Gastroesophageal Reflux Disease Management in Pediatric Patients

Amy Wu, PharmD

US Pharmacist. 2015;40(12):28-33.

Diagnosis

The commonly used diagnostic methods to evaluate pediatric patients with GERD symptoms are upper gastrointestinal (GI) tract contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy with esophageal biopsy.^[7]

The upper GI tract contrast radiography allows the practitioner to delineate anatomy and document any presence of a motility disorder. This diagnostic method involves obtaining a series of fluoroscopic images of swallowed barium until the ligament of Treitz is visualized. This is not the preferred diagnostic method to diagnose GER or GERD since the test is too brief in duration to adequately rule out the occurrence of pathologic reflux. However, the upper GI tract series is helpful in evaluating vomiting to screen for anatomic abnormalities of the upper GI tract.^[2]

The esophageal pH monitoring method is used to quantify the frequency and duration of esophageal acid exposure during a study period. Despite allowing the practitioner to associate a temporal relationship between a symptom and acid reflux and to evaluate the efficacy of pharmacologic therapy on acid suppression, there is evidence suggesting poor reproducibility of pH testing.^[9]

Multiple intraluminal impedance detects the movement of both acidic and nonacidic fluids, solids, and air in the esophagus, which allows a more detailed picture of esophageal events compared to pH monitoring.^[9]

The upper endoscopy diagnostic method of GERD allows direct visualization of the esophageal mucosa in order to assess the presence and severity of injury from the reflux of gastric contents into the esophagus.^[10] Upper endoscopy is indicated for patients with GERD who fail to respond to pharmacologic therapy or as part of initial management if the patient has symptoms of poor weight gain, unexplained anemia or fecal occult blood, recurrent pneumonia, or hematemesis. If the upper endoscopy diagnostic method is used in assessing GERD in pediatric patients, the benefits must be weighed against procedural and sedation risks.^[11] Esophageal biopsy is useful in evaluating conditions that may mimic symptoms of GERD, such as Crohn's disease, Barrett's esophagus, infectious esophagitis, or eosinophilic esophagitis. Esophageal biopsies should be performed during endoscopy because endoscopic findings correlate poorly with histologic testing in infants and children.^[2]

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Table 1. Pediatric Populations at High Risk for GERD
Neurologic impairment Obese History of esophageal atresia (repaired) Hiatal hernia Achalasia Chronic respiratory disorders (bronchopulmonary dysplasia, idiopathic interstitial fibrosis, cystic fibrosis) History of lung transplantation Preterm infants

GERD: gastroesophageal reflux disease. Source: Reference 7.

Table 2. Signs and Symptoms Associated With Gastroesophageal Reflux in Pediatric Patients
Signs	Symptoms
Esophagitis Esophageal stricture Barrett's esophagus Laryngeal/pharyngeal inflammation Recurrent pneumonia Anemia Dental erosion Feeding refusal Dystonic neck posturing (Sandifer syndrome) Apnea spells Life-threatening events	Recurrent regurgitation with/without vomiting Weight loss or poor weight gain Irritability in infants Ruminative behavior Heartburn or chest pain Hematemesis Dysphagia, odynophagia Wheezing Stridor Cough Hoarseness

Source: Reference 2.

Table 3. Pediatric Doses of Medications Prescribed for GERD
Drug	Doses	Ages (FDA-indicated)	Formulations
Histamine₂-Receptor Antagonists (H2RAs)
Cimetidine	20–40 mg/kg/day	≥16 y	Syrup
Ranitidine	5–10 mg/kg/day, divided in 2 doses	1 mo-16 y	Peppermint-flavored syrup; effervescent tablet
Famotidine	<3 mo: 0.5 mg/kg once daily 3–12 mo: 0.5 mg/kg twice daily 1–16 y: 1 mg/kg/day divided twice daily (max: 40 mg twice daily)	<3 mo-16 y	Cherry-banana-mint–flavored oral suspension
Nizatidine	150 mg twice daily for up to 8 wk (max: 300 mg/day)	≥12 y	Bubble gum–flavored solution
Proton Pump Inhibitors (PPIs)
Omeprazole	GERD/maintenance healing of EE: 5 to <10 kg: 5 mg once daily 10 to <20 kg: 10 mg once daily ≥20 kg: 20 mg once daily	1–16 y	Sprinkle contents of capsule onto soft foods
Lansoprazole	Short-term treatment of symptomatic GERD/EE: ≤30 kg: 15 mg once daily for up to 12 wk >30 kg: 30 mg once daily for up to 12 wk	1–11 y	Sprinkle contents of capsule onto soft foods or select juices; administer capsule contents in juice through nasogastric tube. Strawberry-flavored ODT; ODT via oral syringe or nasogastric tube (≥8 French)
Lansoprazole	Short-term treatment of nonerosive GERD: 15 mg once daily for up to 8 wk EE: 30 mg once daily for up to 8 wk	12–17 y
Esomeprazole	EE due to acid-mediated GERD: 3–5 kg: 2.5 mg once daily for up to 6 wk >5–7.5 kg: 5 mg once daily for up to 6 wk >7.5–12 kg: 10 mg once daily for up to 6 wk	1 mo to <1 y	Sprinkle contents of capsule onto soft foods; administer capsule contents in juice through nasogastric tube
	Short-term treatment of symptomatic GERD: 10 mg once daily for up to 8 wk Healing of EE: <20 kg: 10 mg once daily for up to 8 wk ≥20 kg: 10–20 mg once daily for up to 8 wk	1–11 y
	Healing of EE: 20–40 mg once daily for 4–8 wk Symptomatic GERD: 20 mg once daily for 4 wk	12–17 y
Rabeprazole	20 mg daily for up to 8 wk	12–17 y	Oral tablet
Rabeprazole	<15 kg: 5 mg once daily for up to 12 wk with the option to increase to 10 mg if inadequate response ≥15 kg: 10 mg once daily for up to 12 wk	1–11 y	Sprinkle contents of capsule onto soft foods or liquids
Dexlansoprazole	30–60 mg daily	No pediatric indication	Oral tablet
Pantoprazole	≥15 to <40 kg: 20 mg daily ≥40 kg: 40 mg daily	≥5 y	Oral tablet