Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Management of gastroesophageal reflux disease in children and adolescents

Harland S Winter, MD
Section Editor
Deputy Editor
Alison G Hoppin, MD


The passage of gastric contents into the esophagus (gastroesophageal reflux [GER]) is a normal physiologic process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause symptoms, esophageal injury, or other complications. In contrast, gastroesophageal reflux disease (GERD) occurs when the reflux episodes are associated with symptoms or complications. The type of symptoms and complications of GERD in children vary with the child's age.

Several treatment options are available for controlling symptoms and preventing complications in children with GERD. The choice among them depends upon the patient's age, the type and severity of symptoms, and response to treatment.

This topic review focuses on the management of GERD in children and adolescents. Other topic reviews relevant to GER and GERD in the pediatric age group are:

Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents

Gastroesophageal reflux in infants

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 04, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. 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). J Pediatr Gastroenterol Nutr 2009; 49:498.
  2. Lightdale JR, Gremse DA, Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics 2013; 131:e1684.
  3. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965.
  4. U.S. Food and Drug Administration: Drugs@FDA Web site www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm (Accessed on July 16, 2013).
  5. Chiba N, De Gara CJ, Wilkinson JM, Hunt RH. Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: a meta-analysis. Gastroenterology 1997; 112:1798.
  6. Tighe M, Afzal NA, Bevan A, et al. Pharmacological treatment of children with gastro-oesophageal reflux. Cochrane Database Syst Rev 2014; :CD008550.
  7. Hassall E. Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children. J Pediatr 2005; 146:S3.
  8. Hassall E, Israel D, Shepherd R, et al. Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter study of efficacy, safety, tolerability and dose requirements. International Pediatric Omeprazole Study Group. J Pediatr 2000; 137:800.
  9. Cucchiara S, Minella R, Iervolino C, et al. Omeprazole and high dose ranitidine in the treatment of refractory reflux oesophagitis. Arch Dis Child 1993; 69:655.
  10. Gold BD, Gunasekaran T, Tolia V, et al. Safety and symptom improvement with esomeprazole in adolescents with gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr 2007; 45:520.
  11. Boccia G, Manguso F, Miele E, et al. Maintenance therapy for erosive esophagitis in children after healing by omeprazole: is it advisable? Am J Gastroenterol 2007; 102:1291.
  12. van der Pol RJ, Smits MJ, van Wijk MP, et al. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics 2011; 127:925.
  13. Hyman PE, Garvey TQ 3rd, Abrams CE. Tolerance to intravenous ranitidine. J Pediatr 1987; 110:794.
  14. McRorie JW, Kirby JA, Miner PB. Histamine2-receptor antagonists: Rapid development of tachyphylaxis with repeat dosing. World J Gastrointest Pharmacol Ther 2014; 5:57.
  15. Moore DJ, Tao BS, Lines DR, et al. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr 2003; 143:219.
  16. Orenstein SR, Hassall E, Furmaga-Jablonska W, et al. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr 2009; 154:514.
  17. Winter H, Kum-Nji P, Mahomedy SH, et al. Efficacy and safety of pantoprazole delayed-release granules for oral suspension in a placebo-controlled treatment-withdrawal study in infants 1-11 months old with symptomatic GERD. J Pediatr Gastroenterol Nutr 2010; 50:609.
  18. Litalien C, Théorêt Y, Faure C. Pharmacokinetics of proton pump inhibitors in children. Clin Pharmacokinet 2005; 44:441.
  19. Phillips JO, Parsons DS, Fitts SW. Flavored lansoprazole suspension in pediatric GERD. World congress of Pediatric Gastroenterology, Hepatology, and Nutrition 2000. Abstract 750966.
  20. Hoyo-Vadillo C, Venturelli CR, González H, et al. Metabolism of omeprazole after two oral doses in children 1 to 9 months old. Proc West Pharmacol Soc 2005; 48:108.
  21. Ward RM, Kearns GL. Proton pump inhibitors in pediatrics : mechanism of action, pharmacokinetics, pharmacogenetics, and pharmacodynamics. Paediatr Drugs 2013; 15:119.
  22. Gibbons TE, Gold BD. The use of proton pump inhibitors in children: a comprehensive review. Paediatr Drugs 2003; 5:25.
  23. Jimenez J, Drees M, Loveridge-Lenza B, et al. Exposure to Gastric Acid-Suppression Therapy Is Associated With Health Care- and Community-Associated Clostridium difficile Infection in Children. J Pediatr Gastroenterol Nutr 2015; 61:208.
  24. FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs). Available at: http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm (Accessed on February 08, 2012).
  25. Canani RB, Cirillo P, Roggero P, et al. Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Pediatrics 2006; 117:e817.
  26. Rosh JR, Hassall E. Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. J Pediatr Gastroenterol Nutr 2006; 43:545.
  27. Sieczkowska A, Landowski P, Zagozdzon P, et al. Small Bowel Bacterial Overgrowth Associated with Persistence of Abdominal Symptoms in Children Treated with a Proton Pump Inhibitor. J Pediatr 2015; 166:1310.
  28. Rosen R, Amirault J, Liu H, et al. Changes in gastric and lung microflora with acid suppression: acid suppression and bacterial growth. JAMA Pediatr 2014; 168:932.
  29. Klinkenberg-Knol EC, Nelis F, Dent J, et al. Long-term omeprazole treatment in resistant gastroesophageal reflux disease: efficacy, safety, and influence on gastric mucosa. Gastroenterology 2000; 118:661.
  30. Hassall E, Owen D, Kerr W, et al. Gastric histology in children treated with proton pump inhibitors (PPIs) long-term. Gastroenterology 2008; 134:A174.
  31. Björnsson E, Abrahamsson H, Simrén M, et al. Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial. Aliment Pharmacol Ther 2006; 24:945.
  32. Cucchiara S, Gobio-Casali L, Balli F, et al. Cimetidine treatment of reflux esophagitis in children: an Italian multicentric study. J Pediatr Gastroenterol Nutr 1989; 8:150.
  33. Simeone D, Caria MC, Miele E, Staiano A. Treatment of childhood peptic esophagitis: a double-blind placebo-controlled trial of nizatidine. J Pediatr Gastroenterol Nutr 1997; 25:51.
  34. Pivnick EK, Kerr NC, Kaufman RA, et al. Rickets secondary to phosphate depletion. A sequela of antacid use in infancy. Clin Pediatr (Phila) 1995; 34:73.
  35. Cucchiara S, Staiano A, Romaniello G, et al. Antacids and cimetidine treatment for gastro-oesophageal reflux and peptic oesophagitis. Arch Dis Child 1984; 59:842.
  36. Iacono G, Carroccio A, Montalto G, et al. [Magnesium hydroxide and aluminum hydroxide in the treatment of gastroesophageal reflux]. Minerva Pediatr 1991; 43:797.
  37. Tsou VM, Young RM, Hart MH, Vanderhoof JA. Elevated plasma aluminum levels in normal infants receiving antacids containing aluminum. Pediatrics 1991; 87:148.
  38. Woodard-Knight L, Fudge A, Teubner J, Simmer K. Aluminium absorption and antacid therapy in infancy. J Paediatr Child Health 1992; 28:257.
  39. Sedman A. Aluminum toxicity in childhood. Pediatr Nephrol 1992; 6:383.
  40. Hibbs AM, Lorch SA. Metoclopramide for the treatment of gastroesophageal reflux disease in infants: a systematic review. Pediatrics 2006; 118:746.
  41. Maclennan S, Augood C, Cash-Gibson L, et al. Cisapride treatment for gastro-oesophageal reflux in children. Cochrane Database Syst Rev 2010; :CD002300.
  42. Pritchard DS, Baber N, Stephenson T. Should domperidone be used for the treatment of gastro-oesophageal reflux in children? Systematic review of randomized controlled trials in children aged 1 month to 11 years old. Br J Clin Pharmacol 2005; 59:725.
  43. Tighe MP, Afzal NA, Bevan A, Beattie RM. Current pharmacological management of gastro-esophageal reflux in children: an evidence-based systematic review. Paediatr Drugs 2009; 11:185.
  44. Ciccaglione AF, Marzio L. Effect of acute and chronic administration of the GABA B agonist baclofen on 24 hour pH metry and symptoms in control subjects and in patients with gastro-oesophageal reflux disease. Gut 2003; 52:464.
  45. Vadlamudi NB, Hitch MC, Dimmitt RA, Thame KA. Baclofen for the treatment of pediatric GERD. J Pediatr Gastroenterol Nutr 2013; 57:808.
  46. Omari TI, Benninga MA, Sansom L, et al. Effect of baclofen on esophagogastric motility and gastroesophageal reflux in children with gastroesophageal reflux disease: a randomized controlled trial. J Pediatr 2006; 149:468.
  47. Kawai M, Kawahara H, Hirayama S, et al. Effect of baclofen on emesis and 24-hour esophageal pH in neurologically impaired children with gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr 2004; 38:317.
  48. Simon B, Ravelli GP, Goffin H. Sucralfate gel versus placebo in patients with non-erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther 1996; 10:441.
  49. Argüelles-Martin F, Gonzalez-Fernandez F, Gentles MG. Sucralfate versus cimetidine in the treatment of reflux esophagitis in children. Am J Med 1989; 86:73.
  50. Poynard T, Vernisse B, Agostini H. Randomized, multicentre comparison of sodium alginate and cisapride in the symptomatic treatment of uncomplicated gastro-oesophageal reflux. Aliment Pharmacol Ther 1998; 12:159.
  51. Greally P, Hampton FJ, MacFadyen UM, Simpson H. Gaviscon and Carobel compared with cisapride in gastro-oesophageal reflux. Arch Dis Child 1992; 67:618.
  52. Buts JP, Barudi C, Otte JB. Double-blind controlled study on the efficacy of sodium alginate (Gaviscon) in reducing gastroesophageal reflux assessed by 24 h continuous pH monitoring in infants and children. Eur J Pediatr 1987; 146:156.
  53. Forbes D, Hodgson M, Hill R. The effects of gaviscon and metoclopramide in gastroesophageal reflux in children. J Pediatr Gastroenterol Nutr 1986; 5:556.
  54. Pouchain D, Bigard MA, Liard F, et al. Gaviscon® vs. omeprazole in symptomatic treatment of moderate gastroesophageal reflux. a direct comparative randomised trial. BMC Gastroenterol 2012; 12:18.
  55. Vemulapalli R. Diet and lifestyle modifications in the management of gastroesophageal reflux disease. Nutr Clin Pract 2008; 23:293.
  56. National Center for Complementary and Integrative Health. Available at: https://nccih.nih.gov/ (Accessed on December 20, 2015).
  57. Rothenberg SS. Experience with 220 consecutive laparoscopic Nissen fundoplications in infants and children. J Pediatr Surg 1998; 33:274.
  58. Dalla Vecchia LK, Grosfeld JL, West KW, et al. Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients. Ann Surg 1997; 226:315.
  59. Bensoussan AL, Yazbeck S, Carceller-Blanchard A. Results and complications of Toupet partial posterior wrap: 10 years' experience. J Pediatr Surg 1994; 29:1215.
  60. Fonkalsrud EW, Ashcraft KW, Coran AG, et al. Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics 1998; 101:419.
  61. Fonkalsrud EW, Bustorff-Silva J, Perez CA, et al. Antireflux surgery in children under 3 months of age. J Pediatr Surg 1999; 34:527.
  62. Weber TR. Toupét fundoplication for gastroesophageal reflux in childhood. Arch Surg 1999; 134:717.
  63. Gilger MA, Yeh C, Chiang J, et al. Outcomes of surgical fundoplication in children. Clin Gastroenterol Hepatol 2004; 2:978.
  64. Cheung KM, Tse HW, Tse PW, Chan KH. Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux. Hong Kong Med J 2006; 12:282.
  65. Barnhart DC, Hall M, Mahant S, et al. Effectiveness of fundoplication at the time of gastrostomy in infants with neurological impairment. JAMA Pediatr 2013; 167:911.
  66. Sulaeman E, Udall JN Jr, Brown RF, et al. Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopic gastrostomy in children. J Pediatr Gastroenterol Nutr 1998; 26:269.
  67. Papandria D, Goldstein SD, Salazar JH, et al. A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age. J Pediatr Surg 2015; 50:267.
  68. Kubiak R, Böhm-Sturm E, Svoboda D, Wessel LM. Comparison of long-term outcomes between open and laparoscopic Thal fundoplication in children. J Pediatr Surg 2014; 49:1069.
  69. Ru W, Wu P, Feng S, et al. Laparoscopic versus open Nissen fundoplication in children: A systematic review and meta-analysis. J Pediatr Surg 2016; 51:1731.
  70. Diaz DM, Gibbons TE, Heiss K, et al. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol 2005; 100:1844.
  71. Kane TD, Brown MF, Chen MK, Members of the APSA New Technology Committee. Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association. J Pediatr Surg 2009; 44:1034.
  72. Fyhn TJ, Knatten CK, Edwin B, et al. Randomized Controlled Trial of Laparoscopic and Open Nissen Fundoplication in Children. Ann Surg 2015; 261:1061.
  73. Hassall E. Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child 2005; 90:1047.
  74. Taylor LA, Weiner T, Lacey SR, Azizkhan RG. Chronic lung disease is the leading risk factor correlating with the failure (wrap disruption) of antireflux procedures in children. J Pediatr Surg 1994; 29:161.
  75. Boesch RP, Acton JD. Outcomes of fundoplication in children with cystic fibrosis. J Pediatr Surg 2007; 42:1341.
  76. Tovar JA, Luis AL, Encinas JL, et al. Pediatric surgeons and gastroesophageal reflux. J Pediatr Surg 2007; 42:277.
  77. Kristensen C, Avitsland T, Emblem R, et al. Satisfactory long-term results after Nissen fundoplication. Acta Paediatr 2007; 96:702.
  78. O'Loughlin EV, Somerville H, Shun A, et al. Antireflux surgery in children with neurological impairment: caregiver perceptions and complications. J Pediatr Gastroenterol Nutr 2013; 56:46.
  79. Richards CA, Milla PJ, Andrews PL, Spitz L. Retching and vomiting in neurologically impaired children after fundoplication: predictive preoperative factors. J Pediatr Surg 2001; 36:1401.
  80. Antao B, Ooi K, Ade-Ajayi N, et al. Effectiveness of alimemazine in controlling retching after Nissen fundoplication. J Pediatr Surg 2005; 40:1737.
  81. Tovar JA, Angulo JA, Gorostiaga L, Arana J. Surgery for gastroesophageal reflux in children with normal pH studies. J Pediatr Surg 1991; 26:541.
  82. Davies I, Burman-Roy S, Murphy MS, Guideline Development Group. Gastro-oesophageal reflux disease in children: NICE guidance. BMJ 2015; 350:g7703.
  83. Gibson PG, Henry RL, Coughlan JL. Gastro-oesophageal reflux treatment for asthma in adults and children. Cochrane Database Syst Rev 2003; :CD001496.
  84. Gold BD. Asthma and gastroesophageal reflux disease in children: exploring the relationship. J Pediatr 2005; 146:S13.
  85. Mattioli G, Sacco O, Repetto P, et al. Necessity for surgery in children with gastrooesophageal reflux and supraoesophageal symptoms. Eur J Pediatr Surg 2004; 14:7.
  86. Bowrey DJ, Peters JH, DeMeester TR. Gastroesophageal reflux disease in asthma: effects of medical and surgical antireflux therapy on asthma control. Ann Surg 2000; 231:161.
  87. Rothenberg S, Cowles R. The effects of laparoscopic Nissen fundoplication on patients with severe gastroesophageal reflux disease and steroid-dependent asthma. J Pediatr Surg 2012; 47:1101.