Treating GER in Children Younger Than Two Years

Clinical Question

Do thickened feeds, elevating the head of the crib, and metoclopramide therapy improve the symptoms of gastroesophageal reflux (GER) in normally developing children younger than two years?

Evidence-Based Answer

Thickened feeds and metoclopramide reduce symptoms of GER in normally developing infants. However, elevating the head of the crib appears to have no effect.

Practice Pointers

Although virtually all infants regurgitate, or “spit up,” about 3 percent of normally developing infants have clinically significant GER. If an infant has poor weight gain, excessive crying, irritability, disturbed sleep, respiratory problems, or signs of obstruction, diagnostic testing or referral is indicated. Referral also is indicated for patients whose symptoms persist beyond 24 months of age. Common first-line treatments are reassuring parents, elevating the head of the baby’s crib, trying a hypoallergenic formula, and thickening feeds with rice cereal or a rice- or carob-based thickener. Medication sometimes is used for refractory or complicated cases.1

To determine whether common practice is supported by the literature, Craig and colleagues systematically reviewed randomized trials involving thickened feeds, positioning, or metoclopramide to reduce the symptoms of reflux in children younger than two years with no apparent developmental delay. They found 20 trials with a total of 771 infants; eight trials studied thickened feeds, five positioning, and seven metoclopramide. However, not all studies in each group could be compared because of the differences in measured outcomes. Standardized mean differences (SMDs) and weighted mean differences (WMDs) were reported; more negative numbers indicate a greater reduction.

Neither elevating the head of the bed nor putting the patient in prone position (five studies) was found to be effective in reducing reflux. However, thickening feeds (two studies with 48 patients in total) significantly reduced the regurgitation severity score (SMD: −0.94) and frequency of vomiting (SMD:−0.91). Thickened feeds were not found to reduce the reflux index (WMD: 0.48), and may increase the chances of cough and diarrhea. Metoclopramide (two studies totalling 101 patients) significantly reduced daily symptoms (SMD: –0.73), and the reflux index (WMD: –2.80). Side effects such as irritability or drowsiness may occur, although results were heterogeneous. Results of studies that could not be combined generally were similar to those reported above.

Umbilical Cord Clamping in Preterm Infants

Clinical Question

What is the optimal time to clamp the umbilical cord for infants born at less than 37 weeks’ gestation?

Evidence-Based Answer

In preterm infants, clamping the umbilical cord between 30 seconds and two minutes after delivery is associated with lower rates of blood transfusion and intraventricular hemorrhage.

Practice Pointers

Many patients request delayed umbilical cord clamping in their birth plans. Delayed cord clamping allows continued perfusion while the baby transitions to newborn circulation. However, when an infant is high risk, physicians frequently clamp and cut the cord early to allow the neonatal resuscitation team quicker access.

Rabe and colleagues reviewed the literature to determine the impact of early and delayed cord clamping on outcomes in preterm infants. They found seven randomized controlled trials that compared early and delayed cord clamping in a total of 297 preterm infants. Delaying cord clamping up to two minutes was associated with a higher hematocrit at four hours of life than early clamping (weighted mean difference: 5.31 g), fewer blood transfusions for anemia (25 versus 52 percent) and hypotension (20 versus 50 percent), and fewer intraventricular hemorrhages (17 versus 26 percent). All of these differences were significant. No statistically significant differences in respiratory outcomes were reported. However, the numbers of patients in the studies that reported this outcome were small.

Results for term infants also appear to be favorable. Van Rheenen and colleagues1 reviewed the literature on delayed cord clamping in term infants, and found that delaying cord clamping reduced anemia at two to three months of age. The results showed a 12 percent increased risk of hyperbilirubinemia, but in no study was this condition reported to require treatment.

An alternative to early cord clamping for resuscitation access is to deliver the baby without breaking down the bed. This allows resuscitation personnel and equipment to be brought to the bedside before the cord is clamped.