Perspectives of Parents and Health Care Providers about (Non)Medical Treatment in Infants with Reflux

Abstract

Background: Reflux occurs in 50% of healthy infants at some point. This is most often a physiological condition and does not require drug treatment. Various studies have shown that the use of drugs affecting gastric acidity (DAGAs) in infants is increasing. This entails disadvantages such as unnecessary exposure of infants to medication and their side effects and a higher cost to society. Objective: To get an image of the current practice in Flanders regarding diagnosis and treatment of gastro-oesophageal reflux disease (GORD) in infants and the associated use of DAGAs. To this end, we determined both parents’ and health care providers’ experiences and perceptions about these treatments. Method: An observational cross-sectional study was conducted in April and May 2019. We developed a questionnaire for parents and three different questionnaires for health care providers (HCPs), including midwives, general practitioners, paediatricians and community pharmacists (CPs). The questionnaire for parents was only available through an online platform. HCPs were questioned face-to-face and through an online platform. Results: This study made clear that the counselling of children with GORD is multidisciplinary as the median number of counselling HCPs is 3 (interquartile range (IQR) = 2–4). 63% of the included 251 parents also seek support through online forums and groups. 60% of parents report that no physical tests were performed before DAGAs were prescribed and 39% of parents additionally state they perceived no effect of the prescribed DAGAs. Although parents reported to understand HCPs well (average score 7.4/10), satisfaction with care and information provision was scored lower (between 4.8 and 6.1/10). On the other hand, 234 HCPs answered the questionnaire, of which 89 midwives, 78 community pharmacists and 67 physicians. Only 45 HCPs indicate that guidelines to diagnose or treat GORD are clear. Physicians confirm they perform very little physical testing before starting DAGAs. Provided nonmedical measures to patients are largely in line with the European guidelines, however perceived effectiveness is moderate. Conclusion: Parents are in need for more information about tests, nutrition and (non)medical measures. HCPs on the other hand are in need for clear guidelines on diagnosing and treating GORD.

The viscosity‐enhancing effect of carob bean gum and sodium carboxymethylcellulose when added to infant formula

“…Despite limited evidence about the effectiveness of thickened standard infant formula to reduce GOR episodes (Corvaglia et al, 2006;Wenzl et al, 2003) or in children with dysphagia (Cummings et al, 2018;Gosa et al, 2011), thickening of infant feeding is included in de NASPHGAN and ESPHGAN recommendations for the treatment of GORD (symptoms) (Rosen et al, 2018) and is observed to be a widespread practice (Gorsen et al, 2020).…”

“…Gastro‐esophageal reflux disease (GORD) develops when damage to the esophagus is expected or established. For both GOR and GORD, non‐pharmacologic (e.g., dietary management) and pharmacological measures (e.g., use of antacids or proton pump inhibitors) are applied to minimize symptoms (Corvaglia, Martini, et al., 2013 ; Gorsen et al., 2020 ; Vandenplas et al., 2005 ). A commonly used non‐pharmacologic intervention to manage GOR is to thicken infant milk.…”

“…Despite the lack of evidence, thickening formula and even breastmilk is a widespread practice (Gorsen et al., 2020 ). Commonly used feed thickeners include digestible starch‐based thickeners made from rice or maize, and indigestible gum‐based thickeners such as carob bean gum (CBG), sodium carboxymethylcellulose (NaCMC), and xanthan gum (XG) (Kwok et al., 2017 ).…”

“…These studies showed that thickening does not reduce the total number of esophageal reflux episodes or symptoms but might be beneficial to parents by reducing the number of visible vomiting episodes and improving sleep (Chao & Vandenplas, 2007;Corvaglia, Spizzichino, et al, 2013;Kwok et al, 2017;Orenstein et al, 1987;Wenzl et al, 2003). Considering dysphagia, systematic reviews concluded that the overall evidence for recommending thickened liquids as an effective intervention for infants who aspirate or penetrate thin liquids is limited and of low quality (Cummings et al, 2018;Gosa et al, 2011). Results of both reviews however highlight the insufficient evidence base for this nonpharmacological intervention and cite the need for more research to understand the efficacy and effectiveness of thickened liquid use in the pediatric population (Cummings et al, 2018;Gosa et al, 2011).…”

“…Considering dysphagia, systematic reviews concluded that the overall evidence for recommending thickened liquids as an effective intervention for infants who aspirate or penetrate thin liquids is limited and of low quality (Cummings et al, 2018;Gosa et al, 2011). Results of both reviews however highlight the insufficient evidence base for this nonpharmacological intervention and cite the need for more research to understand the efficacy and effectiveness of thickened liquid use in the pediatric population (Cummings et al, 2018;Gosa et al, 2011).…”