Changes in Pediatric GI Reflux Guidelines

Columbus, OH — April 2018

While reflux-related complaints are heard often by pediatric gastroenterologists and primary care physicians, it can be difficult to tell when gastroesophageal reflux (GER) crosses the line into gastroesophageal reflux disease (GERD) – or how that disease should be treated in light of emerging research.

So a joint committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has updated its reflux clinical practice guidelines for the first time since 2009.

Providers will find that among other changes, the recent publication places particular emphasis on reducing the use of acid suppressive medication, says Carlo Di Lorenzo, MD, an author of the guidelines and chief of the Division of Gastroenterology at Nationwide Children’s Hospital. Dr. Di Lorenzo is one of three authors who also wrote the 2009 guidelines.

“Parents are understandably concerned when infants spit-up or when children have troublesome symptoms that may be related to reflux, but we need to make sure we are correctly diagnosing the underlying issues and only using treatments that are likely to be effective,” says Dr. Di Lorenzo, who is also a professor of Clinical Pediatrics at The Ohio State University College of Medicine.

The guidelines include 49 separate recommendations, from the correct definition of GERD to the proper use of the rare total esophagogastric disconnection (the authors suggest only considering it as a rescue procedure for neurologically impaired children with a failed fundoplication).

The authors note four main ways in which the new publication diverges from the 2009 guidelines:

  • In an effort to reduce acid suppressive medication use, it recommends acid suppression courses of only 4 to 8 weeks for children with typical symptoms of GERD, then an assessment of efficacy (and an investigation into alternative causes of the symptoms if the treatment fails)
  • It recommends that in infants, a change to protein hydrolysate or amino acid-based formula should occur before attempting acid suppression
  • It includes a diagnostic algorithm for children with typical symptoms of GERD
  • It suggests not immediately attributing respiratory and laryngeal symptoms to gastroesophageal reflux

The new guidelines also include a number of practical tools that may be especially helpful for primary care physicians, including a table of symptoms and signs that may indicate GERD; “red flags” that may suggest disorders other than GERD; a differential diagnosis for GERD; typical dosages of drugs often used to treat GERD; and a diagnostic algorithm to be used with infants.

“In some cases, the best course of action would be referral to a pediatric subspecialist, but that’s not always possible,” says Dr. Di Lorenzo. “We hope these new guidelines can help bring pediatricians up-to-date on the preferred ways of diagnosing and treating GERD.”   

Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition.  2018 Jan 25. [Epub ahead of print]