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 I. diagnosis

Background Gastroesophageal reflux disease (GERD) is a common reason for referral to pediatric and gastroenterology clinics. Still, uncertainty and variability exist in the evaluation, diagnostic approaches and management among different age groups and clinicians. This study aimed to report the results of a Guidelines process and an Italian expert Consensus focusing on the diagnosis of GERD in children to improve the clinical approach to these patients. Methods A multidisciplinary board of 16 participants identified eight PICO (Population/Patient/Problem, Intervention, Comparator and Outcome) questions, including definition, signs and symptoms, risk factors, diagnostic tests, treatment and prognosis of gastroesophageal reflux (GER) and GERD in children: four PICO questions were related to the diagnosis of GERD. Four databases (PubMed/Medline, Embase, Web of Science and Google Scholar) were searched from their inception to May 11, 2024, limited to children (0–18 years) and English language. For each PICO question a specific search string was developed. Guidelines, systematic reviews and clinical studies on diagnosis and management in children were considered to formulate evidence-based recommendations. Agreement was defined based on a 9-point Likert scale. A two-round Delphi method was conducted and consensus was defined as ≥ 80% agreement or disagreement. This paper focused on clinical symptoms and diagnosis of GER and GERD in pediatric ages. Results 123 studies were included that satisfied systematic research criteria. The panel provided 14 recommendations on diagnosis of GER and GERD and practice points for specific questions to clarify some clinical issues. Conclusion Symptoms of GER(D) are common in the pediatric population while regurgitation is frequently reported in the first months of life. In infancy symptoms mostly disappear spontaneously or after dietary modification. In infants and children with esophageal or extresophageal persistent symptoms, esophageal pH-MII monitoring and endoscopy are indicated to detect and characterize reflux episodes, phenotypes of GERD and esophagitis. In older children and adolescents reporting typical heartburn or in those with severe neurological impairment, a time-limited empirical trial of PPI can be considered as an initial diagnostic approach, with further testing reserved for non-responders.