Spitting up is a normal occurrence for young infants — as long as a child is growing well and not developing other problems, such as breathing difficulties, the problem will resolve on its own without treatment. But how can you determine if your patient has gastroesophageal reflux disease (GERD)? New expert guidelines draw on the latest research findings to help advise specialists and primary care providers on the evaluation and treatment of GERD in infants and children.
“Over the last 10 years, there has been an explosion of advances not only in our understanding the pathophysiology of reflux, but also in the diagnostic tests to evaluate reflux and problems that masquerade as reflux,” she explains. “In prior guidelines, the focus was on acid-related disease and treatment with acid suppression. We now know that gastroesophageal reflux, particularly in infants and young children, is often non-acidic, so treating patients with acid suppression is ineffective. This is a true paradigm shift.” Here, Rosen shares some highlights that every pediatrician should know.
Watch for red flags. Children can present with a number of vague, non-specific symptoms that might be interpreted as GERD. However, it isn’t always clear whether such clinical manifestations are actually the result of this condition. To avoid overtreatment, Rosen and her coauthors recommend considering not just GERD in the differential diagnosis but also cow’s milk protein allergy, colic and even swallowing dysfunction.
Choose the right diagnostic tools. While most children are diagnosed with GERD based on history and physical exam alone, testing is warranted if symptoms are not typical (for example, respiratory symptoms), if symptoms do not respond to very short courses of acid suppression or if there are red flags in the history such as poor weight gain, metabolic abnormalities or systemic signs or symptoms. Many times the testing is not used to diagnose GERD but rather to exclude factors such as allergic disease or rumination.
Use PPIs wisely. Proton-pump inhibitors (PPIs) are effective in treating signs and symptoms related to acid reflux events but are ineffective in treating non-acid reflux. Rosen and her colleagues concluded that a 4- to 8-week course of PPIs or histamine 2 receptor agonists (H2RAs) might be warranted to treat heartburn, chest pain and other typical symptoms of GERD in children. They also recommend a short course of PPIs or H2RAs to treat erosive esophagitis related to reflux. However, clinicians should avoid prescribing these drugs for the treatment of coughing, wheezing or asthma unless these symptoms are accompanied by more typical symptoms or if there is evidence that acid reflux is triggering these respiratory symptoms. Because these medications can be associated with side effects including increased infection risk, the lowest dose possible should be used for the shortest length of time.
Consider non-pharmacologic approaches as first line therapy when possible. Non-drug treatments include as thickened feedings, changes to volume and frequency of feedings in infants, elimination of cow’s milk from maternal diets or from formula in infants, and counseling are recommended prior to starting medications. Rosen and her coauthors also recommend that clinicians provide patients and their families with educational support as part of the treatment of GERD.
“These guidelines highlight the importance of a close collaboration between pediatricians and gastroenterologists with the goal of only using acid suppression to treat patients with acid related disease,” says Rosen. “We hope that the guidelines will empower clinicians to reduce high-dose or long-duration empiric trials of acid suppression and to pursue earlier testing when symptoms are atypical or fail to respond to short courses of standard reflux therapies.”
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