Reflux Guidelines: Modest Changes Best for Most Infants

Diedtra Henderson

April 29, 2013

Two thirds of otherwise healthy infants spit up because of their physiology, and they should be treated not with medication but with modest lifestyle changes, such as altering their position during feeding. Medications should be reserved for infants who actually have gastroesophageal reflux disease (GERD), according to an American Academy of Pediatrics (AAP) clinical report.

Jenifer R. Lightdale, MD, MPH, from the Boston Children's Hospital in Massachusetts; David A. Gremse, MD, from the University of South Alabama in Mobile; and the AAP's Section on Gastroenterology, Hepatology, and Nutrition published the guidance for pediatricians online April 29 in Pediatrics.

During infants' routine 6-month physician's visit, one quarter of parents pepper pediatricians with questions about gastroesophageal reflux (GER), according to the authors. Indeed, parents are consulting pediatric specialists, and an increasing number of inappropriate prescriptions for proton pump inhibitors (PPIs) are being written to treat pediatric patients, the authors note.

The guideline authors encourage pediatricians to follow guidelines updated in 2009 by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, which would apply the most conservative approaches to the vast majority of infants and would reserve more aggressive treatments, including surgery, for children with intractable symptoms and risk for life-threatening complications.

"In the infant with uncomplicated recurrent regurgitation, it may be important to recognize physiologic GER that is effortless, painless, and not affecting growth," the authors write. "In this situation, pediatricians should focus on minimal testing and conservative management. Overuse of medications in the so-called 'happy spitter' should be avoided by all pediatric physicians."

At the heart of the guidelines is the pediatricians' ability to distinguish typical spitting up from the more problematic GERD, in which vomiting is accompanied by such symptoms as irritability, weight loss, refusing to eat, coughing, or wheezing and is confirmed through a series of diagnostic tests.

The guidelines counsel older children and adolescents to avoid caffeine, chocolate, alcohol, and spicy food and note the benefits of chewing sugarless gum. For older children with heartburn, if [PPIs] are indicated, children should take the medicine 30 minutes before eating. However, the guidelines "strike a note of caution" about inappropriate PPI prescriptions, which may increase the risk for lower respiratory tract infections.

"It cannot be overemphasized that pediatric best practice involves both identifying children at risk for complications of GERD and reassuring parents of patients with physiologic GER who are not at risk for complications to avoid unnecessary diagnostic procedures or pharmacologic therapy," the authors conclude.

Pediatrics. Published online April 29, 2013.