Daniel Duncan, MD: Acid Suppression in Infants with BRUE Increases Rehospitalization Odds

A study revealed gastroesophageal reflux disease diagnoses in infants with a brief resolved unexplained event (BRUE) was associated with frequent acid suppression use and greater repeat hospitalization rates. Conversely, evaluating oropharyngeal dysphagia with videofluoroscopic swallow studies (VFSS) and addressing it appropriately reduced the risk of repeat hospital visits.

At the 2024 Annual North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Meeting in Hollywood, Florida, from November 7 to 9, 2024, HCPLive spoke to Daniel Duncan, MD, MPH, from Boston Children’s Hospital, about the study's findings.

“The biggest takeaway from the study is that a lot of clinicians tend to think about blaming these events on gastroesophageal reflux, and they think about that as a benign condition, but our findings suggest that giving that as a diagnosis to babies who come in with proof resolved unexplained events actually might cause some negative outcomes,” Duncan said. “They're actually more likely to come back into the hospital if they were told that their event was caused by reflux, and they're more likely to be treated with acid suppression medications, which don't look like they help.”

Duncan and colleagues conducted a multicenter retrospective cohort study of 17,558 infants admitted with BRUE to 49 hospitals included in the Pediatric Health Information System database between July 1, 2016, and December 31, 2021. Among the sample, 33% were diagnosed with GERD, 0.6% were diagnosed with oropharyngeal dysphagia, and 0.8% were diagnosed with both. In total, 12% of patients were treated with acid suppression, and 413 underwent VFSS.

Approximately 10% to 15% of children had repeat hospitalizations, often caused by a diagnosis of reflux (odds ratio [OR], 1.66; 95% confidence interval [CI], 1.48 – 1.86; P < .001), oropharyngeal dysphagia with aspiration (OR, 2.13; 95% CI, 1.55 – 2.91; P < .001), and treatment with acid suppression.

Duncan said in pediatrics, acid suppression blocks acid but does not actually stop the reflux from occurring. In fact, most infants’ reflux is not caused by acid.

Rather, he said it is more effective to diagnose oropharyngeal dysphagia with aspiration and tailor treatment to the child’s swallowing difficulties. For instance, if a child aspirates thin liquids, switching to thicker liquids may make swallowing safe and reduce symptoms and hospital visits.

Duncan added how the American Academy of Pediatrics recommends against the use of acid suppression in infants, yet still many institutions continue to treat their patients this way. In some institutions, a quarter of babies are placed on acid suppression.

“I think the blaming on reflux and treating with acid suppression either suggests that the diagnosis isn't reflux—a lot of time it might be oropharyngeal dysphagia with aspiration as opposed to reflux, or it might be both reflux and aspiration— or it suggests that they might have reflux, but treating with acid suppression isn't the right approach,” Duncan said. “So, our takeaway from that was to at least consider aspiration if you're considering reflux as the diagnosis and consider treating with thickened feeds as opposed to [the] absence of questioning.”

References

^{Duncan, D, Golden, C, Rosen, R. OUTCOMES FOR INFANTS WITH BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) DIAGNOSED WITH OROPHARYNGEAL DYSPHAGIA OR GASTROESOPHAGEAL REFLUX: A MULTICENTER STUDY FROM THE PEDIATRIC HEALTH INFORMATION SYSTEM (PHIS) DATABASE. Presented at NASPHGAN 2024 in Hollywood, Florida, from November 7 – November 9, 2024.}