Therapy of GORD can be divided into: (1)

Dietary measures

• thickened feedings – useful in reducing regurgitation and vomiting in infants and children under 2 years, rice, or corn can be used as feed thickeners (2)
• frequent small meals – for older infants and children (2)
• removal of cow’s milk protein from diet – in infants with cow’s milk protein allergy (3)

Positioning

• GER is less when placed in the prone position (when infant is awake, specially during post prandial period) compared to supine position (due to the increased risk of sudden infant death syndrome supine position is recommended during sleep) (3)
• seated positioning may increase intra-abdominal pressure and cause reflux and should be avoided (2)
• for children older than 1 year left side positioning and elevation of the head of the bed may be beneficial (3)

Pharmacological

• antacids (e.g. gaviscon) may be indicated
• H2 antagonists e.g. randitidine are widely used in the management of this condition
  • ranitidine has a licence in the UK for use in the management of GORD in infancy and has a good safety record (2). It is available as an oral solution
• omeprazole - this may be more effective than ranitidine but does not have a paediatric licence in the UK or a liquid preparation (5)
• domperidone may be used for its anti-emetic effects although it has no licence for this use (5)
• metoclopramide may have some benefit in comparison to placebo in the symptomatic treatment for GORD, but that must be weighed against possible side effects (4)

Infants with GORD complicated by failure to thrive should receive shared care between primary and secondary services.

Surgery may be indicated if there is failure to thrive, oesophageal ulceration and recurrent or persistent aspiration.

Notes:

• conventional management has involved nursing the infant on a head-up sloping board either in the prone or supine position. However a systematic review provides evidence that elevating the head of the crib in the supine position does not have any effect on GORD in children under two years of age (1)

Reference:

• (1) 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(6):725-9
• (2) Jung A.D. Gastroesophageal Reflux in Infants and Children. Am Fam Physician. 2001;64(11):1853-60
• (3) Vandenplas Y 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). Journal of Pediatric Gastroenterology and Nutrition 2009; 49:498–547
• (4) Craig WR et al. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev 2004; (4):CD003502.
• (5) Pulse (2004), 64 (5), 68.