Synopsis: Prone sleeping positioning of infants with gastro esophageal reflux may produce parental anxiety because of fear of SIDS. Positional therapy should only be used in infants beyond the age of greatest SIDS risk.
Source: Vandenplas Y, et al. The relation between gastroesophageal reflux, sleeping position and sudden infant death and its impact on positional therapy. Eur J Pediatr 1997;156:104-106.
Many infants regurgitate, and some of these have gastroesophageal reflux (GER). The recommended therapy has been to use prone/elevated sleeping position and dietary thickening. Because of the observation of a significant decrease in sudden infant death syndrome (SIDS) and supine sleeping positioning, campaigns to inform parents of possible risks of prone positioning have been initiated in the United States and other countries, including Belgium. Recommending prone positioning may cause considerable parental concern. Vandenplas et al conclude that positional therapy should only be recommended for infants beyond the age of greatest SIDS risk (> 6 months) or in those cases recalcitrant to reassurance, proketic, and antacid therapy.
COMMENT BY CRAIG HILLEMIER, MD, FAAP
This European perspective on the relationship between GER and sleeping position makes several interesting observations. The authors point out that the data suggesting that infants have less GER when sleeping in the prone/head-elevated position are at conflict with the data showing that the risk of SIDS will be markedly decreased when the child is left sleeping in the supine position. The authors point out there are no data in the literature suggesting any relationship between SIDS and the prone/head-elevated position.
While I believe the data that suggest that infants kept in the prone/head-elevated position have less GER, I am skeptical that this information is of use to many patients. For those of you who have not had the experience of sleeping with your trunk elevated at a 30° angle or, even more impressively, have tried to maintain an infant sleeping at this angle, let me tell you, "it ain’t easy." The best studies show a significant but small decrease in pH probe documented GER when infants were kept in the prone/head-elevated positionhardly worth the sophisticated apparatus and procedure required to maintain the infant in this position.
This whole issue brings to the front the recurrent question of "does the normal growing child who has symptoms of GER need much in the way of diagnostic or therapeutic intervention?" A careful history and physical examination might lead you to the diagnosis of idiopathic GER. I have not been convinced that pH probes, UGIs, cisapride, and/or H2 antagonists are of any value to the growing infant who does not suffer from pneumonia, GI bleeding, or other specific complications that may be related to the GER.
I think the benefit of the prone/head-elevated positioning is small at best. This procedure should not be routinely recommended in the face of data which indicate that flat/prone positioning increases the risk of SIDS.
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