ADC Online First, published on March 9, 2015 as 10.1136/archdischild-2014-306232 Review
Gastro-oesophageal reflux in young babies: who should be treated? John W Puntis Correspondence to Dr John W Puntis, Paediatric Offices, off A Floor corridor, Old Main Site, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK; [email protected] Received 31 December 2014 Revised 8 February 2015 Accepted 16 February 2015
ABSTRACT Recent guidelines focus on a non-interventionist approach to management of gastro-oesophageal reflux in infancy and emphasise the importance of explanation, reassurance and simple measures such as attention to feeding. Relying on clinical history alone leads to over diagnosis of disease, and widely used medications are often ineffective for symptom relief and carry significant risk of harm. The association between vomiting in infancy and other problems such as crying and poor feeding should not be interpreted as implying causality. When there are strong pointers to underlying gastrooesophageal reflux disease, invasive investigations are required in order to formulate appropriate intervention.
Gastro-oesophageal reflux (GOR) in young babies is a physiological phenomenon that in the vast majority can be expected to resolve spontaneously. Management involves repeated explanation and reassurance, together with simple advice regarding feeding and positioning. Gastro-oesophageal reflux disease (GORD) occurs when this normal event results in the occurrence of symptoms or complications.1 GOR can result simply from overfeeding, a primary disorder of function of the upper gastrointestinal tract, or a systemic disorder affecting motility such as neurological impairment in cerebral palsy. While uncomplicated reflux does not require treatment, the key issue for clinicians is to differentiate between simple, ‘physiological’ GOR and pathological GORD once less common causes of vomiting have been discounted (box 1). The latter can often be identified by a careful history and examination including growth assessment, followed by targeted investigations. Growth faltering is always a red flag sign indicating likely pathology and the need for investigation. Due to the association between physiological GOR in early life and common behavioural problems such as feeding difficulties, crying and fussing, a diagnosis of ‘GORD’ is often made through causality being wrongly inferred. This in turn leads to both unnecessary treatment and iatrogenic disease (box 2).
vomiting; it is considered physiological in infants when symptoms are absent or not troublesome, ▸ GORD: The presence of troublesome symptoms (ie, those that adversely affect the well-being of the child) and/or complications (eg, tissue damage or inflammation, as in oesophagitis, reactive airways disease or pulmonary aspiration). ▸ Regurgitation (posseting, or spitting up): The effortless return of previously swallowed food or secretions into or out of the mouth. In children 19% of preterm infants cared for in the neonatal intensive care unit had been treated with this agent,3 sometimes referred to as ‘vitamin C’.4 A Cochrane review concluded that there was no evidence that cisapride was effective for treating gastro-oesophageal reflux disease (GORD) in children.5 Domperidone: A peripheral D2 receptor antagonist that increases motility and gastric emptying. Widely prescribed since the unavailability of cisapride, there is little clinical trial evidence of efficacy in GORD. Potential serious cardiac side effects mean it should not be used for long-term treatment.6 Erythromycin: A macrolide antibiotic that increases gastrointestinal motility by acting directly on gut motilin receptors. There is no evidence of efficacy in GORD7; potential side effects include nausea and vomiting, hepatic damage, anaphylaxis, arrhythmias and pyloric stenosis.8 Metoclopramide: A dopamine antagonist that stimulates motility, accelerates gastric emptying and increases lower oesophageal sphincter tone. Ineffective, its use was complicated by adverse effects including extrapyramidal reactions such as dystonia and tardive dyskinesia. Ranitidine: Inhibits H2 receptors of gastric parietal cells and is effective at suppressing acid secretion. Side effects include abdominal pain, nausea vomiting and diarrhoea; tolerance develops quickly. To prevent rebound hypersecretion of acid, stepwise withdrawal is advised; acid suppression by raising stomach pH will negate the effect of antiregurgitation milk (both also apply to proton pump inhibitors (PPI)). Lansoprazole and omeprazole: PPI that inactivate the H+/K+ -ATPase pump in parietal cells preventing gastric acid secretion. Side effects include headache, nausea, vomiting, abdominal pain, diarrhoea or constipation. Gastric polyps,9 increased risk of community acquired pneumonia10 and vitamin B12 deficiency11 have also been reported. No evidence of additional benefit if combined with an H2 receptor inhibitor. PPI given via feeding tubes may cause blockage; although omeprazole is available as an unlicensed solution, it is extremely expensive.
improvement.24 Grol et al25 investigated which attributes of clinical practice guidelines influenced their use in a general practice setting. Recommendations that were non-controversial, clear, did not demand a change in existing practice routine and were based on research evidence were more likely to be followed. Although considered ‘excellent’ by some,23 a recent study evaluated whether the 2009 North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)–European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Puntis JW. Arch Dis Child 2015;0:1–5. doi:10.1136/archdischild-2014-306232
Review clinical practice guideline for GOR13 was in fact being implemented by clinicians.26 A structured questionnaire including a series of case scenarios was sent to a random sample of general paediatricians across 11 European countries. From 567 replies (a return of 42%),
Gastro-oesophageal reflux in young babies: who should be treated? John W Puntis Correspondence to Dr John W Puntis, Paediatric Offices, off A Floor corridor, Old Main Site, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK; [email protected] Received 31 December 2014 Revised 8 February 2015 Accepted 16 February 2015
ABSTRACT Recent guidelines focus on a non-interventionist approach to management of gastro-oesophageal reflux in infancy and emphasise the importance of explanation, reassurance and simple measures such as attention to feeding. Relying on clinical history alone leads to over diagnosis of disease, and widely used medications are often ineffective for symptom relief and carry significant risk of harm. The association between vomiting in infancy and other problems such as crying and poor feeding should not be interpreted as implying causality. When there are strong pointers to underlying gastrooesophageal reflux disease, invasive investigations are required in order to formulate appropriate intervention.
Gastro-oesophageal reflux (GOR) in young babies is a physiological phenomenon that in the vast majority can be expected to resolve spontaneously. Management involves repeated explanation and reassurance, together with simple advice regarding feeding and positioning. Gastro-oesophageal reflux disease (GORD) occurs when this normal event results in the occurrence of symptoms or complications.1 GOR can result simply from overfeeding, a primary disorder of function of the upper gastrointestinal tract, or a systemic disorder affecting motility such as neurological impairment in cerebral palsy. While uncomplicated reflux does not require treatment, the key issue for clinicians is to differentiate between simple, ‘physiological’ GOR and pathological GORD once less common causes of vomiting have been discounted (box 1). The latter can often be identified by a careful history and examination including growth assessment, followed by targeted investigations. Growth faltering is always a red flag sign indicating likely pathology and the need for investigation. Due to the association between physiological GOR in early life and common behavioural problems such as feeding difficulties, crying and fussing, a diagnosis of ‘GORD’ is often made through causality being wrongly inferred. This in turn leads to both unnecessary treatment and iatrogenic disease (box 2).
vomiting; it is considered physiological in infants when symptoms are absent or not troublesome, ▸ GORD: The presence of troublesome symptoms (ie, those that adversely affect the well-being of the child) and/or complications (eg, tissue damage or inflammation, as in oesophagitis, reactive airways disease or pulmonary aspiration). ▸ Regurgitation (posseting, or spitting up): The effortless return of previously swallowed food or secretions into or out of the mouth. In children 19% of preterm infants cared for in the neonatal intensive care unit had been treated with this agent,3 sometimes referred to as ‘vitamin C’.4 A Cochrane review concluded that there was no evidence that cisapride was effective for treating gastro-oesophageal reflux disease (GORD) in children.5 Domperidone: A peripheral D2 receptor antagonist that increases motility and gastric emptying. Widely prescribed since the unavailability of cisapride, there is little clinical trial evidence of efficacy in GORD. Potential serious cardiac side effects mean it should not be used for long-term treatment.6 Erythromycin: A macrolide antibiotic that increases gastrointestinal motility by acting directly on gut motilin receptors. There is no evidence of efficacy in GORD7; potential side effects include nausea and vomiting, hepatic damage, anaphylaxis, arrhythmias and pyloric stenosis.8 Metoclopramide: A dopamine antagonist that stimulates motility, accelerates gastric emptying and increases lower oesophageal sphincter tone. Ineffective, its use was complicated by adverse effects including extrapyramidal reactions such as dystonia and tardive dyskinesia. Ranitidine: Inhibits H2 receptors of gastric parietal cells and is effective at suppressing acid secretion. Side effects include abdominal pain, nausea vomiting and diarrhoea; tolerance develops quickly. To prevent rebound hypersecretion of acid, stepwise withdrawal is advised; acid suppression by raising stomach pH will negate the effect of antiregurgitation milk (both also apply to proton pump inhibitors (PPI)). Lansoprazole and omeprazole: PPI that inactivate the H+/K+ -ATPase pump in parietal cells preventing gastric acid secretion. Side effects include headache, nausea, vomiting, abdominal pain, diarrhoea or constipation. Gastric polyps,9 increased risk of community acquired pneumonia10 and vitamin B12 deficiency11 have also been reported. No evidence of additional benefit if combined with an H2 receptor inhibitor. PPI given via feeding tubes may cause blockage; although omeprazole is available as an unlicensed solution, it is extremely expensive.
improvement.24 Grol et al25 investigated which attributes of clinical practice guidelines influenced their use in a general practice setting. Recommendations that were non-controversial, clear, did not demand a change in existing practice routine and were based on research evidence were more likely to be followed. Although considered ‘excellent’ by some,23 a recent study evaluated whether the 2009 North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)–European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Puntis JW. Arch Dis Child 2015;0:1–5. doi:10.1136/archdischild-2014-306232
Review clinical practice guideline for GOR13 was in fact being implemented by clinicians.26 A structured questionnaire including a series of case scenarios was sent to a random sample of general paediatricians across 11 European countries. From 567 replies (a return of 42%),
