See “Noncompliance With NASPGHAN-ESPGHAN Practice Guidelines for GER in Europe: Is There a Point?” by Thaler on page 396, and “European Pediatricians’ Approach to Children With GER Symptoms: Survey of the Implementation of 2009 NASPGHAN-ESPGHAN Guidelines” by Quitadamo et al on page 505.
In this issue of the Journal of Pediatric Gastroenterology and Nutrition (JPGN), Quitadamo et al (1) reports on a survey performed in 2009 about the low compliance of guidelines by European pediatricians with the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)/European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines for gastroesophageal reflux (GER) applied to children with symptoms of GER. In particular, the general pediatricians underused the recommended diagnostic tests, such as pH probe, impedance, and upper gastrointstinal (GI) endoscopy, and overused proton pump inhibitors. These problems are attributed to practitioners’ ignoring the recommended guidelines.
The ignorance of the guidelines is certainly a part of the problem, but it is not the whole story. Lack of compliance with clinical practice guidelines may be widespread for 3 reasons: guidelines may not be well publicized, guidelines may change radically in a short period, and competing guidelines may exist (2). The first 2 refer to the 2009 NASPGHAN/ESPGHAN GER disease (GERD) guidelines (3), and the third one does not. These guidelines were published only in JPGN, a subspecialty publication. The NASPGHAN/ESPGHAN guidelines are in stark contrast to the American Academy of Pediatrics (AAP) clinical practice guidelines, which are widely publicized by the AAP in multiple venues including Pediatrics, AAP News, online, and in the lay press.
The second problem is the change in clinical practice guidelines. Of course, when new science becomes available, clinical practice guidelines must change. The fact that the 2009 GER guidelines differ radically from the 2001 guidelines on the same subject, also published in JPGN(4), is, however, not immediately apparent upon casual reading of the 2 sets of guidelines. The 2009 guidelines make several recommendations that attempt to limit the overuse of proton pump inhibitors because of the studies documenting the lack of efficacy of these medications for infant crying (5,6); however, nowhere are the changes emphasized. For example, the 2001 guidelines state, “Empiric medical therapy. A trial of time limited medical therapy for GER is useful for determining if GER is causing a specific symptom” and “The infant with recurrent crying and irritability…expert opinion suggests two diagnostic and treatment strategies. Empiric treatment with either a sequential or simultaneous two-week trial of a hypoallergenic formula and acid suppression may be initiated.” In contrast, the 2009 recommendations state: “There is no evidence to support an empiric trial of acid suppression as a diagnostic test in infants and young children where symptoms suggestive of GERD are less specific,” and “Infants with unexplained crying and/or distressed behavior… there is no evidence to support empiric use of acid suppression for the treatment of irritable infants… a time limited trial of antisecretory therapy may be considered, but there is potential risk of adverse effects.”
The consequences of these changes in the recommendations are huge. Instead of the simple treatment trial previously suggested, the invasive testing is recommended before the use of proton pump inhibitors in all but older children and teenagers. This is not emphasized in the 2009 guidelines. Instead, the differences are buried in the text. A pediatrician could be forgiven for not realizing how radical the differences truly are.
Even when the guidelines are known, they may not be followed because they are perceived as impractical. That this problem applies to the 2009 GER guidelines is clearly demonstrated in the survey, which showed, “48% prescribed PPIs in children younger than 8–12 years with vomiting and heartburn without specific testing” and “9.7% use esophageal and gastric ultrasound to diagnose gastroesophageal reflux despite a specificity of only 11% for this test.” General pediatricians see many infants and children who are not seriously ill, but have complaints compatible with GERD. The empiric use of proton pump inhibitors undoubtedly reflects the doctors’ desire to help these patients without subjecting them to invasive testing not justified by their perceived relatively minor symptoms. This consideration probably also applies to the use of ultrasound as a diagnostic tool. In the United States, pediatricians frequently use upper GI series for the same purpose. There is also a problem of access. The recommended testing for GERD (pH probe, impedance, or upper GI endoscopy) can only be done by pediatric gastroenterologists. Minor symptoms do not warrant referral to a subspecialist, and in many areas subspecialty referral may be difficult because of lack of access and long wait times for appointments.
Guidelines may not be followed because of patient and/or parental pressure for a solution to the problem. Parents want their children's distress to be eliminated and frequently request medication. They are often understandably reluctant to subject their children to uncomfortable invasive testing unless such testing is clearly necessary.
Finally, there is sometimes outright disagreement with clinical practice guidelines (2). That happens when there are competing guidelines (not the case here) or when guidelines are perceived as being influenced by conflicts of interest such as the authors receiving money from drug and/or device manufacturers or the sponsoring society being influenced by a desire to save money (2). It is not possible to tell from the survey whether European pediatricians disagree with our guidelines. The guidelines were, however, clearly generated ethically using good science, so they should not be perceived as having conflicts of interest.
In summary, I believe the major barriers to general pediatricians’ implementation of the 2009 NASPGHAN/ESPGHAN clinical practice guidelines for GER are ignorance because of lack of publicity for the guidelines, and lack of clarity about guideline changes and the perceived impracticality of some of the recommendations. We may be able to alleviate these problems by widely publicizing our guidelines in multiple venues and, when changing the guidelines, emphasizing the major changes and the reasons for them upfront. Furthermore, the practicality of the guidelines should be a consideration when generating them.
1. Quitadamo P, Papadopoulou A, Wenzl T, et al. European pediatricians’ approach to children with GER symptoms: survey of the implementation of 2009 NASPGHAN-ESPGHAN guidelines. J Pediatr Gastroenterol Nutr
2. Fletcher R, Clinical practice guidelines. www.uptodate.com
. Accessed June 1, 2013.
3. Vandenplas Y, Rudolph C, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendation of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr
4. Rudolph C, Mazur L, Liptak G, et al. Guidelines for the evaluation and treatment of gastroesophageal reflux in infants and children, recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr
2001; 32 (suppl 2):S1–S31.
5. Orenstein SR, Hassel E, Furmaga-Jablonska W, et al. Multicenter, double-blind, placebo-controlled trial assessing efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr
6. Moore DJ, Tao BS, Lines DR, et al. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr