Gastroesophageal reflux in children

Gastroesophageal reflux (GER) is the movement of stomach contents into the esophagus; gastroesophageal reflux disease (GERD) is troublesome symptoms and/or complications caused by GER. GER is common and often physiological in infants. It manifests with spitting up and/or regurgitation after feeding in otherwise healthy infants with normal weight gain and development and typically resolves by 12 months of age. Symptoms of GERD in infants include irritability, feeding difficulties, poor growth, dysphagia, and extraesophageal symptoms (e.g., respiratory symptoms, wheezing, cough). Additional clinical features in children and adolescents include epigastric, chest, and/or abdominal pain. Diagnosis is primarily clinical; diagnostic studies may be performed by a specialist to confirm the diagnosis and/or assess for an alternative diagnosis in atypical or refractory cases. Management involves lifestyle modifications (e.g., dietary modifications, upright position after meals), pharmacological treatment (e.g., proton pump inhibitors, H₂ receptor antagonists), and, rarely, surgery for refractory disease or complications.

For information on this disease in adults, see “Gastroesophageal reflux disease.”

• Prevalence of pediatric GER
  • Infants: daily occurrence in 40–50% of infants ^[1]
  • Children and adolescents: 2–8% ^[2]
• Prevalence of pediatric GERD ^[3]
  • Infants ^[3]
    • ∼ 25% in the first month of life
    • Decreases to ∼ 3% by 6 months of age
  • Children and adolescents: 10–25% ^[1][3]

The incidence of pediatric GERD is difficult to determine as symptoms vary widely and there is no standardized diagnostic approach. ^[3][4]

Epidemiological data refers to the US, unless otherwise specified.

Transient lower esophageal sphincter relaxation

GER is primarily caused by transient lower esophageal sphincter relaxation and movement of stomach contents into the esophagus due to: ^[2]

• Postprandial abdominal distention
• Increased intraesophageal pressure (e.g., due to large feeds, crying)
• Additional causes in infants ^[5]
  • Immaturity of the esophageal sphincter mechanism in the first 6 weeks of life
  • Supine positioning

Risk factors for pediatric GERD ^[1][2][4]

• In infants and young children
  • Preterm birth
  • Anatomical abnormalities (e.g., hiatal hernia, esophageal atresia, esophageal stenosis, tracheoesophageal fistula)
  • CNS conditions (e.g., neurodevelopmental disorders, seizure disorder)
  • Chronic respiratory conditions (e.g., asthma, cystic fibrosis, bronchopulmonary dysplasia)
  • Family history of GERD
  • Exposure to tobacco smoke
• In older children and adolescents: similar to risk factors for GERD in adults

Exclusive breast milk feeding is associated with a decreased risk of GERD in infants. ^[2]

GER in infants and children ^[2][4]

GER is often physiological, especially in infants. ^[4][6]

• Spitting up and/or regurgitation shortly after eating
• More pronounced with frequent and/or large-volume meals
• Normal physical examination findings and normal development (e.g., normal weight gain, no difficulty eating)
• Additional features in infants ^[2]
  • Age of onset: typically < 8 weeks
  • Symptoms typically resolve by 12 months of age
  • Back arching when feeding
  • Fussiness

GERD in infants and children ^[2][4]

GERD develops if GER causes troublesome symptoms and/or complications, e.g.:

• General
  • Growth faltering or weight loss
  • Irritability and crying
  • Sleep disturbance
• Gastrointestinal
  • Recurrent vomiting
  • Poor appetite and/or refusal to eat
  • Dysphagia
• Respiratory ^[2]
  • Wheezing, stridor, hoarseness, choking, cough
  • Recurrent aspiration pneumonia and/or otitis media
  • Apnea, brief resolved unexplained event (in infants)
• Sandifer syndrome: dystonic neck posturing (acquired torticollis) and opisthotonic arching of the spine associated with eating ^[6][7]
• Additional features in older children and adolescents
  • Heartburn, chest, epigastric, and/or abdominal pain ^[4]
  • Sour taste in mouth ^[1]
  • See also “Clinical features of GERD in adults.”

Approach ^[2][4]

GER and GERD are diagnosed clinically.

• Obtain a comprehensive medical history, including:
  • Age at symptom onset ^[4]
  • Feeding or eating history
  • Regurgitation patterns
  • Environmental and dietary triggers ^[2]
  • Risk factors for pediatric GERD
• No red flags of pediatric GERD
  • GER in infants: no further management; provide reassurance.
  • Pediatric GERD: Start empiric management for pediatric GERD.
• Refer to pediatric gastroenterology for diagnostic studies in case of:
  • Red flag features of pediatric GERD
  • Diagnostic uncertainty
  • Symptoms refractory to empiric management

Red flag features for pediatric GERD

The following features should prompt an evaluation for complications of GERD or an alternative cause of symptoms. ^[2][4]

• General
  • Fever
  • Lethargy
  • Excessive irritability
  • Weight loss
• Gastrointestinal
  • Vomiting that is forceful, bilious, or nocturnal
  • Gastrointestinal bleeding (hematemesis, hematochezia)
  • Chronic diarrhea
  • Abdominal distension, tenderness, mass
  • Additional features in infants:
    • Symptom onset after 6 months of age
    • Persistence of symptoms beyond 12 months of age
• CNS
  • Seizures
  • Macrocephaly, microcephaly
  • Signs of increased intracranial pressure, e.g.:
    • Rapidly increasing head circumference, bulging fontanelle in infants
    • Persistent morning headaches and vomiting in older children

Patients with symptoms of gastric outlet obstruction need immediate evaluation. ^[8][9]

Diagnostics

Diagnostic studies are not routinely recommended to diagnose GERD in infants and children but may be obtained by a specialist. ^[4]

• Confirmatory studies
  • Esophagogastroduodenoscopy (EGD) with or without biopsy to assess for: ^[2][4]
    • Esophageal injury and/or inflammation
    • Complications of GERD
    • Alternative causes for symptoms
  • Esophageal pH monitoring in patients: ^[2][4]
    • With normal EGD findings
    • Persistent symptoms on acid suppression therapy
• Studies to exclude differential diagnoses of pediatric GERD, e.g.: ^[2]
  • Abdominal ultrasound to assess for hypertrophic pyloric stenosis
  • Upper GI series with fluoroscopy to assess for anatomical abnormalities ^[5]

• Gastrointestinal conditions
  • Infections
    • Infectious gastroenteritis in children
    • Hepatitis
  • Esophageal causes
    • Eosinophilic esophagitis
    • Achalasia
  • Bowel obstruction, e.g., due to
    • Hypertrophic pyloric stenosis
    • Midgut volvulus and intestinal malrotation
    • Intussusception
    • Foreign body ingestion
  • Pediatric inflammatory bowel disease
  • Functional causes
    • Cyclical vomiting syndrome
    • Functional dyspepsia
  • Other causes in infants
    • Infantile colic ^[2]
    • Food protein-induced enterocolitis syndrome
    • Cow's milk allergy
• Respiratory conditions
  • Asthma
  • Pneumonia
• Neurological conditions
  • Increased intracranial pressure (e.g., due to intracranial tumors, hemorrhage, or hydrocephalus)
  • Meningitis
• Renal conditions
  • Renal insufficiency
  • Obstructive uropathy
• Metabolic conditions (e.g., galactosemia, urea cycle defects)
• Others
  • Sepsis
  • Heart failure
• In older children and adolescents, see also “Differential diagnosis of GERD in adults.”

The differential diagnoses listed here are not exhaustive.

General principles ^[2][4]

• GER in infants is self-limited.
• Empiric management of pediatric GERD includes:
  • Age-appropriate nonpharmacological measures in all patients
  • Trial of acid suppression therapy if symptoms persist despite nonpharmacological therapy
• Refractory symptoms require further evaluation by a pediatric gastroenterologist.
• Surgery (i.e., fundoplication) may be considered for patients with any of the following: ^[2][4]
  • Symptoms or complications refractory to pharmacological therapy
  • Need for chronic pharmacological therapy to manage symptoms
  • Comorbidities that increase the risk for complications from GERD (e.g., cystic fibrosis)

Infants ^[2][4]

GER in infants

• Reassure caretakers that GER in infants is benign and self-limited.
• Consider nonpharmacological measures as for GERD in infants.

PPIs and H₂ receptor blockers are not recommended for infants with GER without symptoms of GERD as they are ineffective and can cause significant adverse effects. ^[4][10]

GERD in infants

• Encourage breastfeeding. ^[2]
• Advise caregivers to: ; ^[2][4]
  • Avoid overfeeding; educate caregivers on infant hunger cues and signs of infant satiety. ^[11]
  • Reduce feeding volume and increase feeding frequency.
  • Keep infant upright for 20–30 minutes after feeding.
  • Avoid exposure to tobacco smoke.
• Consider dietary modifications.
  • Breastfed infants: Eliminate wheat, soy, and egg from maternal diet. ^[2]
  • Formula-fed infants: Add thickening agents (e.g., rice cereal) to formula or use an antireflux formula.
• Persistent symptoms or suspected cow milk protein allergy ; ^[4]
  • Breastfed infants: Eliminate all dairy (including casein and whey) from maternal diet for 2–4 weeks.
  • Formula-fed infants
    • Avoid all dairy.
    • Consider a 2–4-week trial of extensively hydrolyzed or amino acid-based formula. ^[2]
• Symptoms improve after eliminating dairy: Continue dietary modifications; discuss milk protein reintroduction.
• Refractory symptoms or symptoms persisting beyond 12 months of age
  • Refer to pediatric gastroenterology for further evaluation and management.
  • Consider a trial of acid suppression therapy (off-label) for 4–8 weeks in infants with typical symptoms of GERD while awaiting referral.
    • PPIs (preferred): e.g., omeprazole, esomeprazole
    • H₂ receptor blockers: e.g., famotidine, cimetidine

Older children and adolescents ^[2][4]

Nonpharmacological management

Start nonpharmacological management for 2–4 weeks in all patients with typical symptoms of pediatric GERD. ^[4]

• Recommend lifestyle changes for weight loss (e.g., diet and exercise) for children with overweight or obesity.
• Avoid triggers (e.g., tobacco smoke, caffeine, alcohol). ^[1]
• Advise patients to:
  • Avoid eating within 2 hours of bedtime
  • Elevate head while sleeping and sleep in a lateral decubitus position ^[2][4]

Pharmacological management

If symptoms persist on nonpharmacological management, consider a trial of acid suppression therapy for 4–8 weeks. Wean from medication if symptoms improve; refer to pediatric gastroenterology if symptoms persist. ^[4]

• PPIs (preferred), e.g.: ^[4][12][13]
  • Lansoprazole ^[4]
  • Omeprazole
  • Esomeprazole ^[4]
• H₂ receptor blockers (if PPIs are unavailable or contraindicated), e.g.: ^[4]
  • Famotidine
  • Cimetidine (off-label in children < 12 years) ^[4]
  • Nizatidine (off-label in children < 12 years) ^[4]
• Short-term use of antacids (e.g., magnesium alginate plus simethicone) may be considered for symptomatic relief in adolescents. ^[4]
• Prokinetic therapy (e.g., erythromycin, baclofen) may be used in consultation with a specialist if other treatments have been unsuccessful.

• Complications of GERD in children are similar to complications of GERD in adults, although Barrett esophagus is rare in children. ^[4][6]
• Certain comorbidities (e.g., neurological impairment, cystic fibrosis, hiatal hernia) increase the risk for complications. ^[6]

We list the most important complications. The selection is not exhaustive.