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Updated treatment options for gastroesophageal reflux disease in children: practical guide for clinicians
Francesco Calabrese1,2, Andrea Pasta1, Luisa Bertin3,4
1Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.
Insights
Pediatric reflux esophagitis (RE) requires age-specific management distinct from adults. A stepwise approach, starting with non-pharmacologic methods and cautious medication use, improves outcomes and minimizes harm in children.
Area of Science:
- Pediatric Gastroenterology
- Gastroesophageal Reflux Disease (GERD) Management
- Reflux Esophagitis (RE) in Children
Background:
- Pediatric reflux esophagitis (RE) is a distinct entity within the broader spectrum of gastroesophageal reflux disease (GERD), differing significantly from adult presentations in pathophysiology, clinical manifestation, and therapeutic risk-benefit profiles.
- There is a critical need for clear, age-appropriate clinical guidelines to address the diagnosis and management of RE in pediatric populations.
Purpose of the Study:
- To synthesize current guidelines and research findings on the diagnosis and management of pediatric reflux esophagitis.
- To provide an age-aware, stepwise strategy for optimizing treatment outcomes while minimizing potential harm in children with RE.
Main Methods:
- Narrative review of guidelines and studies identified through PubMed/Embase searches up to 2025.
- Keywords included pediatric GERD/RE, diagnostic methods (endoscopy, pH monitoring, pH-impedance), pharmacotherapy, safety profiles, and surgical interventions.
Main Results:
- Diagnostic approaches include endoscopy with biopsy and ambulatory monitoring (pH for acid, pH-impedance for nonacid reflux).
- First-line management focuses on feeding optimization, thickeners, allergy evaluation, and positional advice.
- Pharmacotherapy options range from proton-pump inhibitors (PPIs) for children ≥1 year with documented esophagitis to H2-receptor antagonists, alginates, and selective use of prokinetics or baclofen for refractory cases. Emerging agents like potassium-competitive acid blockers (P-CABs) are under evaluation.
Conclusions:
- An age-aware, stepwise strategy prioritizing non-pharmacologic interventions, time-limited PPIs with planned step-down, and cautious adjuncts is recommended for pediatric RE.
- Future research priorities include pediatric trials for P-CABs and alginates, development of validated deprescribing guidelines, identification of noninvasive biomarkers, and scalable care models.
Introduction:
Pediatric reflux esophagitis (RE) lies within the gastroesophageal reflux disease (GERD) spectrum but differs from adults in pathophysiology, presentation, and therapy risk - benefit. Clear, age-aware guidance is needed.
Areas Covered:
This narrative review synthesizes guidelines and studies on diagnosis and management of pediatric RE. We outline indications for endoscopy with biopsy and ambulatory monitoring (pH for acid burden; pH-impedance for nonacid reflux and symptom association, especially under acid suppression or in infants). First-line care prioritizes feeding optimization, thickeners, targeted allergy evaluation, and safe positional advice. Pharmacotherapy is summarized with emphasis on efficacy and safety: proton-pump inhibitors for documented esophagitis in children ≥1 year; H2-receptor antagonists for short-term or step-down use; alginates for post-prandial symptoms or mild disease; emerging potassium-competitive acid blockers under pediatric evaluation; and selective prokinetics/baclofen in refractory, dysmotility-predominant cases. Surgical options are addressed for proven, complicated, or refractory disease. Literature was identified in PubMed/Embase through 2025 using predefined pediatric GERD/RE, diagnostics, pharmacotherapy, safety, and surgery keywords.
Expert Opinion:
An age-aware, stepwise strategy - non-pharmacologic first, time-limited proton pump inhibitors with planned step-down, and cautious adjuncts - optimizes outcomes while minimizing harm. Priorities include pediatric trials for potassium-competitive acid blockers (P-CABs) and alginates, validated deprescribing pathways, noninvasive biomarkers, and scalable care models.
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