Guidelines on diagnosis and management of gastroesophageal reflux disease in infants, children and adolescents: a joint consensus from Italian pediatric societies (SIP and SIGENP) -Part II: management

Suspected gastroesophageal reflux disease (GERD) is one of the most common reasons for referral to pediatric and gastroenterology clinics, and proton pump inhibitors (PPIs) are frequently prescribed. Currently, there is still wide heterogeneity in treatment, especially in neonates and extraesophageal presentations. This article aimed to provide guidelines and a consensus of Italian experts on the management of GERD in infants, children, and adolescents, in order to improve the care and treatment of these patients. A multidisciplinary pediatric panel identified four key clinical questions (PICOs) regarding pharmacological and non-pharmacological treatments, surgical intervention, and prognosis of pediatric GERD. Four databases (PubMed/Medline, Embase, Web of Science, and Google Scholar) were searched from inception to May 2024, using a specific search string for each PICO and limiting the search to children (0–18 years) and to English language. Previous pediatric guidelines, systematic reviews, and clinical trials focused on the treatment of GERD were considered to formulate evidence-based recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and AGREE II systems were used to assess study quality; a 9-point Likert scale was used to rate the recommendations. A two-round Delphi method was conducted to reach consensus, defined as ≥ 80% agreement or disagreement. The systematic review identified three previous pediatric guidelines, eight systematic reviews, 83 RCTs, and three observational studies. The panel provided 26 recommendations regarding the management and treatment of GERD in pediatric patients. All reached consensus, with the majority expressing strong support for the intervention. The panel also provided practice insights for each PICO to improve the clinical application and clarity of these guidelines. Regurgitation is common in infants, but in most cases, no treatment is necessary. When regurgitation causes discomfort, a brief trial of alginate or thickened formulas or a cow’s milk elimination diet may be considered, particularly if other symptoms, including crying and dermatitis, are associated. For children who complain of heartburn or have severe neurologic deficits, a short course of empirical PPIs treatment may be considered, monitoring the clinical response and testing if no improvement is seen. PPIs are recommended in infants and children with reflux esophagitis, or acid reflux detected by esophageal pH monitoring. Children at high- risk for chronic GERD requiring prolonged treatment and multidisciplinary care have been identified. Surgery should be considered for severe or complicated GERD after a comprehensive diagnostic workup and optimal pharmacological management.