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Gastroesophageal Reflex Disease (GERD) Referral Guidelines

Gastroesophageal Esophageal Reflux Disease (GERD)

Age: Infancy to adolescence

Gastroesophageal reflux (GER), the retrograde passage of gastric contents into the esophagus, occurs physiologically in all infants multiple times every day. It is exemplified by the effortless regurgitation in normal infants, described as "happy spitters." It is referred to as gastroesophageal reflux disease (GERD) if associated with bothersome symptoms and/or complications. Infant reflux usually has onset in the first few months of life, peaks at four months, and resolves in up to 88 percent of babies by 12 months, and in nearly all by 24 months. It may lead to more persistent symptoms or complications in infants with underlying chronic neurological, pulmonary and cardiac diseases.

Primary care providers are referred to the recent publication that provides evidence based guidelines and recommendations on the diagnosis and management of GER and GERD in infants and children.

References:
1. Rosen R et al. Pediatric GER 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. JPGN 2018;66: 516-554.

Initial Evaluation

A thorough history and physical examination suffice to reach the diagnosis. 

The initial evaluation aims to:

  • Differentiate between GER and GERD
  • Identify the pertinent positives in support of GERD and its complications and the negatives that make other diagnoses unlikely
  • Elicit “red flags” that alert to a need for a targeted work-up (e.g. upper GI series for anatomical evaluation in bilious vomiting, choking)

Initial Management

GER | Conservative therapy with emphasis on:

  • Parental education and guidance
  • Reduced volume and more frequent feeding to maintain adequate daily nutrition
  • Burping during and after feeds
  • Advise against head/crib elevation, lateral or prone positioning
  • Avoid provocative positions (car seats, infant carriers), and excitation, preferably for 1-2 hours after feeds

GERD | Conservative therapy as above

  • Thickened feeds for overt regurgitation and vomiting
  • Consider 2-4 week trial of an extensively hydrolyzed protein based formula OR maternal dietary elimination of cow’s milk protein IF above fail
  • Consider a 4-8 week trial of weight based acid suppression for strongly suspected GERD

When to Refer

  • Presence of “red flags” for another GI diagnosis (e.g. bilious vomiting, severe atopic dermatitis)
  • GERD with complications (e.g. hematemesis secondary to esophagitis, poor oral feeding, failure to gain weight adequately)
  • Unsatisfactory response to an appropriate trial of therapy, either extensively hydrolyzed protein based formula or acid suppression

How to Refer

  • Pain medicine care complex administration: Not applicable
  • Administration fax: 202-476-3032
  • Evenings and weekends: GI doctor on call (for urgent referrals)
  • Nurse triage line: Not applicable
  • Appointment line: Call center
  • If you have a question about referral criteria please contact: 202-476-4880 (covered by a pediatric gastroenterologist)

What to Expect from a Visit to Children's

  • An office encounter with a pediatric gastroenterologist lasting approximately 30 minutes
  • Detailed history
  • General examination with focus on growth, nutritional parameters and abdomen
  • Possible examination of stool to detect occult blood by means of a digital rectal examination or inspection of stool in a diaper
  • Assessment and plan outlining specific treatment, any future testing as warranted and follow up

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Physician Access Line

We have established a physician access line for your use. Please dial 202-476-4880 for consultations, referrals and admissions information.

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