Effectiveness of Positioning Children in Supine with Head Elevated to 30
degrees in the Treatment of Gastroesophageal Reflux - Draft
Prepared for Queen Alexandra Centre for Children’s Health
2400 Arbutus Road
Victoria, BC V8N 1V7
Prepared by:
Susan Gmitroski OT, Phil Harmuth SLP, and Victoria Korby-Fuchs OT
November 2006
Preface:
The Queen Alexandra Centre’s Evidence Based Practice Group (EBPG) was
established as part of a one year pilot project aimed at developing a framework
for answering clinically relevant questions for Speech and Language
Pathologists, Occupational Therapists and Physiotherapists based on the best
available research, and to apply this framework to an initial set of the most
pressing clinical issues facing these stakeholders.
The goal was to develop a model for the collection and analysis of relevant
scientific literature, including evidence-based medicine reviews, clinical
guidelines, and research articles, in order to determine the best available
treatment options.
Queen Alexandra Centre’s Evidence Based Practice Group includes:
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Susan Gmitroski, Senior Occupational Therapist
Phil Harmuth, Senior Speech and Language Pathologist and
Coordinator of the Swallowing Disorders Clinic
Lynn Purves, Senior Physiotherapist
Joan Glover, Resource Physiotherapist, Early Intervention
Program
Victoria Korby-Fuchs, Resource Occupational Therapist, Early
Intervention Program
Acknowledgments:
Thanks go to:
Corinne Dulberg, PhD MPH
Research Consultant
Vancouver Island Health Authority
Overview:
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.
Nelson, Chen, Syniar, and Christoffel (1997) found that “complaints of
regurgitation are common during the first year of life, peaking at 4 months of age.
Many infants ‘outgrow’ overt GER by 7 months and most by 1 year” (p. 569).
Friedman (2006) found the following:
More than 10 episodes of pharyngeal reflux per 24 hours is pathologic, even
in infants less than 1 year of age (Halstead, 2003). GERD is an important
inflammatory cofactor in subglottic stenosis, recurrent croup, apnea, and
chronic cough, and may play a causative role. GERD may persist for many
years in premature children. (p. 7)
GER is a common cause for referral to Queen Alexandra Centre for Children’s
Health. Until now, treatment has often included a wedge and sling to elevate the
infant’s head to a 30-degree angle during sleep in an attempt to reduce the
symptoms of reflux.
However, there is variation and controversy around the treatment of GER and
GERD, concerning positioning, as well as medication, thickened feeds, and
surgery. To reduce inappropriate variation in treatment, practice parameters or
clinical practice guidelines are desirable.
Objectives:
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To review the evidence related to the usefulness of positioning in the
treatment of GER in children. Specifically, does being positioned on a 30degree angle (head up) in supine reduce the symptoms of GER?
To translate the results of the evidence review into treatment and
management practice of GER in children who are seen through the Queen
Alexandra Centre for Children’s Health.
To share findings with other clinicians involved in the treatment and
management of GER in children.
Methodology
Literature Search:
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Electronic Database: PubMed, Ovid using the term Gastroesophageal
Reflux and limits including pediatrics, prevention and control,
rehabilitation, and therapy
Evidence-based Medicine Reviews: Cochrane Database of Systematic
Reviews, Cochrane Brief
Clinical Guidelines: “Guidelines for Evaluation and Treatment of
Gastroesophageal Reflux in Infants and Children: Recommendations of
the North American Society for Pediatric Gastroenterology and Nutrition”
2001
Authors Contacted: Susan R. Orenstein
Selection Criteria:
Studies were selected if they focused on the treatment of GER in children and
were published in English as a full report in peer-reviewed journals. A thorough
systematic review entitled “Metoclopramide, thickened feedings, and positioning
for gastro-oesophageal reflux in children under two years” that was most recently
updated in November of 2004 was located in the Cochrane Database of
Systematic Reviews. As the Cochrane Database is currently considered the gold
standard with respect to reviewing scientific evidence, this article was used and a
search was done for other more recent articles that may have been published
since the Cochrane update in 2004.
Reporting the Evidence:
A multidisciplinary research team was assembled, with the participation of
Speech and Language Pathologists and Occupational Therapists. After multiple
consultations and the evaluation of published systematic reviews and metaanalyses, the following question was selected as the focus of the evidence
report:
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Does being positioned on a 30-degree angle (head up) in supine reduce
the symptoms of GER in children?
To answer this question, while avoiding the duplication of work, making efficient
use of the resources available, and ensuring maximum added value, the scope of
the evidence report focused on prevention and control, rehabilitation, and therapy
relating to GER.
Results of Literature Search:
Craig, Hanlon-Dearman, Sinclair, Taback, and Moffatt (2004), the authors of the
Cochrane Systematic Review on GER, found the following:
 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 side lying positions are intermediate (i.e.: side lying is better than
supine in reducing symptoms, but not as beneficial as prone).
 Positioning children younger than two years in supine, with their heads
elevated is not effective in reducing symptoms of Gastroesophageal
Reflux.
Conclusions by Craig et al. suggest that although the prone position may have
some benefit in reducing the symptoms of GER 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 the supine
horizontal position is no worse than supine elevated.”
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In the Guidelines for Evaluation and Treatment of Gastroesophageal
Reflux in Infants and Children: Recommendations of the North American
Society for Pediatric Gastroenterology and Nutrition, Rudolph et al. (2001)
stated that “prone positioning is acceptable while the infant is awake.”
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Ewer, James, and Tobin (1999) suggest that the left lateral position may
be effective in reducing the symptoms of Gastroesophageal Reflux in
preterm infants.
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In A Critical Appraisal of Current Management Practices for Infant
Regurgitation – Recommendations of a Working Party, Vandenplas et al.
(1996) stated “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.”
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There were no randomized control studies found regarding the
effectiveness of positioning with older children and children with
neurological impairments. However, Rudolph et al. (2001) stated “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.”
Although the EBPG’s research question was specifically related to the
effectiveness of elevating the head of a crib/bed, other evidence of effective
treatment options was found and will be mentioned in brief.
 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.
Finally, most articles suggested that further studies are needed to address the
issue of Gastroesophageal Reflux in children.
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 GER.
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 GER in preterm infants. However, any
position during sleep, 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 for SIDS. The older child
may also benefit from elevation of the head of the bed, as in adults.
Evidence was found for treatment options not specifically related to the question
of positioning and further research is needed in this area. Other treatment
options that may be of benefit include reassurance for parents that GER usually
improves with time, ensuring the infant is not positioned such that the trunk is
flexed following feeds, thickening feeds, and providing smaller, more frequent
feeds throughout the day.
Summary
The evidence for children under two years of age suggests that positioning
children in supine, with their heads elevated is not effective in reducing GER.
There was some evidence to suggest that prone and left lateral lying do help to
reduce symptoms of GER, however infants cannot be left in these positions
unattended due to the increased risk of SIDS.
There is little evidence-based research concerning older children with GER and
positioning. However, older children who are no longer at risk for SIDS may
benefit from left side positioning during sleep and 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
References:
Craig, W. R., Hanlon-Dearman, A., Sinclair, C., Taback, S., & Moffatt, M.
(Updated November 16, 2004). Metoclopramide, thickened feedings, and
positioning for gastro-oesophageal reflux in children under two years. [Cochrane
Review]. In Cochrane Database of Systematic Reviews, 2004 (1). Retrieved
June 5, 2006, from Ovid Evidence Based Medicine Reviews: The Cochrane
Database of Systematic Reviews.
Ewer, A. K., James, M. E., & Tobin, J. M. (1999). Prone and left lateral
positioning reduce gastro-oesophageal reflux in preterm infants. Archives of
Disease in Childhood - Fetal Neonatal Edition, 81, F201-F205.
Friedman, E.N. (2006, November 7). Gastroesophageal reflux disease.
Serious illness potential often misunderstood. The ASHA Leader, 7.
Nelson, S.P., Chen, E.H., Syniar, G.M., & Christoffel K.K. (1997). Prevalence
of symptoms of gastroesophageal reflux during infancy. A pediatric practicebased survey. Archives of Pediatrics & Adolescent Medicine, 151, 569-72.
Rudolph, C. D., Mazur, L. J., Liptak, G. S., Baker, R. D., Boyle, J. T., Colletti,
R. B., Gerson, W. T., Werlin, S. L. (2001) Guidelines for Evaluation and
Treatment of Gastroesophageal Reflux in Infants and Children:
Recommendations of the North American Society for Pediatric Gastroenterology
and Nutrition. Journal of Pediatric Gastroenterology and Nutrition. 32,
Supplement 2, S1-S31.
Vandenplas Y., Belli, D., Benhamou, P., Cadranel, S., Cezard, J. P.,
Cucchiara, S., Dupont, C., Faure, C., Gottrand, F., Hassall, E., Heymans, H.,
Kneepkens, C. M., Sandhu, B. (1996) A critical appraisal of current
management practices for infant regurgitation – recommendations of a working
party. European Journal of Pediarics, 156, 343-357.