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When faced with a fussy infant, it's common to think acid reflux is the cause, but a recent report indicates that it may be time to think of other causes.
Though physicians sometimes empirically prescribe acid inhibitors for infant distress, nonacid reflux causes at least as much—and perhaps more—pain and distress in infants than acid reflux, according to a study in 62 children with persistent unexplained fussiness or distress and a median age of 3.5 months.
The prospective study included all children aged younger than 24 months referred to a European hospital for 24-hour multiple intraluminal impedance-pH (MII-pH) monitoring because of recurrent unexplained inconsolable distress thought to be a symptom of gastroesophageal reflux (GER). In addition to the monitoring, parents filled in a symptom diary and the Face, Legs, Activity, Cry, Consolability (FLACC) scale, a measurement for assessing pain in infants and young children. The scale ranges from 0 to 10 with 0 representing “relaxed and comfortable” and 7-10 “severe discomfort/pain.” Investigators then analyzed the FLACC scores in relation to the presence or absence, duration, chemical composition, and esophageal extension of GER episodes.
During the MII-pH monitoring, 452 episodes of distress were recorded, which parents scored with the FLACC scale. The number of episodes ranged from 1 to 32 per child, with a mean of 7.3. Fewer than half of the episodes (48%) were associated with GER. When associated with symptoms, GER occurred significantly more often before an episode of distress than it did simultaneously or after such an episode.
The median FLACC score did not differ significantly between the distress episodes that were associated with GER and those that did not. Overall, 361 (80%) distress episodes were in patients with an acid reflux index <7% and 91 (20%) in those with a pathologic acid reflux index. Episodes of distress associated with nonacid reflux presented a significantly higher FLACC than those with acid content (FLACC 6 vs 5). In addition, the median FLACC value was significantly lower in the 12 (19%) infants with a pathologic reflux index compared with the 50 infants (81%) with a normal reflux index (Salvatore S, et al. J Pediatr Gastroenterol Nutr. 2020;71:465-469).
Thoughts from Dr. Farber
Acid reflux is often blamed, incorrectly, for fussiness in infants. I have commented previously on the risk of anti-reflux medicines (Contemporary Pediatrics Journal Club, June 2020). I am not advocating for pH probes in fussy children, but rather for innocuous treatments that support parents through the fussy period.