title: Body positioning and medical therapy for infantile gastroesophageal reflux symptoms.
abstract: OBJECTIVE
  Proton-pump inhibitors (PPIs) reduce acid gastroesophageal reflux (GER) and esophageal acid exposure in infants; however, they do not reduce total GER or symptoms attributed to GER. Reflux is reduced in the left lateral position (LLP). We hypothesize that the effect of LLP in combination with acid suppression is most effective in reducing GER symptoms in infants.
  
  
  METHODS
  In this prospective sham-controlled trial, infants (0-6 months) with symptoms suggestive of gastroesophageal reflux disease were studied using 8-hour pH-impedance, cardiorespiratory and video monitoring, direct nurse observation, and a validated questionnaire. Infants demonstrating a positive GER symptom association were randomized to 1 of 4 groups; PPI + LLP, PPI + head of cot elevation (HE), antacid (AA) + LLP, or AA + HE. HE and AA were considered "sham" therapies. After 2 weeks the 8-hour studies were repeated on-therapy.
  
  
  RESULTS
  Fifty-one patients were included (aged 13.6 [2-26] weeks). PPI + LLP was most effective in reducing GER episodes (69 [13] to 46 [10], P < 0.001) and esophageal acid exposure (median [interquartile range] 8.9% [3.1%-18.1%] to 1.1% [0%-4.4%], P = 0.02). No treatment group showed improvement in crying/irritability, although vomiting was reduced in AA + LLP (from 7 [2] to 2 [0] episodes P = 0.042). LLP compared with HE produced greater reduction in total GER (-21 [4] vs -10 [4], P = 0.056), regardless of acid-suppressive therapy. Acid exposure was reduced on PPI compared with AA (-6.8 [2.1] vs -0.9 [1.4]%, pH < 4, P = 0.043) regardless of positional intervention. A post-hoc analysis using automated analysis software revealed a significant reduction in crying symptoms in the PPI + LLP group (99 [65-103] to 62 [32-96] episodes, P = 0.018).
  
  
  CONCLUSIONS
  "Symptomatic gastroesophageal reflux disease" implies disease causation for distressing infant symptoms. In infants with symptoms attributed to GER, LLP produced a significant reduction in total GER, but did not result in a significant improvement in symptoms other than vomiting; however, automated analysis appeared to identify infants with GER-associated crying symptoms who responded to positioning therapy. This is an important new insight for future research.
authors.affiliation: *Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands †School of Medicine, Flinders University, Adelaide ‡Pediatric Gastroenterology, Royal Children's Hospital, Brisbane §Neonatal Intensive Care Unit, Women's and Children's Health Network, Adelaide ||North Western Academic Centre University of Melbourne, Melbourne, Australia.
authors.forename: Clara
authors.initials: C
authors.lastname: Loots
authors.forename: Stamatiki
authors.initials: S
authors.lastname: Kritas
authors.forename: Michiel
authors.initials: M
authors.lastname: van Wijk
authors.forename: Lisa
authors.initials: L
authors.lastname: McCall
authors.forename: Laura
authors.initials: L
authors.lastname: Peeters
authors.forename: Peter
authors.initials: P
authors.lastname: Lewindon
authors.forename: Rob
authors.initials: R
authors.lastname: Bijlmer
authors.forename: Ross
authors.initials: R
authors.lastname: Haslam
authors.forename: Jacinta
authors.initials: J
authors.lastname: Tobin
authors.forename: Marc
authors.initials: M
authors.lastname: Benninga
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Davidson
authors.forename: Taher
authors.initials: T
authors.lastname: Omari
mesh_terms: D003131:Combined Modality Therapy; D003448:Crying; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications / Q000628:therapy*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D056888:Patient Positioning; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D013315:Stress, Psychological / Q000209:etiology / Q000628:therapy*; D014839:Vomiting / Q000209:etiology / Q000628:therapy*
chemical_list: D054328:Proton Pump Inhibitors