Body positioning and medical therapy for infantile gastroesophageal reflux symptoms

Clara Loots, Stamatiki Kritas, Michiel van Wijk, Lisa McCall, Laura Peeters, Peter Lewindon, Rob Bijlmer, Ross Haslam, Jacinta Tobin, Marc Benninga, Geoffrey Davidson, Taher Omari

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43 Citations (Scopus)


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. 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. 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). "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
Original languageEnglish
Pages (from-to)237-243
Number of pages7
JournalJournal of pediatric gastroenterology and nutrition
Issue number2
Publication statusPublished - Aug 2014


  • Combined Modality Therapy
  • Crying
  • Female
  • Gastroesophageal Reflux/complications
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Patient Positioning
  • Prospective Studies
  • Proton Pump Inhibitors/therapeutic use
  • Stress, Psychological/etiology
  • Vomiting/etiology

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