Choosing Wisely:

Avoid routine use of antireflux medications for treatment of symptomatic GERD or for treatment of apnea and desaturation in preterm infants.

Rationale and Comments: Gastroesophageal reflux is normal in infants. There is minimal evidence that reflux causes apnea and desaturation. Similarly, there is little scientific support for the use of H2 antagonists, proton pump inhibitors, and motility agents for the treatment of symptomatic reflux. Importantly, several studies show that their use may have adverse physiologic effects as well as an association with necrotizing enterocolitis, infection and, possibly, intraventricular hemorrhage and mortality.
Sponsoring Organizations:
  • American Academy of Pediatrics - Section on Perinatal Pediatrics
  • Sources:
  • Systematic review
  • Disciplines:
  • Gastroenterologic
  • Pediatric
  • Neonatology
  • References: • Beck-Sague CM, Azimi P, Fonseca SN, Baltimore RS, Powell DA, Bland LA, Arduino MJ, McAllister SK, Huberman RS, Sinkowitz RL, et al. Bloodstream infections in neonatal intensive care unit patients: results of a multicenter study. Pediatr Infect Dis J. 1994 Dec;13(12):1110-6.
    • Bianconi S, Gudavalli M, Sutija VG, Lopez AL, Barillas-Arias L, Ron N. Ranitidine and late-onset sepsis in the neonatal intensive care unit. J Perinat Med. 2007; 35(2):147-50.
    • Chung EY, Yardley J. Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013 Jan;3(1):16-23.
    • Guillet R, Stoll BJ, Cotten CM, Gantz M, McDonald S, Poole WK, Phelps DL; National Institute of Child Health and Human Development Neonatal Research Network. Association of H2-blocker therapy and higher incidence of necrotizing enterocolitis in very low birth weight infants. Pediatrics. 2006 Feb;117(2):e137-42.
    • Hibbs AM, Lorch SA. Metoclopramide for the treatment of gastroesophageal reflux disease in infants: a systematic review. Pediatrics. 2006 Aug;118(2):746-52.
    • Rojas MA, Efird MM, Lozano JM, Bose CL, Rojas MX, Rondón MA, Ruiz G, Piñeros JG, Rojas C, Robayo G, Hoyos A, Gosendi MH, Cruz H, O’Shea M, Leon A. Risk factors for nosocomial infections in selected neonatal intensive care units in Colombia, South America. J Perinatol. 2005 Aug;25(8):537–41.
    • Terrin G, Passariello A, De Curtis M, Manguso F, Salvia G, Lega L, Messina F, Paludetto R, Canani RB. Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns. Pediatrics. 2012 Jan;129(1):e40-5.
    van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35.
    • Wheatley E, Kennedy KA. Cross-over trial of treatment for bradycardia attributed to gastroesophageal reflux in preterm infants. J Pediatrics. 2009 Oct;155(4):516-21.

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