This transcript has been edited for clarity.
Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders. This is a video recap of our recent podcast, Stomachs in (re)Flux: Pediatric Gastroesophageal Reflux Disease.
Christopher J. Chiu, MD: We talked about pediatric gastroesophageal reflux disease (GERD) with Dr Carlo Di Lorenzo of Nationwide Children's Hospital in Columbus, Ohio, at the recent American Association of Pediatrics Experience National Conference and Exhibition.
Berk: Can we start with the right nomenclature for reflux in children?
Chiu: The word reflux on its own refers to gastroesophageal reflux. We are most worried about reflux when it becomes a disease. How do we decide whether it's a disease? We look at the child's symptoms. Are the symptoms bothersome? By that, we mean behaviors such as excessive crying and irritability that are worse than the child's baseline behavior. Then we start thinking that this is a disease that must be treated. In contrast, ordinary spitting up isn't considered a disease. It doesn't typically irritate the child, although it might irritate the parents.
Berk: What symptoms suggest that this is GERD? What are the red flags?
Chiu: Vomiting blood or coffee ground emesis, delayed symptom onset (symptoms arising after a couple of asymptomatic months), or symptoms that last longer than 12 months of age are red flags, and you should think about referring the child to pediatric gastroenterology.
Berk: Let's say we have a patient with reflux who is not gaining weight appropriately and seems irritable and colicky. We suspect GERD. When do we consider treating GERD?
Chiu: Before we start thinking about medicines, we should think about dietary changes. The evidence and the guidelines indicate that diet is the first-line management of GERD. Thickened feeds should be tried before medication is prescribed. Dr Di Lorenzo uses 1 tsp of rice or oat cereal per 1 oz of formula or breast milk. He noted that some people recommend adding 1 tbsp of cereal per 1 oz, but he feels that makes it too thick for the child to ingest. He mentioned a product called Gelmix, which seems to work a little better than rice cereal.
Berk: Let's say we aren't seeing improvement with thickened feedings. What's next?
Chiu: There is one more dietary change to try. Feeding a partially hydrolyzed formula might be the next step because it can be difficult to tell whether the child's symptoms are caused by GERD or a dietary protein allergy. By changing to a partially hydrolyzed formula, you might be able to get some improvement of the symptoms, suggesting that it's a dietary protein allergy. A protein allergy can cause inflammation, so it may take several weeks for that symptom to resolve. Dr Di Lorenzo recommends trying this before starting a medicine for reflux.
Berk: That makes a lot of sense. Give it a try and see if the inflammation calms down. But let's say we're ready to pull the trigger and consider some acid suppression. What should we reach for?
Chiu: If you have tried dietary changes without improvement, you might think about referring to a pediatric gastroenterologist at this point. It may depend on where you're located. If it's easy to get to a specialist, you should consider sending the patient there before starting medications.
But if you want to take a couple of months to try to get the patient feeling better, you can consider acid suppression medication. Dr Di Lorenzo said that he used to use ranitidine, but it's no longer available. So now, he uses famotidine because it's a liquid formulation and easy to take. He prescribes 0.5 mg/kg given twice daily. If he wants to prescribe something stronger, he'll use a protein pump inhibitor which is useful for short term management of GERD. It's dosed once daily and given 30-60 minutes before a meal.
Berk: What are the other take-home points from this episode?
Chiu: If you've already started the child on a medication, but the child hasn't improved by age 12 months or the child has late-onset GERD, consider sending them to a pediatric gastroenterologist. This specialist may perform an esophagogastroduodenoscopy or impedance testing and evaluate the patient for treatments such as Nissen fundoplication.
Other main take-home points:
First-line treatment for reflux is thickened feedings.
Feeding a partially hydrolyzed formula should be tried before starting medication.
Spitting up isn't always GERD. We may need to counsel parents about reasonable expectations.
Berk: Thank you for joining us for another Medscape video recap of The Cribsiders pediatric podcast. If you want to listen to the full episode or check out some of our other episodes, you can download them at any podcast player or on our website, www.thecribsiders.com.
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Cite this: Justin L. Berk, Christopher J. Chiu. GERD: When 'Spitting Up' Is Serious - Medscape - Apr 17, 2023.
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