Acid Suppression Should Not Be the First Treatment for Infants With Reflux

Baby

Although common, the use of acid suppression medication lacks evidence and could cause adverse effects.

Gastroesophageal reflux (GER) is common in infants. Many show no symptoms more serious than agitation and frequent regurgitation, and most cases resolve on their own by the time the child is 1 year old.

Despite a paucity of well-controlled clinical trials, acid suppression medications are commonly prescribed for infants with GER. In a new paper, physician researchers from Nationwide Children’s Hospital review the data regarding acid suppressants for infants as well as new clinical practice guidelines for how and when to use these medications.

“Infant reflux has been an issue for parents since the beginning of time,” says Steven Ciciora, MD, director of division educational activities in the Division of Gastroenterology, Hepatology, and Nutrition at Nationwide Children’s and one of the study’s authors. “What is new is using acid suppression medications designed to help adults with their reflux symptoms.”

While the data supporting the use of acid suppressants like proton pump inhibitors and histamine-2 receptor antagonists in adults is robust, there is no solid evidence that these medications change outcomes in infant GER. In fact, there are multiple studies that show these drugs may be associated with harmful effects.

“Since these medications change the acid balance in the stomach, and stomach acid helps protect us from pathogens we ingest, they can make that line of defense less effective,” says Dr. Ciciora, who is also an assistant professor of Pediatrics at The Ohio State University College of Medicine. “There are concerns about leaving patients at risk for infections.”

This year, the North American and European Societies for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN/ESPGHAN) released updated clinical practice guidelines that emphasize trying non-pharmacologic changes and reducing the use of acid suppressants.

Before considering medication, the guidelines recommend clinicians reassure caretakers that GER is normal and self-limiting and try changes like thickening of feeds, altering the formula or maternal diet protein sources, and providing smaller and more frequent feeds. Subsequent trials of acid suppressants should be kept brief (4-8 weeks).

“No medicine is without risk, including acid suppressants,” says Dr. Ciciora. “For a problem that will likely get better with the passage of time, do you want to submit the child to those risks? Especially when the evidence that the benefit of these medications is about the same as a placebo with no active ingredient whatsoever?”

Dr. Ciciora acknowledges that infant reflux is a common problem that is often distressing for caregivers. But he says that the practitioner’s first step in management should not be acid suppressants.

“In many cases, reassurance and management with non-pharmacologic means can be just as helpful and perhaps safer for the patient,” says Dr. Ciciora. “Not every problem requires a pill for an answer.”

Reference:

Ciciora, SL and Woodley, FW. Optimizing the use of medications and other therapies in infant gastroesophageal reflux. Pediatric Drugs. 2018 Sep 10. [Epub ahead of print].