Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) is a physiologic process in which the stomach contents pass into the esophagus; gastroesophageal reflux disease (GERD) is defined by the troublesome symptoms or complications that result from reflux. [Lightdale: 2013] Both are common in children with special health care needs, particularly in children with prematurity, neurological impairment, obesity, repaired esophageal atresia, hiatal hernia, achalasia, and chronic respiratory disorders that include bronchopulmonary dysplasia (chronic lung disease of prematurity), idiopathic interstitial fibrosis, and cystic fibrosis. [Lightdale: 2013] Although not completely understood, the mechanisms for reflux may include abnormal esophageal motility and delayed gastric emptying, possibly exacerbated by constipation. Clinical symptoms or signs suggestive of GERD vary by age.

Child Experiencing Discomfort and Holding Stomach - Signs of Gastroesophageal Reflux
Voisin/Phanie/Science Photo Library
Infants (0-12 months old) may experience regurgitation and vomiting with: [Lightdale: 2013]
  • Irritability
  • Feeding refusal or decreased appetite
  • Dysphagia/painful swallowing
  • Poor weight gain
  • Arching of the back during feeds
  • Disturbed sleep
  • Coughing
  • Choking
  • Wheezing
  • Upper respiratory symptoms
Children (1-5 years old) may experience: [Lightdale: 2013]
  • Regurgitation or vomiting, which can lead to poor weight gain or nutritional deficiencies
  • Feeding refusal or decreased appetite
  • Abdominal pain

Children (6 years old-adolescents) may experience: [Lightdale: 2013]
  • Heartburn
  • Epigastric pain
  • Painful swallowing/dysphagia
  • Nausea
  • Sour burps
  • Nocturnal cough
  • Wheezing
  • Sore throat, laryngitis, or hoarseness
  • Recurrent pneumonia or sinusitis
  • Eroded tooth enamel
Many infants have GER due to the normal physiological process of how the esophageal sphincter develops tone, with symptoms that tend to peak at 4 months of age and resolve by 1 year of age. For specific information about management of reflux in babies, see Feeding and Gastrointestinal Issues of the Preterm Infant.

Evaluation

In many situations, empiric treatment without specific evaluation is appropriate with further evaluation or referral to gastroenterology if symptoms do not resolve. Also, empirically treat constipation if suspected based on history. Management information can be found in the Portal's Constipation.
Questionnaires and screening instruments have been published to help detect GERD, including the Infant Gastrointestinal Symptom Questionnaire [Riley: 2015], the Gastroesophageal Reflux Questionnaire (GERQ) and GERQ-Revised [Kleinman: 2006], and the GERD Symptom Questionnaire in infants (GSQ-I) and young children (GSQ-YC) [Deal: 2005]; however, their usefulness in primary care has not been clearly demonstrated.
Red flags that might indicate other etiologies include bilious emesis, hematemesis or melena, consistently forceful vomiting, dysphagia, distension or abdominal tenderness, hepatomegaly or splenomegaly, fever, bulging fontanelle, lethargy, or seizures.  [Lightdale: 2013]
An upper gastrointestinal barium study (UGI) can be ordered to evaluate anatomy and to document the presence of reflux, but the study lacks sensitivity, reflux may not occur during the study, and sensitivity to diagnose esophagitis is also low. However, the UGI can identify abnormalities, such as an esophageal stricture, duodenal web, malrotation, or delayed gastric emptying. The clinician can consider including delayed films (“small bowel follow-through”) to evaluate abnormalities in the small intestine.
Bravo pH Monitoring - Capsule in the Esophagus
Bravo pH Monitoring - Capsule in Esophagus
Tim Vernon/Science Photo Library
A Bravo pH probe may be used in children ages ≥5 years. A capsular probe is attached via endoscopy to the esophagus then left in place for 48 hours. The probe wirelessly transmits data to an external receiver about acid refluxing into the esophagus. After 48 hours, the probe passes through the intestinal tract and is eliminated naturally. This study is considered more tolerable for children because unlike many other pH tests, there is no need for a catheter to be placed intranasally. 

A multichannel impedance pH probe can detect and measure both anterograde and retrograde movement of acid and non-acid fluids. In addition, it detects solids and air moving through the esophagus. The impedance probe can correlate with reflux, cough, apnea, rumination, and risk for aspiration. [Lightdale: 2013]
A dual channel pH probe tests for reflux frequency and duration by measuring acid in the esophagus during routine activities and sleep. It can help demonstrate patterns associated with the reflux and whether it is associated with respiratory symptoms. The test itself may be difficult for some children to endure as it requires having a tube extend from the nose to the esophagus for a 24-hour period, and it may require a brief hospital stay. The study does not differentiate between GER and GERD; clinical correlation must be used to do this. This study is no longer in common use.
An esophagogastroduodenoscopy (EGD) with biopsies can help diagnose moderate to severe cases of reflux that result in erosions or tissue changes suggestive of esophagitis. It can also help in diagnosing other conditions of the upper GI tract that include abnormal esophageal anatomy, eosinophilic esophagitis, celiac disease, esophageal Crohn disease, webs, infections (including candida, herpes, or H. pylori), Barrett esophagus, or peptic ulcers. Since the test is invasive and requires sedation, its value should be weighed against the severity of symptoms and response to treatment.
A modified barium swallow study (MBSS) is used to evaluate aspiration risk and swallowing disorders. While evidence of reflux may be noted during the study, it is not recommended for routine evaluation of isolated reflux.

Treatment

Lifestyle Changes

Management of GER is often accomplished through lifestyle changes, whereas management of GERD involves lifestyle changes as well as judicious use of medications, and less commonly, surgical interventions. When recommending the following lifestyle changes, it is important to weigh the perceived burden by the family versus the knowledge that limited evidence exists for many of the interventions.
Considerations for infants:
  • For breastfed infants, remove dairy and egg products from the maternal diet for 2-4 weeks to determine if a protein allergy may be causing reflux-like symptoms. [Lightdale: 2013] Soy or wheat exclusion may also be considered if balanced with the mother's nutritional needs.
  • In formula-fed infants, initiate a trial of extensively hydrolyzed or amino acid based formulas. See Formulas for examples of brands.
  • Thicken breastmilk or formula using rice cereal (up to 1 tablespoon per ounce) [Lightdale: 2013] or a commercial “anti-reflux” formula (contains added starch). Keep in mind that thickening breastmilk and formula increases caloric density. Commercial thickeners may also be considered; however, the risk of necrotizing enterocolitis may be increased in preterm infants. A Cochrane review did not demonstrate sufficient evidence to support or refute thickening for management of GER and GERD in infants, and little is known about the long-term effects of using thickeners. [Huang: 2002]
  • Eliminate second- and third-hand smoke exposure (residue from tobacco products that is left behind after smoking).
  • Position the infant upright during and after feeds, or prone while observed and awake. Supine and semi-supine positions, such as in a car seat, increase refluxing. Positioning recommendations mostly are based on pH probe or pH/impedance studies (described below). [Lightdale: 2013]
  • Offer smaller, more frequent feeds.
Considerations for children and adolescents:
  • Reduce excess body weight to reduce pressure on the esophageal sphincter.
  • No smoking. Avoid second- and third-hand smoke exposure.
  • Avoid alcohol use (especially relevant for some adolescents)
  • Avoid foods that may increase reflux (chocolate, peppermint, onions, garlic) and spicy, fatty, or acidic (citrus- or tomato-based) foods.
  • Chew sugarless gum after meals to promote motility. [Lightdale: 2013]
Considerations for patients with feeding tubes:
  • Adjustments in feeding schedule (reducing bolus sizes and limiting feedings given in the recumbent position) may be helpful. Jejunal tube feeds are not shown reduce reflux symptoms. [Srivastava: 2009] [Campwala: 2015] [Wales: 2002]

Medications

Typically, treatment trials start with a short course (e.g., 14 days) of an H2 blocker (histamine-2 receptor antagonists), followed by step-up therapy with a proton pump inhibitors (PPIs) if the H2 blocker is insufficient for treatment and the suspicion for GERD is still high.
  • For infants, the use of anti-reflux medications is limited and usually considered as a last resort after attempting lifestyle changes. [Lightdale: 2013] When using medications, the general advice is to proceed with caution and limit duration of therapy.
  • For medically complex children who may require long-term medication use for GERD, frequently review the benefits and risks with caregivers and attempt to wean medications, whenever possible, in coordination with the child’s specialists. Use of medications for treatment of GERD in children, particularly in children with neurodisability, has limited high-quality evidence. [Tighe: 2014]
  • Over the counter formulations for acid suppressants and prokinetic agents are available.

Acid Suppressants

H2 Blockers
While many consider PPIs to be more effective for treatment of GERD, H2 blockers usually cost less and tend to be covered better by insurers (who may require treatment failure with H2 blockers before authorizing coverage for a PPI). When taken orally, H2 blockers offer quicker relief than PPIs and start working within an hour to neutralize acid and relieve reflux pain. The effect lasts 10-12 hours. Administration is typically 2 times daily (BID) at meals or bedtime; it is sometimes given 3 times daily in smaller doses for children whose symptoms recur more quickly.
  • Long-term use can induce tachyphylaxis or tolerance. [Vandenplas: 2009] Risks of longer-term use can include vitamin B12 deficiency and increased risk for developing gastroenteritis and pneumonia. Use caution in patients with renal or hepatic impairment, and consult a drug reference due to multiple interactions with other drugs.
Ranitidine (Zantac) [Lightdale: 2013]
  • FDA indicated for ≥1 month old
  • Formulations -Tablets (75 mg, 150 mg, 300 mg), capsules (150 mg, 300 mg), peppermint flavored syrup (15 mg/1 mL), effervescent tablets (25 mg), and oral suspension for compounding (22.4 mg/1 mL).
  • Dosing - 5-10 mg/kg/day divided 2 or 3 times a day, or:
    • ≥16 years old - 150 mg BID
Famotidine (Pepcid) [Lightdale: 2013]
  • FDA indicated for ages ≥1 year
  • Formulations - Cherry-banana-mint solution (40 mg/5 mL) and tablets (10 mg, 20 mg, 40 mg). Benzyl alcohol solution associated with adverse events in neonates. Torsades de pointes has been associated with use of famotidine.
  • Dosing - 0.5-1 mg/kg/day divided BID
Nizatidine (Axid) [Lightdale: 2013]
  • FDA indicated for ages ≥12 years
  • Formulations - Bubble-gum flavored solution (15 mg/1 mL), capsules (150 mg, 300 mg), and tablets (75 mg).
  • Dosing - 5-10 mg/kg/day divided BID, or:
    • ≥12 years old - 150 mg BID
Cimetidine (Tagamet) [Lightdale: 2013]
  • FDA indicated for ages ≥16 years
  • Formulations - Solution (300 mg/5 mL) and tablets (200 mg, 300 mg, 400 mg, 800 mg).
  • Dosing - 30–40 mg/kg/d, divided in 4 doses, or:
    • Infants - 10-20 mg/kg/day divided every 6-12 hours
    • Children - 20-40 mg/kg/day in divided doses every 6 hours
Proton Pump Inhibitors (PPIs)
PPIs work in the stomach to prevent gastric acid production, thus alleviating pain associated with acid reflux. Moderate evidence supports short-term use (1-2 months) of PPIs in children with GERD [Tighe: 2014]; evidence does not demonstrate a clear benefit for infants. [Chen: 2012] Depending on the formulation, PPIs are given about 30 to 60 minutes before meals. Symptom relief is slower compared to H2 blockers and antacids; PPIs can take 1-5 hours until onset of action, and the effect can last 3-5 days. Due to the pharmacokinetics, PPIs are not typically used for an as-needed, quick-relief medication; instead, they are given daily to achieve a steady effect. Insurers may require prescribers to demonstrate the patient’s lack of response to less costly H2 blockers and receive prior authorization before covering PPIs. 
  • PPIs historically have been considered safe and well tolerated; however, prescribers are growing increasingly concerned about risks associated with long-term PPI use, such as increased risk for enteric infections including Clostridium difficile, dysbiosis (an imbalance of microflora in the body), small intestinal bacterial overgrowth, acute interstitial nephritis, and possibly pneumonia in infants. [Scarpignato: 2016]
  • Use additional caution when prescribing these medications for children with liver disease or for children taking anticoagulants, seizure medications, antibiotics, chemo agents, and other medications.
  • The medications work in the stomach, so children with feeding tubes that bypass the stomach may not benefit from their use.
Lansoprazole (Prevacid, First-Lansoprazole) [Lightdale: 2013]
  • FDA indicated for ages ≤1 year
  • Formulations - Capsules (15 mg, 30 mg) that can be swallowed whole, sprinkled on soft food, dissolved in certain juices, or used for nasogastric tube, and strawberry-flavored orally disintegrating tablets (15 mg, 30 mg) that can be dissolved and delivered via syringe or nasogastric tube.
  • Dosing - 3 months-13 years: 1.4 mg/kg/day (range 0.7–3 mg/kg/day) once daily. Younger infants requiring PPI use may be dosed at 0.5-1 mg/kg/day, or:
    • ≥3 months old - 7.5 mg BID or 15 mg once daily
    • 1-11 years old - ≤30 kg: 15 mg once daily; >30 kg: 30 mg once daily
    • ≥12 years old-adolescents - 15 mg once daily
Omeprazole (Prilosec, First-Omeprazole) [Lightdale: 2013]
  • FDA indicated for ages ≤1 year
  • Formulations - Delayed-release capsules (10 mg, 20 mg, 40 mg) (can sprinkle into soft foods); delayed release tablets (20 mg) (swallow whole); packets (2.5 mg, 10 mg) (reconstitute with water for each dose – recommended if using a nasogastric tube); and suspension (compounded to 2 mg/1 mL). FDA indicated for ages ≥2 years.
  • Dosing - 0.7-3.3 mg/kg/day. Infant dosing is 0.7-1.5 mg/kg/day, or:
    • 5 kg - <10 kg - 5 mg once daily
    • 10 kg - ≤20 kg - 10 mg once daily
    • >20 kg: 20 mg - once daily, or 1 mg/kg/dose once or BID
Esomeprazole (Nexium) [Lightdale: 2013]
  • FDA indicated for ages ≥1 year
  • Formulations - Delayed-release capsules (20 mg, 40 mg) (can open and sprinkle contents into soft foods or used for nasogastric tube; delayed release tablets (20 mg) (swallow whole); and packets (2.5 mg, 5 mg, 10 mg, 20 mg, 40 mg) (ok for nasogastric tube).
  • Dosing - 0.7-3.3 mg/kg/day, or:
    • 1-11 years old - 10 mg
    • ≥12 years old - 20 mg
Rabeprazole (Aciphex) [Lightdale: 2013]
  • FDA indicated for ages ≥12 years
  • Formulations - Capsules (5 mg, 10 mg) (sprinkle contents into soft food) and tablets (10 mg, 20 mg).
  • Dosing
    • 1-11 years - <15 kg: 5-10 mg once daily; ≥15 kg: 10 mg once daily
    • ≥12 years-adolescents - 20 mg once daily.
Pantoprazole (Protonix) [Anderson: 2016]
  • FDA indicated for pediatric GERD with history of erosive esophagitis
  • Formulations - Tablets (20 mg, 40 mg) and delayed-release granules for oral suspension (40 mg in a unit dose packet) (mix with applesauce or apple juice, or used for nasogastric tube)
  • Dosing - ≥5 years - 15-39 kg: 20 mg orally once a day; ≥40 kg: 40 mg orally once a day
Antacids
Over-the-counter medications used for occasional reflux symptoms include acid neutralizers (e.g., Tums) and other types of medications (alginates or sucralfate) that coat the surface of the stomach. Though commonly used for symptomatic relief in adults and sometimes to help determine if the child’s symptoms improve with acid neutralization, these medications are not recommended for use in children and can result in toxicity from components such as calcium or aluminum.  [Lightdale: 2013]

Prokinetics

Slow gut motility can prolong gastric emptying and contribute to retrograde flow of stomach contents into the esophagus, potentially causing irritation and inflammation. If impaired gut motility is suspected to contribute to a child’s reflux symptoms, prokinetic agents may reduce reliance on acid suppressants or be used as adjuvant therapy; however, lack of convincing evidence of efficacy, potential side effects, and safety risks should be considered. Ensuring that constipation is effectively managed is an essential precursor to use of a prokinetic because stool clogging the intestines could block the passage of stomach contents. Management of constipation information can be found in the Portal's Constipation.
  • Strongly consider consultation with a pediatric gastroenterologist prior to initiating therapy with a prokinetic agent. Due to the risks associated with these medications, dosing guidelines are provided here only for erythromycin ethylsuccinate (EES), which is considered the safest option
  • Common side effects of EES include gastrointestinal upset and rashes. When used for chronic treatment, tachyphylaxis may develop, so 2-week breaks are frequently employed. [Waseem: 2009] Be aware that EES increases the risk of cardiac toxicity, particularly when used with certain other medications, including antipsychotics, and when used at antibiotic doses. [Ericson: 2015] EES use in neonates in the first 2 weeks of life is associated with increased risk for pyloric stenosis. Consider electrocardiograph monitoring before treatment and periodically during treatment as well, and avoid use in patients with prolonged QT interval.
Erythromycin ethylsuccinate (EES)
Initially developed as an antibiotic, researchers found that low-dose EES has promotility benefits by stimulating the hormone motilin, which results in increased contractions in the antrum of the stomach and faster gastric emptying. Low-dose EES may have better efficacy than metoclopramide with increasing gastric motility.
  • Formulations - Various fruit-flavored suspensions (200 mg/5 mL, 400 mg/5 mL); tablets (200 mg, 400 mg, 500 mg); and delayed release tablets (250 mg, 333 mg, 500 mg) [Lightdale: 2013]
  • Dosing - 3 mg/kg/dose 4 times daily (may increase as needed to effect); maximum dose: 10 mg/kg or 250 mg [Lightdale: 2013]
Azithromycin
Azithromycin has been used by pediatric gastroenterologists as an alternative to EES in certain cases. Consultation with a pediatric gastroenterologist is recommended before starting azithromycin for motility.
Baclofen
This GABA-B receptor antagonist is typically used to reduce muscle spasticity; it also can improve gastric motility and reduce relaxations of the lower esophageal sphincter, which prevent some refluxing episodes. Side effects include sedation and lowered seizure threshold. Therefore, a seizure-free child with reflux (related to slow motility), cerebral palsy, and spasticity may be an ideal candidate for using baclofen and may receive dual benefit from using this medication. Consultation with a pediatric rehabilitation medicine specialist (physiatrist) is recommended when using baclofen to treat spasticity (see all Pediatric Physical Medicine & Rehab services providers (10) in our database).
Metoclopramide (Reglan)
Metoclopramide may mediate its impact through increased lower esophageal sphincter pressure, accelerated gastric emptying, and increased small bowel peristalsis. Metoclopramide also has centrally acting anti-emetic properties. However, in a large percentage of children, it can cause significant central nervous system side effects that include fatigue, restlessness, tremors, increased tone, extrapyramidal reactions (dystonic, oculogyric crisis), and tardive dyskinesia. Monitor for irritability, sedation, diarrhea, increased emesis/feeding intolerance, and neurological symptoms. There is a black box warning due to the risk of tardive dyskinesia.
Cisapride
Because severe cardiac arrhythmias (e.g., ventricular tachycardia, ventricular fibrillation, torsades de pointes, and QT prolongation) have been reported in patients taking cisapride, this medication is only available through a limited access protocol or as part of a clinical trial. This medication may be considered by a pediatric gastroenterologist for use with certain patients.
Domperidone
Due to risk of multiple severe side effects, this medication is not available in the United States.

Surgical Therapy

For intractable GERD or risk of severe complications associated with GERD, referral to pediatric gastroenterology is advised. In consultation with these specialists, surgical procedures such as Nissen fundoplication (anti-reflux surgery) may be considered. The Nissen fundoplication is performed laparoscopically unless there is a contraindication.

Subspecialist Collaborations

Consider referral to pediatric gastroenterology for:
  • Recurrent, severe symptoms
  • Failure of empiric therapy
  • GI bleeding
  • If a feeding tube or reflux surgery (e.g., Nissen fundoplication) is being considered
  • Iron deficiency associated with chronic esophagitis
  • Consideration of other diagnoses
  • Determining most useful studies for further evaluation
  • Determining benefit of placement of a nasojejunal tube or gastrojejunal tube
Please see all Pediatric Gastroenterology services providers (3) in our database.

Resources

Information & Support

Feeding and Gastrointestinal Issues of the Preterm Infant
Diagnosis and management information pertinent to newborns and premature infants with GERD; Medical Home Portal.

Constipation
Assessment and management information; Medical Home Portal.

For Professionals

Acid Reflux in Children with Autism (Autism Speaks)
A video about recognizing the signs of reflux in children with autism; presented by GI Specialist Tim Buie, director of pediatric gastroenterology and nutrition at MassGeneral Hospital’s Lurie Center for Autism, in Boston.

For Parents and Patients

GER and GERD in Children and Teens (NIDDK)
Extensive information that includes symptoms, causes, diagnosis, treatment, and diet; National Institute of Diabetes and Digestive and Kidney Diseases.

Children and Adolescents with GERD (University of Utah)
A brief, informative, overview of GERD.

Practice Guidelines

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).
J Pediatr Gastroenterol Nutr. 2009;49(4):498-547. PubMed abstract

Services

Pediatric Gastroenterology

See all Pediatric Gastroenterology services providers (3) in our database.

Pediatric Physical Medicine & Rehab

See all Pediatric Physical Medicine & Rehab services providers (10) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

PubMed search for gastroesophageal reflux disease in children, last 1 year.

Lightdale JR, Gremse DA.
Gastroesophageal reflux: management guidance for the pediatrician.
Pediatrics. 2013;131(5):e1684-95. PubMed abstract / Full Text

Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM.
Pharmacological treatment of children with gastro-oesophageal reflux.
Cochrane Database Syst Rev. 2014;11:CD008550. PubMed abstract

Scarpignato C, Gatta L, Zullo A, Blandizzi C.
Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression.
BMC Med. 2016;14(1):179. PubMed abstract / Full Text

Authors

Reviewing Author: Molly O'Gorman, MD - 3/2017
Content Last Updated: 3/2017

Page Bibliography

Anderson LA (editor).
Pantoprazole Dosage.
Drugs.com; (2016) https://www.drugs.com/pantoprazole.html. Accessed on Feb 21, 2017.

Campwala I, Perrone E, Yanni G, Shah M, Gollin G.
Complications of gastrojejunal feeding tubes in children.
J Surg Res. 2015;199(1):67-71. PubMed abstract

Chen IL, Gao WY, Johnson AP, Niak A, Troiani J, Korvick J, Snow N, Estes K, Taylor A, Griebel D.
Proton pump inhibitor use in infants: FDA reviewer experience.
J Pediatr Gastroenterol Nutr. 2012;54(1):8-14. PubMed abstract

Deal L, Gold BD, Gremse DA, Winter HS, Peters SB, Fraga PD, Mack ME, Gaylord SM, Tolia V, Fitzgerald JF.
Age-specific questionnaires distinguish GERD symptom frequency and severity in infants and young children: development and initial validation.
J Pediatr Gastroenterol Nutr. 2005;41(2):178-85. PubMed abstract

Ericson JE, Arnold C, Cheeseman J, Cho J, Kaneko S, Wilson E, Clark RH, Benjamin DK Jr, Chu V, Smith PB, Hornik CP.
Use and Safety of Erythromycin and Metoclopramide in Hospitalized Infants.
J Pediatr Gastroenterol Nutr. 2015;61(3):334-9. PubMed abstract / Full Text

Huang RC, Forbes DA, Davies MW.
Feed thickener for newborn infants with gastro-oesophageal reflux.
Cochrane Database Syst Rev. 2002(3):CD003211. PubMed abstract

Kleinman L, Revicki DA, Flood E.
Validation issues in questionnaires for diagnosis and monitoring of gastroesophageal reflux disease in children.
Curr Gastroenterol Rep. 2006;8(3):230-6. PubMed abstract

Lightdale JR, Gremse DA.
Gastroesophageal reflux: management guidance for the pediatrician.
Pediatrics. 2013;131(5):e1684-95. PubMed abstract / Full Text

Riley AW, Trabulsi J, Yao M, Bevans KB, DeRusso PA.
Validation of a Parent Report Questionnaire: The Infant Gastrointestinal Symptom Questionnaire.
Clin Pediatr (Phila). 2015;54(12):1167-74. PubMed abstract / Full Text

Scarpignato C, Gatta L, Zullo A, Blandizzi C.
Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression.
BMC Med. 2016;14(1):179. PubMed abstract / Full Text

Srivastava R, Downey EC, O'Gorman M, Feola P, Samore M, Holubkov R, Mundorff M, James BC, Rosenbaum P, Young PC, Dean JM.
Impact of fundoplication versus gastrojejunal feeding tubes on mortality and in preventing aspiration pneumonia in young children with neurologic impairment who have gastroesophageal reflux disease.
Pediatrics. 2009;123(1):338-45. PubMed abstract

Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM.
Pharmacological treatment of children with gastro-oesophageal reflux.
Cochrane Database Syst Rev. 2014;11:CD008550. PubMed abstract

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).
J Pediatr Gastroenterol Nutr. 2009;49(4):498-547. PubMed abstract

Wales PW, Diamond IR, Dutta S, Muraca S, Chait P, Connolly B, Langer JC.
Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux.
J Pediatr Surg. 2002;37(3):407-12. PubMed abstract

Waseem S, Moshiree B, Draganov PV.
Gastroparesis: current diagnostic challenges and management considerations.
World J Gastroenterol. 2009;15(1):25-37. PubMed abstract / Full Text