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DOI: 10.1542/Peds.2013-0421 ; Originally Published Online April 29

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DOI: 10.1542/Peds.2013-0421 ; Originally Published Online April 29 Gastroesophageal Reflux: Management Guidance for the Pediatrician Jenifer R. Lightdale, David A. Gremse and SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION Pediatrics 2013;131;e1684; originally published online April 29, 2013; DOI: 10.1542/peds.2013-0421 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/131/5/e1684.full.html PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from pediatrics.aappublications.org by guest on June 1, 2013 Guidance for the Clinician in Rendering Pediatric Care CLINICAL REPORT Gastroesophageal Reflux: Management Guidance for the Pediatrician Jenifer R. Lightdale, MD, MPH, David A. Gremse, MD, and abstract SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND Recent comprehensive guidelines developed by the North American NUTRITION Society for Pediatric Gastroenterology, Hepatology, and Nutrition define KEY WORDS fl fl fl gastroesophageal re ux, gastroesophageal re ux disease, the common entities of gastroesophageal re ux (GER) as the physio- pediatrics, guidelines, review, global consensus, reflux-related logic passage of gastric contents into the esophagus and gastroesoph- disease, vomiting, regurgitation, rumination, extraesophageal ageal reflux disease (GERD) as reflux associated with troublesome symptoms, Barrett esophagus, proton pump inhibitors, diagnostic imaging, impedance monitoring, gastrointestinal symptoms or complications. The ability to distinguish between GER endoscopy, lifestyle changes and GERD is increasingly important to implement best practices in ABBREVIATIONS the management of acid reflux in patients across all pediatric age GER—gastroesophageal reflux groups, as children with GERD may benefit from further evaluation GERD—gastroesophageal reflux disease and treatment, whereas conservative recommendations are the only GI—gastrointestinal — fl H2RA histamine-2 receptor antagonist indicated therapy in those with uncomplicated physiologic re ux. This MII—multiple intraluminal impedance clinical report endorses the rigorously developed, well-referenced PPI—proton pump inhibitor North American Society for Pediatric Gastroenterology, Hepatology, This document is copyrighted and is property of the American and Nutrition guidelines and likewise emphasizes important concepts Academy of Pediatrics and its Board of Directors. All authors fi fl for the general pediatrician. A key issue is distinguishing between clin- have led con ict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through ical manifestations of GER and GERD in term infants, children, and ado- a process approved by the Board of Directors. The American lescents to identify patients who can be managed with conservative Academy of Pediatrics has neither solicited nor accepted any treatment by the pediatrician and to refer patients who require con- commercial involvement in the development of the content of this publication. sultation with the gastroenterologist. Accordingly, the evidence basis The guidance in this report does not indicate an exclusive presented by the guidelines for diagnostic approaches as well as treat- course of treatment or serve as a standard of medical care. ments is discussed. Lifestyle changes are emphasized as first-line ther- Variations, taking into account individual circumstances, may be apy in both GER and GERD, whereas medications are explicitly indicated appropriate. only for patients with GERD. Surgical therapies are reserved for chil- dren 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, atten- tion is paid to increasing evidence of inappropriate prescriptions for proton pump inhibitors in the pediatric population. Pediatrics 2013;131:e1684–e1695 www.pediatrics.org/cgi/doi/10.1542/peds.2013-0421 INTRODUCTION doi:10.1542/peds.2013-0421 fl All clinical reports from the American Academy of Pediatrics Gastroesophageal re ux (GER) occurs in more than two-thirds of automatically expire 5 years after publication unless reaffirmed, otherwise healthy infants and is the topic of discussion with pedia- revised, or retired at or before that time. tricians at one-quarter of all routine 6-month infant visits.1,2 In addition PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). to seeking guidance from their pediatricians, parents often request Copyright © 2013 by the American Academy of Pediatrics evaluation by pediatric medical subspecialists.3 It is, therefore, not surprising that strongly evidence-based guidelines incorporating e1684 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org by guest on June 1, 2013 FROM THE AMERICAN ACADEMY OF PEDIATRICS state-of-the-art approaches to the contents via a coordinated autonomic rarely Barrett esophagus and adeno- evaluation and management of pedi- and voluntary motor response. Re- carcinoma. atric GER have been welcomed by both gurgitation and vomiting can be fur- Although the reported prevalence of general pediatricians and pediatric ther differentiated from rumination, in GERD in patients of all ages world- medical subspecialists and surgical which recently ingested food is ef- wide is increasing,5 GERD is never- specialists. GER, defined as the passage fortlessly regurgitated into the mouth, theless far less common than GER. of gastric contents into the esophagus, masticated, and reswallowed. Rumi- Population-based studies suggest is distinguished from gastroesophageal nation syndrome has been identified reflux disorders are not as common reflux disease (GERD), which includes as a relatively rare clinical entity that in Eastern Asia, where the prevalence troublesome symptoms or complica- involves the voluntary contraction of is 8.5%,19 compared with Western tions associated with GER.4 Differen- abdominal muscles.9 In contrast, both Europe and North America, where the tiating between GER and GERD lies at regurgitation and vomiting can be current prevalence of GERD is esti- the crux of the guidelines jointly de- considered common and often non- mated to be 10% to 20%.20 New epi- veloped by the North American Soci- pathologic manifestations of GER. demiologic and genetic evidence ety for Pediatric Gastroenterology, Symptoms or conditions associated suggests some heritability of GERD Hepatology, and Nutrition and the with GERD are classified by the prac- and its complications, including ero- European Society for Pediatric Gas- tice guidelines as being either sive esophagitis, Barrett esophagus, – troenterology, Hepatology, and Nutri- esophageal or extraesophageal.4 Both and esophageal adenocarcinoma.21 23 tion.4 These definitions have further classifications can be used to define A few pediatric populations at high been recognized as representing a the disease, which can be further risk of GERD have also been identi- 5 fi global consensus. Therefore, it is characterized by findings of mucosal ed, including children with neuro- important that all practitioners who injury on upper endoscopy. Esopha- logic impairment, certain genetic fl 24,25 treat children with re ux-related dis- geal conditions include vomiting, poor disorders, and esophageal atresia orders are able to identify and dis- weight gain, dysphagia, abdominal (Table 1). The prevalence of severe, tinguish those children with GERD, or substernal/retrosternal pain, and chronic GERD is much higher in pe- fi “ who may bene t from further eval- esophagitis. Extraesophageal con- diatric patients with these GERD- ” uation and treatment, from those ditions have been subclassified promoting conditions. These patients maybemorepronetoexperienc- with simple GER, in whom conser- according to both established and ing complications of severe GERD vative recommendations are more proposed associations; established than patients who are otherwise appropriate. extraesophageal manifestations of GERD healthy.26 GER is considered a normal physio- can include respiratory symptoms, in- logic process that occurs several cluding cough and laryngitis, as well Population trends hypothesized to times a day in healthy infants, children, as wheezing in infancy.10,11 Although contribute to a general increase in and adults. GER is generally associated older studies from the 1990s sug- the prevalence of GERD include glo- with transient relaxations of the lower gested that GERD may aggravate bal epidemics of both obesity and esophageal sphincter independent of asthma, recent publications have asthma. In some instances, GERD can swallowing, which permits gastric suggested that the impact of GERD on be implicated as either the underlying contents to enter the esophagus. Epi- asthma control is considerably less etiology (ie, recurrent pneumonia in sodes of GER in healthy adults tend to than previously thought.10,12–18 Other occur after meals, last less than 3 extraesophageal manifestations in- TABLE 1 Pediatric Populations at High Risk minutes, and cause few or no symp- clude dental
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