Richmond, VA—Acid suppressants are being overused in infants, at least partly because of a misunderstanding that gastroesophageal reflux (GER) versus gastroesophageal reflux disease (GERD) occurs in a majority of infants, according to a new study.

The report in the journal Pediatrics pointed out that GER occurs in up to two-thirds of healthy infants and usually resolves within the first year. “In contrast to GER, gastroesophageal reflux disease (GERD) is reflux that can involve (a) poor weight gain, (b) pain or (c) mucosal injury on endoscopy,” wrote the Children’s Hospital of Richmond at Virginia Commonwealth University–led authors. Acid suppressants such as histamine-2 receptor antagonists (H2RA) and proton-pump inhibitors (PPI) reduce gastric acidity but are not effective against GER.”

The study also advised that acid suppressants can lead to a higher risk of serious infections and fractures, and that guidelines from Choosing Wisely and the American Academy of Pediatrics recommend against their use in infants with GER.

The study team sought to determine the individual and healthcare system characteristics associated with acid suppressant overuse using the Virginia All-Payers Claim Database. Included in the study were 270,437 infants aged 0 to 11 months with at least 30 days of continuous enrollment between 2016 to 2019. Of those, 7% of nonmedically complex children were prescribed an H2RA or PPI, with an additional 2% excluded with a diagnosis of GERD.

For the 5,433 (2%) of the children without one of the exclusion criteria who were prescribed a H2RA or a PPI, researchers found that the odds of being prescribed an H2RA or PPI were higher (adjusted odds ratio [aOR] 1.9; 95% CI, 1.8-2.0) for infants with commercial insurance compared with those with public insurance. In addition, children from rural settings had higher odds of being prescribed an H2RA or PPI compared with children from both urban (aOR 1.2; 95% CI, 1.1-1.3) and suburban (aOR 1.6; 95% CI, 1.5-1.7) settings.

“In our statewide analysis, nearly 7% of all infants and 2% of infants without one of the exclusion criteria were prescribed an acid suppressant,” according to the authors. “Earlier studies found that 2% to 6% of infants were prescribed an acid suppressant, although the change from ICD-9 to ICD-10 codes and lack of 1:1 mapping makes comparisons with older data challenging. Our estimate being at the lower end of this range may be a result of 2014 Choosing Wisely recommendation, the growing recognition of the harms of acid suppressants, or the updated exclusion criteria that we employed.”

The researchers emphasized that acid suppressant overuse “remains a persistent problem, particularly among commercially insured infants and those residing in rural areas. Reduction efforts should include providers and patients outside of urban academic children’s hospitals to achieve maximal benefit.”

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