Overuse of reflux medications in Neonates

The diagnosis, management and differentiating of gastroesophageal reflux (GER) and pathologic gastroesophageal reflux disease (GERD) in infants remains a clinical challenge. There is significant clinical and economic burden attributed to GERD in the NICU leading to longer length of stays, higher financial costs, and overuse of medications.

Current guidelines promote reduced reliance on acid suppression medication with shorter empiric trials (4 to 8 weeks) for the treatment of GERD, not attributing respiratory or laryngeal symptoms to GER due to a lack of diagnostic evidence, and a recommendation for trial of hydrolyzed formula before initiation of acid suppression. Few studies are demonstrating overall decrease use in all classes of medication for GERD, however, use of medications in infants remains high.

Diagnostic challenges remain in pediatrics including interchangeable use of GER and GERD amongst clinicians, non-specific symptoms attributed to GERD, and lack of gold-standard diagnostic testing. Multichannel intraluminal impedance-pH monitoring (pH/MII) probes allow for an objective assessment of reflux episodes, reflux content, acidity, distance of reflux column or bolus direction, and symptom correlation.

For any infant with a suspicion of GERD, priority should be made to take a thoughtful and complete history and physical exam, review of growth charts, and not only reviewing charted intake and output but observing feeding and episodes of reflux. A stepwise approach emphasizing non-pharmacological care, shared decision-making, and institutional-level stewardship remains essential to providing high-value care.