Intended for healthcare professionals

Practice Change

Reducing the use of proton pump inhibitors in infants with reflux symptoms

BMJ 2024; 385 doi: (Published 30 May 2024) Cite this as: BMJ 2024;385:e074588
  1. Ketil Størdal, professor; consultant paediatrician1 2,
  2. Amy Ma, co-chair Family Advisory Forum3,
  3. Carolyn E Beck, hospitalist pediatrician and inpatient director; associate professor4 5
  1. 1Department of Paediatric Research, Faculty of Medicine, University of Oslo, Pb 4956 Nydalen, NO-0424 Oslo, Norway
  2. 2Department of Paediatrics, Oslo University Hospital, Oslo
  3. 3Choosing Wisely Canada
  4. 4Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
  5. 5University of Toronto, Toronto
  1. Correspondence to: K Størdal ketil.stordal{at}

What you need to know

  • Regurgitation and fussiness are common and transient symptoms in infancy and should be regarded as normal physiology in otherwise thriving infants

  • The acid content of regurgitation and reflux is low during infancy; symptoms are caused more often by volume rather than acid

  • In clinical trials, proton pump inhibitors are equal to placebo for resolution of symptoms in infants with suspected gastroesophageal reflux disease, even though reduced oesophageal acidity has been documented

Regurgitation is common in the first months of life, and concern of disease often prompts parents to seek medical care and advice. Treatment with proton pump inhibitors is common and increasing, but it is largely unnecessary and not supported by evidence in infancy. This article describes the clinical features that may reflect gastro-oesophageal reflux in infants and guidelines on management, which recommend against routine use of proton pump inhibitors for isolated reflux symptoms in infants.

Gastro-oesophageal reflux in children is defined as the effortless passage of gastric contents to the oesophagus with or without regurgitation or vomiting.1 This is usually physiological, commonly occurs after meals, and is usually without associated symptoms in healthy infants. Daily episodes of regurgitation are particularly common in newborns and infants.2 A review found that up to a quarter of healthy infants under 1 year old were affected by two or more daily episodes of regurgitation lasting more than three weeks.2 The review also found that fussiness and infantile colic were equally prevalent and may consequently overlap with regurgitation.2

Gastro-oesophageal reflux disease (GORD), unlike physiological gastroesophageal reflux, is a pathological process in which reflux events cause persistent or severe symptoms that require treatment or when there are complications as a result of reflux.1 Clinical features that may be seen in infants with GORD include general discomfort or irritability, wheezing, refusing …

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