What approach should we take to treat gastroesophageal symptoms in children?

Citing overinvestigation and overtreatment of infants and children with symptoms of reflux, this guideline recommends, in the absence of alarm signs, dietary changes but no proton pump inhibitor (PPI) therapy for infants. In older children, lifestyle and dietary changes should come first, saving short-term acid-suppression therapy (4-8 weeks) only for when these changes don't work, and then referral to a pediatric gastroenterologist for further work-up only if symptoms persist or return after discontinuing acid suppression. (LOE = 5)

Rosen R, Vandenplas Y, Singendonk M, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018;66(3):516-554.  [PMID:29470322]

Practice guideline

Self-funded or unfunded

Various (guideline)

These guidelines were developed by the North American and the European societies for pediatric gastroenterology, hepatology, and nutrition. The guideline development group consisted solely of specialists without patient or other specialty representation. The group included a methodologist. Most of the group members had financial conflicts of interests. The guideline was based on a systematic review of the literature and the quality of the evidence was graded. The group differentiated gastroesophageal reflux as a set of symptoms, defining gastroesophageal reflux disease as reflux accompanied by troublesome "red flag" findings, such as esophagitis. The guidelines suggest a conservative approach, basing initial treatment on reported symptoms without an extensive work-up. Initial treatment of infants should include thickened feed for treating regurgitation/vomiting (weak recommendation), avoiding overfeeding (weak recommendation), and attempting a trial of hydrolyzed protein formula if these approaches don't work (weak recommendation). Head elevation while sleeping can be tried in children but not infants (weak recommendation). PPI therapy should not be used in healthy infants or infants with regurgitation, but can be used in children with typical heartburn symptoms (strong recommendation).