31 , 32 ].
According to data in adults with typical symptoms, 1 week of PPI is sufficient to observe a significant response.
Continuous esophageal pH monitoring was developed in the s and for a long time was regarded as the best technique to measure reflux since it was the only technique available to measure GER outside the postprandial period. More recently, wireless pH recording has been proposed as an alternative to pH probe monitoring. The capsule is clipped to the esophageal mucosa and is supposed to drop off after 48 hours, although up to 5 days of recording has been reported.
Pediatric studies have shown that the wireless pH recording results were comparable to the pH probe studies in patients who had both techniques performed simultaneously [ 33 ]. Outside the USA, this capsule is hardly used, although it certainly might be helpful in patients with behavioral disorders. Of course, impedance cannot be recorded with this device. Oropharyngeal monitoring is not recommended as most studies failed to show that the technique was appropriate.
Indeed, MII in combination with pH-metry allows the detection of both acid and non-acid reflux. Since MII is expensive, the technique is only available in a limited number of centers. The analysis of an MII is time-consuming and requires experience. The determination of a normal value range is difficult to obtain since it is not ethically acceptable to perform such a technique in healthy asymptomatic infants and children. Reference values in different age groups have been recently proposed and cut-off values for symptom association indices have also been proposed.
However, data for true asymptomatic, presumably healthy children are not available. The indications to perform pH-MII are: 1 to measure the efficacy of acid suppression medication; 2 to differentiate NERD, hypersensitive esophagus, and functional heartburn in patients with normal endoscopies and histology; 3 to correlate persistent troublesome symptoms with acid and non-acid GER events; and 4 to establish the role of acid and non-acid reflux in the etiology of esophagitis and other signs and symptoms suggestive of GERD.
Patient education, specific methods to prevent or treat symptoms, and patient empowerment have been shown to decrease parental and patient anxiety. Management should always start with parental support. Despite the possible benefits of positioning in the management of GER, only supine positions can be recommended for infants because the risk of sudden infant death syndrome SIDS is associated with all other sleeping positions.
Because elevating the head of an infant's crib while the infant is supine may result in the infant rolling to the foot of the crib into a position that may comprise respiration, elevating the head of the crib is not recommended by the AAP [ 36 ].
An anti-regurgitation AR bed was developed and is available in some European countries. However, limited data hamper a global recommendation.
There is no evidence that reduced feeding volume, more frequent feedings, or extensively hydrolyzed or amino-acid based formula is effective for the treatment of infants presenting with troublesome GER symptoms. However, there is a consensus that overfeeding is a risk factor for GER and regurgitation.
Although the overall quality of studies is low to very low, there is a consensus that thickened formula reduces regurgitation. There is no evidence to suggest that 1 thickening agent is more effective than another [ 37 ]. The impact of thickened formula on non-regurgitation symptoms is not clear.
Safety concerns regarding rice cereals were raised because of high levels of inorganic arsenic, which may cause neurotoxicity and long-term cancer risk. Despite an Food and Drug Administration warning, rice cereal does have some advantages over other cereals, including its ability to dissolve easily, its low cost, and it has been used for a long time.
Bean gum has the advantage of adding no calories. It is important to realize that breast milk cannot be used to thicken with cereal because of the amylases present.
Troublesome regurgitation and GERD are almost never a good reason to stop breastfeeding. Commercially-prepared thickened formula is preferred over adding thickeners to formula because the effect of the thickener on the composition of the formula has been taken into account in commercially-prepared formula. Most of the infant formula companies have developed AR and Comfort formula.
While the first is positioned to reduce regurgitation in the "happy spitter", the second is positioned in the management of the infant presenting with regurgitation and distress. These comfort formulas are thickened, often the proteins are partially hydrolyzed, and lactose is reduced. In some infants, the differential diagnosis between troublesome GER-symptoms, GERD, and cow's milk protein allergy may be hard to make.
Extensively hydrolyzed formula reduces GER-symptoms in cases where the symptoms are due to an allergy or delayed gastric emptying. A thickened extensive hydrolysate will be effective, independent of the cause of the symptoms, but does not make a precise diagnosis.
Limited data suggest that Lactobacillus reuteri DSM given as drops daily may be effective in reducing episodes of regurgitation, and may prevent future episodes [ 2 ].
Obese children are at increased risk of developing GER symptoms [ 38 , 39 ]. There is insufficient evidence to recommend lifestyle modifications, such as avoidance of alcohol and tobacco, massage therapy, complementary therapy hypnotherapy, homeopathy, acupuncture, and herbal medicine , and specific dietary modifications for the reduction of GERD symptoms. Alginates are reported to reduce reflux symptoms and the number of episodes of regurgitation and vomiting [ 40 , 41 ].
Alginates were also shown to reduce the number of reflux episodes measured by pH-MII [ 42 ].
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