Non-pharmacologic therapy may be effective for infants with gastroesophageal reflux
Article Outline
- Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr 2008;152:310-4
- References
- Copyright
Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr 2008;152:310-4
Question Among infants with gastroesophageal reflux disease (GERD), does nonpharmacologic conservative therapy result in symptomatic improvement over time?
Design Observational cohort before a randomized trial.
Setting Five general pediatric outpatient practices in the United States.
Participants Of the first 50 screened infants, 40 (range 4 to 43 weeks; median age, 13 weeks) met inclusion/exclusion criteria including abnormal (>16/42) scores on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R).
Intervention Parents of the infants were taught conservative therapy measures by each site's study nurse: feeding modifications, positioning, and tobacco smoke avoidance.
Outcomes I-GERQ-R scores and symptom response details before and 2 weeks after institution of these measures.
Main Results The median initial and final scores were 23 (16-36) and 18 (7-34; P < .000001). The median score change was −5 (+6 to −16). Scores of 78% improved at all; 59% improved at least the threshold of 5 points; 24% became normal. Scores for individual symptoms related to regurgitation, crying, and arching improved significantly.
Conclusions Two weeks of conservative therapy measures taught in a primary care setting improved 59% beyond the 5-point threshold and normalized 24% of infants with symptom severity diagnostic for GERD, as substantiated with a responsiveness-validated instrument.
Commentary The authors concluded that conservative therapy without medication was sufficient for the majority of healthy infants with GERD. I agree that primary caregivers can deal effectively with physiological gastroesophageal reflux without medications. In the absence of a control group, however, it is not certain that even conservative therapy was actually required as the symptoms could simply have improved with time. The authors dealt with this issue by comparing responses of the older and younger infants, but I did not find this analysis convincing. Semielemental formula for bottle-fed infants and a milk-free diet for breast-feeding mothers were part of the recommended conservative therapy. This suggests that the responders might have had milk protein sensitivity, an unrelated condition with similar symptoms. The authors' questionnaire is a good tool to monitor symptom frequency and severity, but studies have shown poor correlation between symptoms and quantitative measures of reflux such as esophageal pH monitoring or endoscopy.1 Indeed, the severity of infant symptoms is probably a reflection of the infant's responsiveness, rather than the severity of reflux. Finally, the acronym GERD used in this study is inappropriate. “D” stands for disease, and these patients were not diseased. They had bothersome symptoms of a transient situation of infancy better called physiologic gastroesophageal reflux, which improves with no intervention in infants2, 3 as feeding frequency decreases, self-settling skills develop, truncal stability increases, and the esophagus elongates.
References
- . Gastroesophageal reflux disease in infants: how much is predictable with questionnaires, pH-metry, endoscopy and histology?. J Pediatr Gastroenterol Nutr. 2005;40:210–215
- . Prevalence of symptoms of gastroesophageal reflux during infancy (A pediatric practice-based survey. Pediatric Practice Research Group). Arch Pediatr Adolesc Med. 1997;151:569–572
- . One year follow-up of symptoms of gastroesophageal reflux during infancy (Pediatric Practice Research Group). Pediatrics. 1998;102:e67–e70
PII: S0022-3476(08)00487-3
doi:10.1016/j.jpeds.2008.05.056
© 2008 Mosby, Inc. All rights reserved.
