Distinguishing between Gastro-oesophageal reflux (GOR) and Gastro-oesophageal reflux disease (GORD) in infants is critical to providing appropriate treatment and avoiding over classifying infants with GORD that leads to over testing and over treatment.
Paediatricians need to learn how to recognise infants with “simple GOR in whom conservative recommendations are more appropriate, and identifying infants with GORD in whom more diagnostic evaluation and treatment is appropriate,” according to David A. Gremse, MD, professor and chair of paediatrics, University of South Alabama, Mobile.
Gremse discussed indications for acid suppression in infants with an emphasis on the importance of distinguishing GOR from GORD and walked participants through various treatment strategies based on different clinical situations in a session on Saturday, October 11, titled “To treat or not to treat? Avoiding the over prescription of medications for infant GORD.”
Highlighted in his presentation was the need to avoid over testing and over treatment of GORD. Most patients with GORD, he explained, can be treated by primary care providers without the need for testing. Indications for referral to a gastroenterologist or for further testing include patients who do not respond to therapy with proton pump inhibitors; those with significant side effects to or unable to be weaned from medical therapy; or patients with signs of complications or severe disease.
Key to avoiding over prescribing drugs for infant GORD, Gremse commented, is for paediatricians to recognize conditions in infants who have symptoms that mimic GORD, such as an allergy to cow’s milk, for which acid suppression therapy will be ineffective. For example, projectile vomiting may occur in infants with milk protein intolerance associated with delayed gastric emptying.
He stressed that for many infants with GORD their symptoms will improve without medications by implementing appropriate lifestyle modifications, such as placing the infant in an upright position when awake and not feeding the infant prior to riding in an infant car seat.
Of particular importance is for paediatricians to prescribe a 2-week trial of changing to a hypo-allergenic formula for infants with vomiting and poor weight gain before prescribing acid suppression therapy. Finally, Gremse said to consider disorders other than GORD if symptoms begin in infants and toddlers after the age of 6 months.
*Adapted from the article by Karen Rosenberg which first appeared in the US Journal Contemporary Paediatrics in October 2014.