Effectiveness Of Positioning Children In Supine With Head Elevated To 30
Degrees In The Treatment Of Gastroesophageal Reflux
Merriam-Webster's Medical Dictionary defines Gastroesophageal Reflux (GER)
as the backward flow of the gastric contents into the lower end of the esophagus.
Gastroesophageal Reflux Disease (GERD) is in turn defined as a highly variable
chronic condition that is characterized by periodic episodes of Gastroesophageal
Reflux usually accompanied by heartburn and that may result in histopathological
changes in the esophagus.
There is variation and controversy around the treatment of GER and GERD,
including positioning, medication, thickened feeds, and surgery. To reduce
inappropriate variation in treatment, practice parameters or clinical practice
guidelines to guide treatment decisions are desireable.
Main Results:
 When infants with Gastroesophageal Reflux are positioned in either
horizontal prone, or 30 degree head elevated prone, symptoms are
significantly reduced compared to when positioned in an infant seat.
 There is no significant clinical difference between horizontal prone and
prone with 30 degrees elevation, thus elevating the head of the crib with
the infant in the prone position is likely not worth the effort.
 Symptoms of Gastroesophageal Reflux are most improved in the prone
position, least likely to be improved in the supine position, and the left and
right positions are intermediate.
 Positioning children younger than two years in supine, with their heads
elevated is not effective in reducing symptoms of Gastroesophageal
Reflux.
Conclusions by the authors of the Cochrane Systematic Review suggest that
although the prone position may have some benefit in reducing the symptoms of
gastroesophageal reflux in children under the age of two years, the “prone
position must not be used in any infant who is still in the age range to be at risk
for SIDS, and the evidence would suggest that supine horizontal position is no
worse than supine elevated.”
 Recommendations of the North American Society for Pediatric
Gastroenterology and Nutrition suggest “prone positioning is acceptable
while the infant is awake.”
 The left lateral position may be effective in reducing the symptoms of
Gastroesophageal Reflux in preterm infants.
 The literature suggests “positional treatment remains, in view of its
efficacy, as a valid ‘adjuvant’ treatment in patients not responding to other
therapeutic approaches or beyond the age of SID risk.”
 There were no randomized control studies found regarding the
effectiveness of positioning with older children and children with
neurological impairments. However, the Guidelines for Evaluation and
Treatment of Gastroesophageal Reflux in Infants and Children:
Recommendations of the North American Society for Pediatric
Gastroenterology and Nutrition suggest that in children older than one
year, it is likely that there is a benefit to left side positioning during sleep
and elevation of the head of the bed, as in adults.
Other evidence of effective treatment options found:
 Thickening feeds reduces the frequency of vomiting, decreases crying,
and increases sleep time, however it does not reduce Gastroesophageal
Reflux. Thickening feeds may increase coughing and diarrhea.
 There is some evidence to suggest that thickening food with carob bean
gum is more successful than rice flour in reducing the symptoms of
Gastroesophageal Reflux.
 There is some evidence to suggest that smaller volumes and lower
osmolality of the feeds also decrease symptoms.
Conclusions:
 The evidence for children under two suggests that positioning children in
supine, with their heads elevated is not effective in reducing the symptoms
of Gastroesophageal Reflux.
 Evidence seemed to suggest that the prone position was superior to
positioning in an infant seat, in supine, or in left and right lateral positions
in reducing symptoms.
 There was also evidence to suggest that the left lateral position may be
effective in reducing the symptoms of Gastroesophageal Reflux in preterm
infants. However, any position, other than supine, is contraindicated as
this puts the infant at greater risk for developing SIDS.
 Prone and left lateral positioning may be acceptable when the child is
awake and when supervised or once the child is no longer at risk of
developing SIDS. The older child may also benefit from elevation of the
head of the bed, as in adults.
Recommendations:
1. Revision of QA’s GERD Wedge and Sling Provision Checklist.
2. Literature search for the most recent and relevant research related to this
topic every six months.
3. Children at risk for SIDS and children under the age of one year should be
positioned in supine for sleep, and no elevation of the head of the crib is
necessary.
4. Equipment that encourages trunk flexion (ex: infant seats, car seats)
should be avoided following feeding and during sleep.
5. In children under the age of one year, prone and left lateral positioning
may be considered for short periods during wakefulness and with adult
supervision to help reduce the symptoms of GER.
6. For children over the age of one year who are no longer at risk for SIDS,
prone and left lateral lying positions can be encouraged, as evidence
suggests a reduction in GER symptoms.
7. For children over the age of one year, elevating the head of the bed may
have some benefit, as in adults, however further investigation into
positioning for older children by the EBPG would be valuable.
8. For the EBPG to consider further investigation into the use of thickening
feeds and of smaller volume feeds as treatment strategies.