Full text: NASPGHAN Pediatric Gastroesophageal Reflux Clinical Practice Guidelines (R Rosen et al. JPGN 2018; 66: 516-54)

This is a lengthy report with ~50 recommendations/302 references –many with several subrecommendations. I will highlight a few below. Tables 2 defines “red flags” that suggest the need for additional diagnostic tests and Table 3 provides a lengthy differential diagnosis (=everything).

R Rosen et al. JPGN 2018; 66: 516-54

The article reviews several frequent clinical diagnostic/management issues and provides two algorithms with suggested evaluation/treatment for infants and older children.  The older child algorithm (algorithm 2) suggests referral to GI if not improved with acid suppression or unable to wean after course of treatment.  For pediatric GI physicians, this algorithm suggests use of endoscopy if persistent symptoms on PPI or inability to stop PPI; pH-MII or pH-metry recommended if normal-appearing endoscopy.

Key point:

• For infants: “if excessive irritability and pain is the single manifestation, it is unlikely to be related to GERD.”

Some of the Recommendations -My Top Ten:

• 3.5 We suggest not to use esophago-gastro-duodenoscopy to diagnose GERD in infants and children.
• 3.13 We suggest not to use a trial of PPIs as a diagnostic test for GERD in infants.
• 3.14 We suggest a 4 to 8 week trial of PPIs for typical symptoms (heartburn, retrosternal or epigastric pain) in children as a diagnostic test for GERD
• 3.15 We suggest not to use a trial of PPIs as a diagnostic test for GERD in patients presenting with extraesophageal symptoms.
• 5.1 We suggest not to use antacids/alginates for chronic treatment of infants and children with GERD.
• 5.4 We recommend not to use H2RA or PPI for the treatment of crying/distress in otherwise healthy infants.
• 5.5 We recommend not to use H2RA or PPI for the treatment of visible regurgitation in otherwise healthy infants
• 5.7 We suggest not to use H2RAs or PPIs in patients with extraesophageal symptoms (ie, cough, wheezing, asthma), except in the presence of typical GERD symptoms and/or diagnostic testing suggestive of GERD.
• 5.10 We suggest to consider the use of baclofen prior to surgery in children in whom other pharmacological treatments have failed.
• 6.4 We suggest to consider the use of transpyloric/jejunal feedings in the treatment of infants and children with GERD refractory to optimal treatment as an alternative of fundoplication.

My take: This is an excellent updated summary of current best clinical practices for evaluation/management of pediatric GERD.

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• Esophageal Diseases Special
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• PPI Webinar NAPSPGHAN
• Treating reflux does not help asthma | gutsandgrowth
• Salivary Pepsin Doesn’t Pass Muster for Reflux
• Does Reflux Lead to Increased Aspiration Pneumonia? | gutsandgrowth
• How Likely is Reflux in Infants with “Reflux-like … – gutsandgrowth
• No Effect of Proton Pump Inhibitors and Irritability on … – gutsandgrowth
• Even the Experts Agree: pH-MII is a “Flawed Test” | gutsandgrowth
• Why didn’t patient with documented reflux get better with PPI?
• Gastroesophageal Reflux: I know it when I see it | gutsandgrowth

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

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