Management of suspected gastroesophageal reflux in children

GI: gastroenterology; PPI: proton pump inhibitor; UGI: upper gastrointestinal; GERD: gastroesophageal reflux disease; H2RA: histamine type 2 receptor antagonist; EoE: eosinophilic esophagitis.
* Alarm symptoms suggesting a cause other than GERD include dysphagia, odynophagia, weight loss, hematemesis, or recurrent forceful vomiting.
¶ Lifestyle changes may include weight management for overweight patients; smoking cessation and avoidance of tobacco smoke; head of bed elevation; and avoidance of chocolate, caffeine, spicy foods, alcohol, and other foods that exacerbate symptoms.
Δ For the initial trial of acid suppression, we suggest a PPI. An H2RA is a reasonable alternative but is limited by the possibility of tachyphylaxis (loss of acid-suppressing effect), which may occur within a few days of beginning H2RA treatment. If an H2RA is used initially, therapy should be advanced to a PPI if there is no improvement or partial improvement during a 2- to 4-week trial or if long-term treatment is needed.
◊ The main causes of esophagitis in children are GERD or EoE. For evaluation and management, refer to UpToDate algorithm on esophagitis in infants and children and UpToDate topics on GERD and EoE.