Clinical Review & Education
Clinical Guideline Synopsis
Guideline for Management of Pediatric
Gastroesophageal Reflux
Leo A. Heitlinger, MD
GUIDELINE TITLE: Pediatric Gastroesophageal Reflux Clinical
Practice Guideline
RELEASE DATE: March 2018
PRIOR VERSION: October 2009
DEVELOPER: North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
and the European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (ESPGHAN)
FUNDING SOURCE: NASPGHAN and ESPGHAN
Summary of Clinical Problem
Gastroesophageal reflux is common in infancy and childhood and a fre-
quent cause of visits to the primary care and specialty office. Most in-
fants and children who exhibit symptoms of reflux, such as regurgita-
tion, vomiting, or discomfort, have uncomplicated reflux rather than
gastroesophageal reflux disease. Despite this, the numbers of infants
and children who receive treatment with acid suppression, undergo
noninvasiveorinvasivetestingismuchlargerthaniswarrantedbytheir
clinicalcourse.Therelativelackofresponsetoacidsuppressionofsome
groups of patients including irritable infants, infants and children with
extraesophageal symptoms, such as hoarseness, cough, or asthma
promptedareevaluationofthepreviouslypublishedguidelines(Table).
Characteristics of the Guideline Source
A joint committee representing the North American Society for Pedi-
atric Gastroenterology, Hepatology, and Nutrition and the European
Society for Pediatric Gastroenterology, Hepatology, and Nutrition was
formedin2015andchargedtoreviewtheliteratureandupdatethepre-
vious guideline published in 2009.1,2 The committee included a gen-
eralpediatricianandascientistwithexpertiseinguidelinedevelopment.
Potential conflicts of interest were disclosed and resolved by recusal
when specific topics were discussed. Literature search was performed
of articles from 2008 through 2015 with clear inclusion and exclusion
criteria.TheGradingofRecommendations,Assessment,Development,
and Evaluation (GRADE) approach was used to identify outcome mea-
sures for questions that were developed.3 The level and quality of evi-
dence was evaluated using the Quality Assessment of Studies of Diag-
nostic Accuracy (QUADAS) tools.4
Evidence Base
Similar to the previous guideline published in 2009, most recom-
mendations were supported by expert opinion rather than new re-
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TARGET POPULATIONS: Infants and children
MAJOR RECOMMENDATIONS:
• Limit acid-suppression therapy of patients with typical reflux
symptoms to 4 to 8 weeks. Assessment of efficacy and
investigations if treatment is ineffective is appropriate
at that time.
• In infants, a trial of hypoallergenic formula or maternal
elimination diet for breast fed infants is recommended
before use of acid suppression.
• Avoid use of acid suppression for cough, wheezing,
or asthma in the absence of typical reflux symptoms.
Table. Guideline Rating
Standard Rating
1. Establishing transparency Good
2. Management of conflicts of interest Good
in the guideline development group
3. Clinical development group composition Fair
4. Clinical practice guideline/systematic review intersection Fair
5. Establishing evidence foundations and rating strength Good
for each of the guideline recommendations
6. Articulation of recommendations Good
7. External review Poor
8. Updating Fair
9. Implementation issues Fair
search of high quality. Consensus was formally achieved through the
nominal group technique using a 9-point scale, anonymous voting,
and agreement of consensus if more than 75% scored the state-
ment greater than 6 on the 9-point scale. Using this approach, sev-
eral strong recommendations were made. Esophagogastroduode-
noscopy (EGD) with biopsies was recommended to assess
complications of gastroesophageal reflux disease (GERD)
to determine if suspected underlying disease was present or prior
to escalation of therapy. Salivary pepsin and currently available ex-
traesophageal biomarkers were not recommended to diagnose
GERD in infants and children. Manometry should not be used to di-
agnose GERD but should be performed if an underlying motility dis-
order is suspected. Scintigraphy should not be used to diagnose
GERD in infants and children. pH impedance studies were
preferred over prolonged pH monitoring to correlate troublesome
symptoms with acid reflux, clarify the role of acid reflux in esopha-
gitis, and determine efficacy of acid-suppression therapy. Posi-
tional therapy was not recommended to treat reflux in infants. Fi-
E1
 Clinical Review & Education Clinical Guideline Synopsis

nally, proton pump inhibitors (PPIs) were recommended as
treatment for erosive esophagitis.
Potential Benefits and Unintended Consequences
The recommendations of the joint committee are clearly designed
to diminish overtreatment and overtesting of infants and children
with typical symptoms of gastroesophageal reflux. Clinicians are di-
rected to use less aggressive means to provide relief where pos-
sible to patients and to refer to specialists early when desired out-
comes are not achieved in a timely fashion. The hope is that the
specialists will be effective and efficient in addressing parental and
patient concerns. The burden on clinicians who do not have ready
access to specialists to fulfill this role is acknowledged by the com-
mittee and suggestions for treatment are clearly stated in the
guideline.
Areas for Future Research
The committee acknowledged the relative paucity of high-quality
studies regarding the correlation between troublesome symptoms
and presence or absence of reflux. Similarly, better characteriza-
tion of the means to address extraesophageal manifestations in the
airway remain a challenge for those in referral practice.

ARTICLE INFORMATION REFERENCES Society for Pediatric Gastroenterology, Hepatology,

Author Affiliations: Lewis Katz School of Medicine 1. Rosen R, Vandenplas Y, Singendonk M, et al. and Nutrition (NASPGHAN) and the European
at Temple University, Philadelphia, Pennsylvania; Pediatric gastroesophageal refux clinical practice Society for Pediatric Gastroenterology, Hepatology,
St Luke’s University Hospital, Bethlehem, guidelines: Joint recommendations of the North and Nutrition (ESPGHAN). J Pediatr Gastroenterol
Pennsylvania. American Society for Pediatric Gastroenterology, Nutr. 2009;49(4):498-547.

Corresponding Author: Leo A. Heitlinger, MD,
St Luke’s Pediatric Gastroenterology, 701 Ostrum
St, Ste 102, Bethlehem, PA 18015 (leo.heitlinger
@sluhn.org).
Published Online: June 28, 2018.
doi:10.1001/jamaoto.2018.1236
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Hepatology and Nutrition and the European Society
for Pediatric Gastroenterology and Nutrition.
J Pediatr Gastroenterol Nutr. 2018;66(3):516-554.
doi:10.1097/MPG.0000000000001889
2. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al;
North American Society for Pediatric
Gastroenterology Hepatology and Nutrition;
European Society for Pediatric Gastroenterology
Hepatology and Nutrition. Pediatric
gastroesophageal reflux clinical practice guidelines:
joint recommendations of the North American
3. Guyatt GH, Oxman AD, Vist GE, et al; GRADE
Working Group. GRADE: an emerging consensus on
rating quality of evidence and strength of
recommendations. BMJ. 2008;336(7650):924-926.
doi:10.1136/bmj.39489.470347.AD
4. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM,
Kleijnen J. The development of QUADAS: a tool for
the quality assessment of studies of diagnostic
accuracy included in systematic reviews. BMC Med
Res Methodol. 2003;3:25.
doi:10.1186/1471-2288-3-25

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