Antireflux Medications for infants

Khoshoo V, Edell D, Aaron Thompson A, et al. Are We Overprescribing Antireflux Medications for Infants With Regurgitation? Pediatrics 2007 120:946-949. [Full text] [PDF]

Objective. Our goal was to evaluate the diagnosis and treatmentof infants with persistent regurgitation who were referred toa pediatric gastroenterology service.

Methods. The records of 64 infants with persistent regurgitationand without any neurodevelopmental abnormalities, underlyingillness, or cigarette smoke exposure were evaluated for diagnosticworkup and treatment. Forty-four infants underwent extendedesophageal pH monitoring.

Results. Only 8 of 44 pH studies showed abnormal acid reflux.Forty-two of these 44 infants were already on antireflux medications.Other etiologies included hypertrophic pyloric stenosis (4)and renal tubular acidosis (1). Discontinuation of medicationdid not result in worsening of symptoms in most infants withnormal pH studies.

Conclusions. The majority of infants who were prescribed antirefluxdrugs did not meet diagnostic criteria for gastroesophagealreflux disease.

Comments. The finding of this study is based on evaluating 44 infants which I believe that the sample size is too small to draw a significant conclusion. The authors excluded those who were born at preterm. This is considered as a biased selection for the studied population. As it has been confirmed in several studies that gastroesophageal reflux (GER) occurs commonly in premature infants and if they were included in the study I believe that the difference will be insignificant. In addition, mild GER typically is a developmental process that resolves with maturation and in many occasions, antireflux medications are not required. Although the esophageal pH monitoring is used as a diagnostic test for GER disease in infants, previous studies reported substantial variability among patients due to the difficulty in controlling and standardizing the feeding regimen. See also the study by T I Omari, G P Davidson (Archives of Disease in Childhood Fetal and Neonatal Edition 2003). Finally, GER is common but it is difficult to diagnose. I might agree with the authors that anti-reflux medications are over-used however this needs to be well studied. SAA.

Editors Note: As I have said in the past, GER is one of the most over-diagnosed and over-treated conditions in premature babies. The fact is that almost all premature babies (and probably most term babies) have some degree of GE reflux that you will be able to demonstrate if you look hard enough. This reflux is usually not the cause of the apnea, bradycardia or desaturation episodes that we frequently see in premature babies. Treating the reflux with medications that block release of stomach acids may interfere with digestion, and may predispose to fungal infections. More studies are needed to determine if the use of prokinetic agents (such as metoclopramide) to improve GI motility and reduce feeding intolerance may be helpful in premature infants with or without GE reflux. For further discussion of the diagnosis and treatment of GER in infants, see 3-011, 3-012, 5-011, 5-030, 6-041, and 7-033. ABK.

You may add your own comments to the discussion of this topic by selecting : Submit Comments.