New Guidelines Offer Practical Tools to Treat GI Reflux

New Guidelines Offer Practical Tools to Treat GI Reflux 150 150 Jeb Phillips

An international committee’s new recommendations reflect shifting opinions about acid-suppressive medications and include an expanded diagnostic algorithm.

While reflux-related complaints are heard often by pediatric gastroenterologists and primary care physicians, it can be difficult to tell when gastroesophageal reflux (GER) crosses the line into gastroesophageal reflux disease (GERD) — or how that disease should be treated in light of emerging research.

So a joint committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has updated its reflux clinical practice guidelines for the first time since 2009.

Providers will find that among other changes, the recent publication places particular emphasis on reducing the use of acid-suppressive medication, says Carlo Di Lorenzo, MD, an author of the guidelines and chief of the Division of Gastroenterology at Nationwide Children’s Hospital. Dr. Di Lorenzo is one of three authors who also wrote the 2009 guidelines.

“Parents are understandably concerned when infants spit up or when children have troublesome symptoms that may be related to reflux, but we need to make sure we are correctly diagnosing the underlying issues and only using treatments that are likely to be effective,” says Dr. Di Lorenzo.

The guidelines, published in the Journal of Pediatric Gastroenterology and Nutrition, include 49 separate recommendations, from the correct definition of GERD to the proper use of the rare total esophagogastric disconnection.

The authors note four main ways in which the new publication diverges from the 2009 guidelines:

  • In an effort to reduce acid-suppressive medication use, it recommends acid suppression courses of only 4 to 8 weeks for children with typical symptoms of GERD, then an assessment of efficacy (and an investigation into alternative causes of the symptoms if the treatment fails)
  • It recommends that in infants, a change to protein hydrolysate or amino acid-based formula should occur before attempting acid suppression
  • It includes a diagnostic algorithm for children with typical symptoms of GERD
  • It suggests not immediately attributing respiratory and laryngeal symptoms to gastroesophageal reflux

The new guidelines also include a number of practical tools that may be especially helpful for primary care physicians, including a table of symptoms and signs that may indicate GERD; “red flags” that may suggest disorders other than GERD; a differential diagnosis for GERD; typical dosages of drugs often used to treat GERD; and a diagnostic algorithm to be used with infants.

“In some cases, the best course of action would be referral to a pediatric subspecialist, but that’s not always possible,” says Dr. Di Lorenzo. “We hope these new guidelines can help bring pediatricians up to date on the preferred ways of diagnosing and treating GERD.”


Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)Journal of Pediatric Gastroenterology and Nutrition. 2018 Jan 25. [Epub ahead of print]

Image credit: Nationwide Children’s

About the author

Jeb is the Managing Editor, Executive Communications, in the Department of Marketing and Public Relations at Nationwide Children's Hospital. He contributes feature stories and research news to PediatricsOnline, the hospital’s electronic newsletter for physicians and other health care providers, and to Pediatrics Nationwide. He has served as a communications specialist at the Center for Injury Research and Policy at The Research Institute and came to Nationwide Children’s after 14-year career as daily newspaper reporter, most recently at The Columbus Dispatch.