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19th o April, 2008
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NEW YORK (Reuters Health) Nov 05 - By Karla Gale
Many infants with regurgitation but without any other symptoms of gastroesophageal reflux disease (GERD) are being prescribed antireflux medications unnecessarily, physicians in New Orleans report in the November issue of Pediatrics.
"We have seen a tremendous increase in the use of antireflux medications, especially proton pump inhibitors, over the past 5-6 years. This was concerning," Dr. Vikram Khoshoo told Reuters Health. "There was no reason for the incidence of reflux to have suddenly increased, so either there was increased/improved diagnosis or over-treatment."
Dr. Khoshoo and associates at the Pediatric Specialty Center at West Jefferson Medical Center reviewed the charts of 64 infants referred to the center because of persistent regurgitation. Diagnostic testing included upper gastrointestinal imaging, ultrasonography, blood gas analysis, and extended esophageal pH monitoring with and without impedance monitoring. Eight patients were diagnosed with GERD, four with hypertrophic pyloric stenosis, and one with renal tubular acidosis.
Anti-GERD medications were discontinued in the remaining 51 patients, and this "did not result in worsening of symptoms in most infants with normal pH studies."
Parents worry, Dr. Khoshoo noted, because "persistent regurgitation invokes a fear of dehydration or an underlying surgical problem, such as obstruction." Many parents in such cases persuade the doctor to try an anti-GERD medication. He maintains that "clinical evaluation has good accuracy in diagnosing GERD in infants." He and his associates observed that patients with regurgitation and no underlying symptoms had normal test results and did not meet diagnostic criteria for GERD.
"Red flags" for an underlying condition include irritability, feeding problems, respiratory symptoms, and poor weight gain, the authors note.
When reporting their findings to referring physicians, "we reinforce the message about conservative management and discuss the red flags that should prompt concern and referral," Dr. Khoshoo said. In the absence of other symptoms, reassuring parents of the benign nature of the condition is in order, the authors advise. They found that overfeeding and under-thickening of the formula were common causes of regurgitation (40% and 70%, respectively), so advice about appropriate small-volume thickened feeds is helpful, along with correct positioning, avoidance of cigarette smoke, and trial of a hypoallergenic formula.
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