Pediatric Reflux

Aka: Pediatric Reflux, Pediatric GERD, Pediatric Gastroesophageal Reflux, Infantile Gastroesophageal Reflux, Infant Reflux, Spitting Up, Infant Spitting Up, Acid Reflux in Children

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II. Epidemiology

  1. Regurgitation is common for infants
    1. Peak age: 4 months old
      1. Onset may occur before 8 weeks of age
      2. Regurgitation in 40% of infants with most feedings
      3. Spitting Up more than 4 times per day occurs in 25% of infants
    2. Resolution by age 10 to 14 months
      1. Persists in 5% of infants
  2. Pediatric Reflux persists in some children
    1. Ages 3-9 years old: 2-7% Prevalence
    2. Prevalence gradually declines until age 12 years, then peaks again after age 16 years old

III. Precautions

  1. Empiric prophylaxis of Preterm Infants may not be warranted
    1. Antireflux medications evaluated in very Low Birth Weight Infants
    2. Not associated with a difference in growth or neurodevelopment
    3. Malcolm (2008) Pediatrics 121(1): 22-7 [PubMed]
  2. Mild physiologic Gastroesophageal Reflux (spitting-up) is an expected condition
    1. Best treated conservatively (e.g. upright for feeds)
    2. No evidence for significant cardiopulmonary complications
      1. No increased risk of chronic lung disease, recurrent aspiration
  3. Gastroesophageal Reflux disease is more severe than physiologic spitting-up
    1. Associated with complications such as respiratory symptoms and growth restriction

IV. Pathophysiology: Mechanism

  1. Postprandial gastric distention associated with Delayed Gastric Emptying
    1. Exacerbated by large volume feedings
  2. Transient reflexive Lower Esophageal Sphincter (LES) relaxation (response to increased pressure)
    1. Exacerbated by factors that increase gastric pressure (e.g. crying)

V. Risk Factors

  1. Prematurity
  2. Esophageal disorders
    1. Esophageal atresia with repair
    2. Transesophageal fistula
    3. Congenital Hiatal Hernia
  3. Cardiopulmonary disease
    1. Bronchopulmonary Dysplasia
    2. Asthma
    3. Chronic Cough
    4. Cystic Fibrosis
    5. Congenital Heart Disease
  4. Neurodevelopmental disorders
    1. Cerebral Palsy or Developmental Disability
    2. Down Syndrome
    3. Seizure Disorder
  5. Medications
    1. Theophylline
    2. Caffeine
    3. Albuterol
    4. Passive Smoke Exposure

VI. Findings: Reflux

  1. Precipitating factors
    1. Frequent, large volume feedings
    2. Supine position
  2. Typical findings
    1. Effortless Spitting Up 1-2 mouthfuls (under age 1)
    2. Irritability may be present, but typically asymptomatic
  3. Findings absent in simple reflux (differentiates from GERD)
    1. No significant gastrointestinal, respiratory or neurologic findings

VII. Findings: Symptoms and Signs

  1. Uncommon
    1. Hematemesis
    2. Poor growth or poor weight gain
    3. Anemia
    4. Esophageal Stricture
    5. Respiratory disease
      1. Recurrent Pneumonia
      2. Chronic Cough
      3. Wheezing or Stridor
      4. Apnea or Cyanosis
    6. Barrett's Esophagus
  2. Rare
    1. Protein loss
    2. Sandifer Syndrome
      1. Lateral Head Tilt with contralateral chin rotation
      2. Torticollis or neck tilting in infants
      3. Distinguish from Movement Disorders (refer for evaluation)

VIII. Findings: Gastroesophageal Reflux Disease (GERD)

  1. Approach
    1. Factors that distinguish simplex reflux from GERD
    2. These factors also prompt more thorough evaluation, closer monitoring and pharmacologic GERD management
  2. Constitutional
    1. Poor weight gain, weight loss or Failure to Thrive
  3. Gastrointestinal
    1. Feeding refusal (or prolonged feedings)
    2. Infant with postprandial irritability
    3. Dysphagia
    4. Recurrent Vomiting
  4. Cardiopulmonary
    1. Chest Pain or Epigastric Pain
    2. Asthma
    3. Chronic Cough, Wheezing, Stridor or Hoarseness
    4. Recurrent respiratory disease (e.g. Otitis Media, Aspiration Pneumonia)
    5. Brief Resolved Unexplained Event (BRUE, apnea, Cyanosis)
  5. Neurologic
    1. Dystonic neck Posture in infants (Sandifer Syndrome)

IX. Exam

  1. Growth measurements
    1. Plot height and weight on growth curve
    2. Evaluate for Failure to Thrive
  2. Head and Neck Exam
    1. Bulging Fontanelle
    2. Microcephaly
    3. Macrocephaly
  3. Lung Exam
    1. Wheezing
    2. Respiratory distress
  4. Abdominal exam
    1. Hepatosplenomegaly
    2. Abdominal Distention or tenderness
    3. Palpable abdominal mass
  5. Neurologic Exam
    1. Neurodevelopmental abnormalities

X. Differential Diagnosis: Common Alternative Causes

  1. Viral Gastroenteritis
  2. Cow's Milk Allergy
  3. Hiatal Hernia
  4. Infantile Colic
  5. Nongastrointestinal Infection
    1. Urinary Tract Infection
    2. Meningitis
    3. Pneumonia
    4. Sepsis
  6. Rumination Syndrome
    1. Recently swallowed food is regurgitated, chewed and re-swallowed

XI. Differential Diagnosis: Less common Alternative Causes

  1. Pyloric Stenosis
  2. Intestinal Atresia
  3. Intestinal Malrotation
  4. Hydrocephalus
  5. Achalasia
  6. Crohn Disease
  7. Eosinophilic Esophagitis
  8. Cyclic Vomiting Syndrome
  9. Electrolyte disturbance
    1. Renal Tubular Acidosis
    2. Hypocalcemia

XII. Precautions Red Flags suggestive of Alternative Diagnosis (Alarm Findings)

  1. Persistent or Recurrent Fever
  2. Gastrointestinal
    1. Bilious Vomiting (e.g. Intestinal Obstruction)
    2. Forceful Vomiting (e.g. Pyloric Stenosis)
    3. Vomiting onset after 6 months (or persists or increases at 12-18 months)
    4. Abdominal Pain, Abdominal Distention or palpable mass
    5. Hepatosplenomegaly
    6. Chronic Diarrhea
    7. Hematemesis or other Gastrointestinal Bleeding
  3. Neurologic
    1. Lethargy
    2. Bulging Fontanelle
    3. Seizures
    4. Developmental Delay
    5. Microcephaly or Macrocephaly
    6. Rapidly increasing Head Circumference (>1 cm/week, possible Increased Intracranial Pressure)

XIII. Diagnostic Tests

  1. Indications
    1. Not generally indicated in most cases
    2. Obtain in severe and refactory cases that fail empiric management or demonstrate alarm, red flags
  2. Endoscopy
    1. Most sensitive test for Barrett's Esophagus
    2. Can also identify gastric outlet obstruction
  3. pH Probe (24 hour)
    1. Gold standard for Reflux diagnosis (esp. multichannel intraluminal impedance testing)
    2. Variable Test Sensitivity (41-81%), invasive and expensive
    3. pH probe placed in distal Esophagus
    4. pH below 4.0 suggests reflux
      1. Abnormal if esophageal pH <4 for more than 7% of the time
    5. Specific indications only
      1. Correlate reflux with respiratory symptoms
  4. Barium Swallow (Upper GI)
    1. Poor sensitivity and Specificity for GERD
      1. Not recommended for GERD evaluation unless anatomic abnormalities are suspected
    2. Very good for identifying underlying anatomic conditions
      1. Hiatal Hernia
      2. Pyloric Stenosis
      3. Malrotation
      4. Esophageal Webs and strictures
      5. Tracheoesophageal fistula
      6. Achalasia
  5. Milk study
    1. Good to assess gastric emptying
    2. Fair for identifying Reflux
  6. Manometry
    1. Can assess lower esophageal sphincter and mechanisms of Swallowing
    2. Not recommended in GERD evaluation unless other indications (e.g. postoperative reflux surgery)
  7. Abdominal Ultrasound
    1. Evaluates Pyloric Stenosis
    2. May identify Hiatal Hernia

XIV. Management: Step 1 Conservative Management

  1. Indications
    1. Physiologic Reflux
    2. Normal weight gain
  2. Interventions in infants
    1. Smaller, more frequent feedings
    2. Thickened Feedings (most evidence)
      1. Avoid commercial thickeners due to risk of Necrotizing Enterocolitis
        1. Xantham gum (e.g. SimplyThick)
        2. Carob bean gum
        3. Pectin
      2. Rice cereal up to 1 tablespoon per ounce formula
        1. Rice cereal may cause excessive weight gain, Abdominal Pain and stool changes
        2. Arsenic contamination has been found in some rice cereal formulations
    3. Positioning
      1. Danny Sling
      2. Due to safe sleep guidelines to prevent SIDS, optimal position changes are not recommended
        1. GERD Is reduced when positioned prone, upright or lying on right side
        2. However prone and side sleeping are an increased SIDS risk
      3. Minimize seated position
        1. May worsen reflux
        2. Increases intra-abdominal pressure
    4. Consider trial of formula change to extensively hydrolyzed formula (if refractory to other conservative measures)
      1. Identifies Cow's Milk Allergy
      2. Trial of casein hydrolysate formula for 2-4 weeks
    5. Consider changes in maternal diet in Breast fed infants
      1. Dairy elimination (including casein and whey Protein avoidance)
      2. May also avoid other common triggers (wheat, soy, egg)
  3. Interventions in older children and adolescents
    1. See Gastroesophageal Reflux for lifestyle management
    2. Upright for 2-3 hours after eating
    3. Avoid Caffeine
    4. Elevate the head of the bed
    5. Target 64 ounces non-caffeinated fluid per day

XV. Management: Step 2 Evaluate for Pathologic Reflux

  1. Indications
    1. Persistent regurgitation despite management in Step 1 for 2-4 weeks
    2. Poor weight gain
    3. Signs of Esophagitis or respiratory symptoms (see GERD related findings as above)
  2. Evaluation
    1. Consider differential diagnosis (see above)
    2. Consider Upper GI Study
  3. Trial of acid suppression
    1. Approach
      1. Start with initial trial for 4 weeks (and continue for 2-3 months if effective)
    2. Precautions
      1. Avoid acid suppression when reflux is effortless, painless and does not impact growth
      2. Acid suppression is overutilized in Pediatric GERD and has significant associated risks
        1. Risk of Necrotizing Enterocolitis in preterm and Low Birth Weight Infants
        2. Associated with increased risk of Pneumonia and gastrointestinal infections
        3. Microbiome alterations on acid suppression risk of allergy, Asthma and Obesity
        4. Increased risk of Pediatric Fractures
      3. References
        1. Wolf (2023) Am Fam Physician 108(6): 614-5 [PubMed]
    3. H2 Receptor Blockers (e.g. Famotidine, Cimetidine)
      1. See H2 Blockers for dosing
      2. Famotidine
        1. Age <3 months: 0.5 mg/kg daily for age
        2. Age >3 months: 0.5 mg/kg (up to 40 mg) twice daily
      3. Cimetidine (300 mg/ml oral solution)
        1. For age <12 years (use adult dose of 400-800 mg twice daily for age >12 years)
        2. Newborns
          1. Dose: 5-10 mg/kg/day divided every 8-12 hours
        3. Infants
          1. Dose: 10-20 mg/kg/day divided every 6-12 hours
          2. Doses up to 20-40 mg/kg/day may be needed in GERD
        4. Children <12 years old
          1. Dose: 20-40 mg/kg/day divided every 6 hours
      4. Nizatidine (15 mg/ml suspension)
        1. For age 6 months to 11 years old (use adult dose of 150 twice daily for age >=12 years)
        2. Dose: 5-10 mg/kg/day divided every 12 hours
        3. Doses up to 10-20 mg/kg/day may be needed in GERD
    4. Proton Pump Inhibitors (e.g. Prevacid, Prilosec, Aciphex)
      1. See Proton Pump Inhibitors for additional dosing and adverse effects
      2. Esomeprazole
        1. Capsule contents sprinkled on food
        2. Weight 3 to 5 kg
          1. Give 2.5 mg orally daily for up to 6 weeks
        3. Weight 5 to 7.5 kg
          1. Give 5 mg orally daily for up to 6 weeks
        4. Weight 7.5 to 20 kg
          1. Give 10 mg orally daily for up to 6 weeks
        5. Weight >20 kg and age <11 years
          1. Give 20 mg orally daily for up to 8 weeks
        6. Age <12 to 17 years
          1. Take 20 to 40 mg orally daily for up to 8 weeks
      3. Lansoprazole
        1. May be compounded into liquid for dosing in infants
        2. May sprinkle opened capsule onto food or into juice
        3. Available in a disintegrating tablet
        4. Weight <10 kg (and age 3-12 months)
          1. Dose: 7.5 mg twice daily or 15 mg daily
          2. Dose: 1 mg/kg/day (0.5 to 1.6 mg/kg)
          3. May use up to 2 mg/kg/day in GERD
        5. Weight 10 to 30 kg (age 1 to 11 years)
          1. Dose: 15 mg orally daily for up to 12 weeks
        6. Weight >30 kg (age 12 to 17 years)
          1. Dose: 30 mg orally daily for up to 12 weeks
      4. Omeprazole
        1. May sprinkle opened capsule onto applesauce or acidic liquid
        2. Infants
          1. Give 0.7 mg/kg orally daily
          2. Doses up to 1-4 mg/kg/day may be needed in GERD
        3. Weight 5-10 kg (and age >1 year old)
          1. Give 5 mg orally daily
        4. Weight 10-20 kg
          1. Give 10 mg orally daily
        5. Weight >20 kg
          1. Give 20 mg orally daily
      5. Pantoprazole
        1. Weight <15 kg (off-label)
          1. Give 0.5 to 1 mg/kg/day
          2. Doses up to 1-2 mg/kg/day may be needed in GERD
        2. Weight 15 to 40 kg
          1. Give 20 mg orally daily for up to 8 weeks
        3. Weight >=40 kg
          1. Give 40 mg orally daily for up to 8 weeks
  4. Other measures to consider (avoid in most cases, consult gastroenterology)
    1. Prokinetics
      1. Metoclopramide (Reglan) 1 mg/ml oral solution
        1. Dose: 0.1 to 0.2 mg/kg/dose three to four times daily
        2. Risk of Extrapyramidal Effects, Dystonic Reaction, drowsiness
        3. Not recommended due to adverse effects in over one third of patients
      2. Erythromycin (EES) 200 mg/ml
        1. Dose 1.5 to 12.5 mg/kg every 6-8 hours
        2. Very expensive, no proven efficacy, no established doses in GERD
        3. Not recommended
    2. Other gastrointestinal agents
      1. Antacid solutions (Magnesium Hydroxide, aluminum hydroxide)
        1. Magnesium Hydroxide only has been FDA approved in infants
        2. Not recommended <12 years old
        3. Risk of Milk Alkali Syndrome
        4. Magnesium Alginate with Simethicone
          1. Weight <5 kg: 2.5 ml three times daily
          2. Weight >=5 kg: 5 ml three times daily
      2. Sucralfate (Carafate)
        1. Dose 40-80 mg/kg/day divided every 6 hours
        2. No established dosing or efficacy in Pediatric Reflux
  5. Follow-up: Evaluate efficacy after 2-3 weeks
    1. Interventions effective: Continue for 2-3 months
    2. Interventions not effective: See Step 3 below

XVI. Management: Step 3 Refractory Reflux

  1. Indications
    1. Failed management in Step 2
  2. Evaluation
    1. Pediatric Gastroenterology Consultation
    2. Consider further studies
      1. pH probe for 24 hours
      2. Endoscopy
  3. Interventions for medically Intractable disease
    1. Nissen Fundoplication

XVII. Complications

  1. Pulmonary aspiration
  2. Chronic Bronchitis
  3. Bronchiectasis
  4. Esophagitis
  5. Esophageal Stricture

XVIII. References

  1. Antono (2025) Am Fam Physician 111(1): 62-72 [PubMed]
  2. Baird (2015) Am Fam Physician 92(8): 705-14 [PubMed]
  3. Boyle (1989) Gastroenterol Clin North Am 18:315-337 [PubMed]
  4. Faubion (1998) Mayo Clin Proc 73:166-73 [PubMed]
  5. Gauer (2014) Am Fam Physician 90(4): 244-51 [PubMed]
  6. Jung (2001) Am Fam Physician 64(11):1853-60 [PubMed]
  7. Orenstein (1999) Pediatr Rev 20:24-8 [PubMed]
  8. Tsou (1998) Otolaryngol Clin North Am 31:419-34 [PubMed]

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