Editor's Note: The American Academy of Pediatrics (AAP) has released its second list of common tests and treatments to question as part of the Choosing Wisely® initiative. Concurrent with this list, AAP also launched an online learning module related to 2 items on its original list released in 2013. The tool is designed to assist clinicians with avoidance of antibiotics for viral respiratory illnesses and unnecessary CT scans. Medscape spoke with experts from a range of specialties about the specific recommendations in the 2014 list and specific advice regarding implementation.
The recommendation: Avoid using acid blockers and motility agents such as metoclopramide for physiologic gastroesophageal reflux that is effortless, painless, and not affecting growth. Do not use medication in the so-called "happy spitter."
The rationale: There is accumulating evidence that acid-blocking and motility agents such as metoclopramide are not effective in physiologic gastroesophageal reflux. Parents should be counseled that reflux in an infant who is growing well and not experiencing significant respiratory symptoms is normal and predominantly a laundry rather than a health problem.
Medscape spoke with Sarah Jane Schwarzenberg, MD, Director of Pediatric Gastroenterology, Hepatology, and Nutrition at the University of Minnesota Amplatz Children's Hospital in Minneapolis.
Medscape: This recommendation is particularly strong, indicating that these medications should not be used in children who have reflux but are growing well. In addition to concerns about efficacy, there are also safety issues. Can you review them?
Dr. Schwarzenberg: The evidence that children who are happy spitters are having any adverse impact from spitting up is just not there. If an infant is growing normally and having no respiratory problems but spits up all the time -- there's just no evidence that that is harmful in the long run. If the first principle of medicine is to do no harm, giving a healthy child anything that could make them less healthy has no merit. These drugs may be valuable in children with serious gastroesophageal reflux, but as we gain more experience with these drugs in children who don't have serious disease, we're finding 2 things.
First, many motility drugs have side effects, yet there is no evidence for their efficacy in treating reflux. The recommendation right now is not to use them in children who have normal physiologic infant reflux. The question of whether to use them for anyone is a different question, but certainly in normal physiologic infant reflux you cannot document that they are doing anything positive, and they come with some side effects.
Second, the other class of drugs, proton pump inhibitors, also has significant side effects associated with it. While not common, the side effects are serious and include increased risk for pneumonia,possible increased risk for necrotizing enterocolitis in young infants, and increased risk for changes in gastric mucosa. While the risks do not occur frequently, the drug is also not being used for true disease but rather to treat a physiologically normal developmental process in a child. It's sort of like saying that I could give a newborn a drug that would make them not urinate so frequently, and I wouldn't have to change diapers so much. Well, you could, but why would you do that? Gastroesophageal reflux is a developmental process. Annoying and messy, yes. Harmful, no.
Medscape: Are there any data about how commonly these drugs are used in children for whom they are not indicated?
Dr. Schwarzenberg: As many prescriptions as are being written by providers who care for children, it's hard to believe that many of these are not going to very young children.
Medscape: Is there anything else you would like to add?
Dr. Schwarzenberg: I would emphasize that these recommendations for happy spitters do not mean that there is not a role for these agents in the management of reflux in children who have true reflux disease. In those children, there are comprehensive guidelines  available to guide care, including recently published updated guidelines from AAP.
These guidelines are helpful in pointing providers to those situations when reflux needs to be investigated more thoroughly and thought of as something that might be a disease rather than a normal physiologic process.