Danielle Carcia, DO

Opioids are commonly prescribed for chronic pain, and in fact approximately 20% of patients presenting with noncancer pain symptoms will receive an opioid prescription in a physician’s office. Opioid prescriptions increased 7% per capita between 2007 and 2012. Along with this increase in prescriptions has been a proportional increase in opioid-related deaths.

The Centers for Disease Control and Prevention guidelines provides recommendations aimed at primary care clinicians for prescribing opioid medications for chronic pain in the outpatient setting. Chronic pain is defined as pain that lasts longer than 3 months, which may be a result of underlying medical disease, injury, medical treatment, or unknown causes. The target population for the guidelines are patients over 18 years of age with chronic noncancer pain. The guidelines are not intended for the clinical care of patients at the end of life, palliative care, or active cancer patients. Special populations that are addressed in the guidelines include older adults, pregnant women, and patients with a history of substance use disorder.

After a detailed review of the evidence, the CDC summarized 12 recommendations for physicians when prescribing opioids for chronic pain, outlined below, and divided them into three sections. All of the recommendations are category A, meaning they apply to most patients. The exception is recommendation No. 10, as it pertains to urine drug testing, which is a category B recommendation, meaning that different choices may be appropriate for some patients.

Determining when to initiate or continue opioids for chronic pain

1. Nonpharmacologic treatment and nonopioid pharmacologic treatments are preferred for chronic pain. Opioids are not a first-line option and should be combined with nonpharmacologic therapy and nonopioid medications if appropriate.

2. Treatment goals should be established with all patients when initiating therapy. Continuation of opioid treatment should occur only if improvement in pain and/or function continues to outweigh the risks of the treatment.

3. Discussion of the risks and realistic benefits of opioid therapy should occur with patients at initiation and during the treatment course.

Opioid selection, dosage, duration, and discontinuation

4. When starting opioid therapy for chronic pain immediate-release opioids should be used initially. Extended-release/long-acting opioids are associated with a higher risk of overdose when treatment is initiated with these; therefore, extended-release/long-acting opioids should be used only for patients with severe, continuous pain and only after a patient has received immediate-release opioids for at least 1 week.

5. Opioids should be prescribed at the lowest effective dose. Avoid dosages greater than 90-mg morphine equivalents per day, and exercise caution at doses greater than 50-mg morphine equivalents per day.

6. Because most chronic pain is initially treated as acute pain, when treating acute pain be sure to use the lowest dose, and prescribe only the amount anticipated to be required for the acute injury/complaint. Prescriptions of longer than 7 days for acute pain are usually not necessary.

7. Evaluate the benefits and harms of opioid prescription within 1-4 weeks of initiation or dose escalation. Always consider tapering or discontinuation if goals are not being met.

8. Evaluate risk factors for opioid-related harms both when initiating medications and periodically during treatment. Risk factors include a history of substance use disorder, high opioid doses, or benzodiazepine use.

Assessing risk and addressing harms of opioid use

9. Review patients’ prescription drug monitoring program to help determine the risk for overdose. Intervals of review may range from when each prescription is given to every 3 months.

10. Utilize urine drug screening when initiating medication and periodically (at least annually). Discuss all unexpected results with the lab, patient, and possibly toxicologist. Repeatedly negative urine drug screens indicate the patient is not taking a prescribed opioid, and therefore medication can be discontinued without a taper.

11. Avoid prescribing a benzodiazepine and opioids concurrently because of a higher risk of fatal overdose.

12. Arrange treatment for patients with opioid-use disorder such as referral to a medication-assisted treatment center for buprenorphine or methadone treatment.

Special populations

The CDC addressed several special populations for which special care when initiating or titrating opioid therapy should be taken:

• Patients with sleep-disordered breathing. Any patient with moderate-to-severe sleep-disordered breathing, including sleep apnea, should avoid opioids if possible; if opioids can’t be avoided, slow titration and lower starting doses should be used.

• Pregnant women and reproductive age women. Use in pregnancy can lead to additional risks for both mother and fetus; therefore, initiation of opioids for chronic pain in any reproductive age woman should include this information so a proper joint decision may be made between patient and clinician. The risks include preterm delivery, birth defects, stillbirth, poor fetal growth, and neonatal abstinence syndrome.

• Patients older than 65. Because of decreasing renal function, this population is at risk for the accumulation of opioids and may be unable to tolerate nonopioid pharmacologic therapy such as NSAIDs as a result of comorbidities. When opioids are necessary, the recommendations indicate a need for fall risk assessment, monitoring for cognitive impairment, and an appropriate bowel regimen.

• Patients with mental health conditions. These patients pose a high risk for overdose both because of polypharmacy, specifically benzodiazepine use, and mental instability. Make sure patients are being optimally treated for their mental health disorders, and when possible consider the use of tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors for additional pain relief.

• Patients with substance use disorders. Those who use illicit substances contribute to a significant proportion of deaths related to opioid use. However, the previously recommended risk assessment tools were found to be inaccurate and should not provide clinicians with a sense of security when prescribing to this patient population. In addition, consulting a substance use disorder specialist and/or pain specialist may be best for this population.

The bottom line

Opioid use has been increasing steadily in the United States with a proportional increase in opioid overdoses. The CDC guidelines present a strategy to prescribing opioids that emphasizes caution, careful decision making, and monitoring when prescribing opioids in order to best control pain while mitigating the risks of opioid use disorder and overdose.

Reference

CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-50.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is currently a third-year resident and chief resident in the family medicine program at Abington Memorial Hospital.

Opioids are commonly prescribed for chronic pain, and in fact approximately 20% of patients presenting with noncancer pain symptoms will receive an opioid prescription in a physician’s office. Opioid prescriptions increased 7% per capita between 2007 and 2012. Along with this increase in prescriptions has been a proportional increase in opioid-related deaths.

The Centers for Disease Control and Prevention guidelines provides recommendations aimed at primary care clinicians for prescribing opioid medications for chronic pain in the outpatient setting. Chronic pain is defined as pain that lasts longer than 3 months, which may be a result of underlying medical disease, injury, medical treatment, or unknown causes. The target population for the guidelines are patients over 18 years of age with chronic noncancer pain. The guidelines are not intended for the clinical care of patients at the end of life, palliative care, or active cancer patients. Special populations that are addressed in the guidelines include older adults, pregnant women, and patients with a history of substance use disorder.

After a detailed review of the evidence, the CDC summarized 12 recommendations for physicians when prescribing opioids for chronic pain, outlined below, and divided them into three sections. All of the recommendations are category A, meaning they apply to most patients. The exception is recommendation No. 10, as it pertains to urine drug testing, which is a category B recommendation, meaning that different choices may be appropriate for some patients.

Determining when to initiate or continue opioids for chronic pain

1. Nonpharmacologic treatment and nonopioid pharmacologic treatments are preferred for chronic pain. Opioids are not a first-line option and should be combined with nonpharmacologic therapy and nonopioid medications if appropriate.

2. Treatment goals should be established with all patients when initiating therapy. Continuation of opioid treatment should occur only if improvement in pain and/or function continues to outweigh the risks of the treatment.

3. Discussion of the risks and realistic benefits of opioid therapy should occur with patients at initiation and during the treatment course.

Opioid selection, dosage, duration, and discontinuation

4. When starting opioid therapy for chronic pain immediate-release opioids should be used initially. Extended-release/long-acting opioids are associated with a higher risk of overdose when treatment is initiated with these; therefore, extended-release/long-acting opioids should be used only for patients with severe, continuous pain and only after a patient has received immediate-release opioids for at least 1 week.

5. Opioids should be prescribed at the lowest effective dose. Avoid dosages greater than 90-mg morphine equivalents per day, and exercise caution at doses greater than 50-mg morphine equivalents per day.

6. Because most chronic pain is initially treated as acute pain, when treating acute pain be sure to use the lowest dose, and prescribe only the amount anticipated to be required for the acute injury/complaint. Prescriptions of longer than 7 days for acute pain are usually not necessary.

7. Evaluate the benefits and harms of opioid prescription within 1-4 weeks of initiation or dose escalation. Always consider tapering or discontinuation if goals are not being met.

8. Evaluate risk factors for opioid-related harms both when initiating medications and periodically during treatment. Risk factors include a history of substance use disorder, high opioid doses, or benzodiazepine use.

Assessing risk and addressing harms of opioid use

9. Review patients’ prescription drug monitoring program to help determine the risk for overdose. Intervals of review may range from when each prescription is given to every 3 months.

10. Utilize urine drug screening when initiating medication and periodically (at least annually). Discuss all unexpected results with the lab, patient, and possibly toxicologist. Repeatedly negative urine drug screens indicate the patient is not taking a prescribed opioid, and therefore medication can be discontinued without a taper.

11. Avoid prescribing a benzodiazepine and opioids concurrently because of a higher risk of fatal overdose.

12. Arrange treatment for patients with opioid-use disorder such as referral to a medication-assisted treatment center for buprenorphine or methadone treatment.

Special populations

The CDC addressed several special populations for which special care when initiating or titrating opioid therapy should be taken:

• Patients with sleep-disordered breathing. Any patient with moderate-to-severe sleep-disordered breathing, including sleep apnea, should avoid opioids if possible; if opioids can’t be avoided, slow titration and lower starting doses should be used.

• Pregnant women and reproductive age women. Use in pregnancy can lead to additional risks for both mother and fetus; therefore, initiation of opioids for chronic pain in any reproductive age woman should include this information so a proper joint decision may be made between patient and clinician. The risks include preterm delivery, birth defects, stillbirth, poor fetal growth, and neonatal abstinence syndrome.

• Patients older than 65. Because of decreasing renal function, this population is at risk for the accumulation of opioids and may be unable to tolerate nonopioid pharmacologic therapy such as NSAIDs as a result of comorbidities. When opioids are necessary, the recommendations indicate a need for fall risk assessment, monitoring for cognitive impairment, and an appropriate bowel regimen.

• Patients with mental health conditions. These patients pose a high risk for overdose both because of polypharmacy, specifically benzodiazepine use, and mental instability. Make sure patients are being optimally treated for their mental health disorders, and when possible consider the use of tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors for additional pain relief.

• Patients with substance use disorders. Those who use illicit substances contribute to a significant proportion of deaths related to opioid use. However, the previously recommended risk assessment tools were found to be inaccurate and should not provide clinicians with a sense of security when prescribing to this patient population. In addition, consulting a substance use disorder specialist and/or pain specialist may be best for this population.

The bottom line

Opioid use has been increasing steadily in the United States with a proportional increase in opioid overdoses. The CDC guidelines present a strategy to prescribing opioids that emphasizes caution, careful decision making, and monitoring when prescribing opioids in order to best control pain while mitigating the risks of opioid use disorder and overdose.

Reference

CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-50.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is currently a third-year resident and chief resident in the family medicine program at Abington Memorial Hospital.

Opioids are commonly prescribed for chronic pain, and in fact approximately 20% of patients presenting with noncancer pain symptoms will receive an opioid prescription in a physician’s office. Opioid prescriptions increased 7% per capita between 2007 and 2012. Along with this increase in prescriptions has been a proportional increase in opioid-related deaths.

The Centers for Disease Control and Prevention guidelines provides recommendations aimed at primary care clinicians for prescribing opioid medications for chronic pain in the outpatient setting. Chronic pain is defined as pain that lasts longer than 3 months, which may be a result of underlying medical disease, injury, medical treatment, or unknown causes. The target population for the guidelines are patients over 18 years of age with chronic noncancer pain. The guidelines are not intended for the clinical care of patients at the end of life, palliative care, or active cancer patients. Special populations that are addressed in the guidelines include older adults, pregnant women, and patients with a history of substance use disorder.

After a detailed review of the evidence, the CDC summarized 12 recommendations for physicians when prescribing opioids for chronic pain, outlined below, and divided them into three sections. All of the recommendations are category A, meaning they apply to most patients. The exception is recommendation No. 10, as it pertains to urine drug testing, which is a category B recommendation, meaning that different choices may be appropriate for some patients.

Determining when to initiate or continue opioids for chronic pain

1. Nonpharmacologic treatment and nonopioid pharmacologic treatments are preferred for chronic pain. Opioids are not a first-line option and should be combined with nonpharmacologic therapy and nonopioid medications if appropriate.

2. Treatment goals should be established with all patients when initiating therapy. Continuation of opioid treatment should occur only if improvement in pain and/or function continues to outweigh the risks of the treatment.

3. Discussion of the risks and realistic benefits of opioid therapy should occur with patients at initiation and during the treatment course.

Opioid selection, dosage, duration, and discontinuation

4. When starting opioid therapy for chronic pain immediate-release opioids should be used initially. Extended-release/long-acting opioids are associated with a higher risk of overdose when treatment is initiated with these; therefore, extended-release/long-acting opioids should be used only for patients with severe, continuous pain and only after a patient has received immediate-release opioids for at least 1 week.

5. Opioids should be prescribed at the lowest effective dose. Avoid dosages greater than 90-mg morphine equivalents per day, and exercise caution at doses greater than 50-mg morphine equivalents per day.

6. Because most chronic pain is initially treated as acute pain, when treating acute pain be sure to use the lowest dose, and prescribe only the amount anticipated to be required for the acute injury/complaint. Prescriptions of longer than 7 days for acute pain are usually not necessary.

7. Evaluate the benefits and harms of opioid prescription within 1-4 weeks of initiation or dose escalation. Always consider tapering or discontinuation if goals are not being met.

8. Evaluate risk factors for opioid-related harms both when initiating medications and periodically during treatment. Risk factors include a history of substance use disorder, high opioid doses, or benzodiazepine use.

Assessing risk and addressing harms of opioid use

9. Review patients’ prescription drug monitoring program to help determine the risk for overdose. Intervals of review may range from when each prescription is given to every 3 months.

10. Utilize urine drug screening when initiating medication and periodically (at least annually). Discuss all unexpected results with the lab, patient, and possibly toxicologist. Repeatedly negative urine drug screens indicate the patient is not taking a prescribed opioid, and therefore medication can be discontinued without a taper.

11. Avoid prescribing a benzodiazepine and opioids concurrently because of a higher risk of fatal overdose.

12. Arrange treatment for patients with opioid-use disorder such as referral to a medication-assisted treatment center for buprenorphine or methadone treatment.

Special populations

The CDC addressed several special populations for which special care when initiating or titrating opioid therapy should be taken:

• Patients with sleep-disordered breathing. Any patient with moderate-to-severe sleep-disordered breathing, including sleep apnea, should avoid opioids if possible; if opioids can’t be avoided, slow titration and lower starting doses should be used.

• Pregnant women and reproductive age women. Use in pregnancy can lead to additional risks for both mother and fetus; therefore, initiation of opioids for chronic pain in any reproductive age woman should include this information so a proper joint decision may be made between patient and clinician. The risks include preterm delivery, birth defects, stillbirth, poor fetal growth, and neonatal abstinence syndrome.

• Patients older than 65. Because of decreasing renal function, this population is at risk for the accumulation of opioids and may be unable to tolerate nonopioid pharmacologic therapy such as NSAIDs as a result of comorbidities. When opioids are necessary, the recommendations indicate a need for fall risk assessment, monitoring for cognitive impairment, and an appropriate bowel regimen.

• Patients with mental health conditions. These patients pose a high risk for overdose both because of polypharmacy, specifically benzodiazepine use, and mental instability. Make sure patients are being optimally treated for their mental health disorders, and when possible consider the use of tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors for additional pain relief.

• Patients with substance use disorders. Those who use illicit substances contribute to a significant proportion of deaths related to opioid use. However, the previously recommended risk assessment tools were found to be inaccurate and should not provide clinicians with a sense of security when prescribing to this patient population. In addition, consulting a substance use disorder specialist and/or pain specialist may be best for this population.

The bottom line

Opioid use has been increasing steadily in the United States with a proportional increase in opioid overdoses. The CDC guidelines present a strategy to prescribing opioids that emphasizes caution, careful decision making, and monitoring when prescribing opioids in order to best control pain while mitigating the risks of opioid use disorder and overdose.

Reference

CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-50.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is currently a third-year resident and chief resident in the family medicine program at Abington Memorial Hospital.

Pressure ulcers affect approximately 3 million adults in the United States and cause significant morbidity, with treatment costs of approximately $11 billion per year. The prevalence varies between 0.4% and 38% in acute care settings and 2%-24% in long-term care settings. Because of the high prevalence and cost associated with pressure ulcers, there has been a push toward prevention and appropriate treatment.

Pressure ulcers are defined as damage to a localized area of skin resulting from pressure or pressure and shear. They are most common in patients who are limited in their mobility. Other risk factors include advanced age, black or Hispanic ethnicity, cognitive and physical impairments, and low body weight. Any comorbid condition that decreases skin integrity or healing may also be considered a risk factor, including fecal or urinary incontinence, diabetes, prolonged edema, a low albumin level, or malnutrition.

The American College of Physicians’s guidelines grade its recommendations by the strength and basis of the supporting data. A strong recommendation is one for which the benefits clearly outweigh the risks and burdens; a weak recommendation is defined as one in which the benefits do not outweigh the risks and burdens. There are three levels of evidence quality: low, moderate, and high.

The first recommendation for the prevention of pressure ulcers is to perform a risk assessment on all patients in order to identify who is at risk. There was no specific recommendation as to which, if any, risk assessment tool should be used. This was a weak recommendation supported by low-quality evidence. There are various scales available for assessing a patient’s risk of pressure ulcer development, including the Braden, Cubbin, Jackson, Norton, and Waterlow scales. There are pitfalls with each tool, and they have all been found to have a low sensitivity and specificity. There has not been any evidence to show that the use of a risk assessment scale is superior to clinical judgment in assessing a patient’s risk for developing pressure ulcers. Although there have been a few studies that directly compared the various risk assessment tools, none of the tools emerged as superior.

The second recommendation for the prevention of pressure ulcers is to use advanced static mattresses or mattress overlays in patients who are at increased risk for developing pressure ulcers. This was a strong recommendation supported by moderate-quality evidence. There are few studies that exist on interventions for pressure ulcer prevention, and the different types of interventions are often each used in only one study. This made comparing the strategies for prevention difficult.

The third recommendation for the prevention of pressure ulcers is not to use alternating air mattresses or air overlays in patients at increased risk for developing pressure ulcers. This weak recommendation is supported by moderate-quality evidence. Most of the studies compared found no significant difference between these and static mattresses; however, air-alternating mattresses were less tolerable to patients and cost more.

It should be noted that the analysis of commonly used methods for the prevention of pressure ulcers – heel support boots, wheelchair cushions, nutritional supplementation, dressings, and repositioning – found no statistically significant difference in the prevention of pressure ulcers. Therefore, they are not part of the recommendations from the ACP. Multicomponent team-based interventions do appear to show a benefit.

The first recommendation for the treatment of pressure ulcers is that protein and amino acid supplementation be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was no recommendation as to what dose of protein supplementation to use, and it should be noted it is unclear whether this is applicable to the entire population or reserved for patients with nutritional deficiencies. There was no evidence to suggest other supplementation with vitamin C should be recommended.

The second recommendation for the treatment of pressure ulcers is that hydrocolloid or foam dressings be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was insufficient evidence to comment on complete wound healing with hydrocolloid or foam dressings, and the relationship between the reduction of wound size and complete healing has not been well defined. The analysis evaluated other dressing types – dextranomer paste, topical collagen, and radiant heat dressings – and did not recommend their use.

The third recommendation for the treatment of pressure ulcers from the ACP is the use of electrical stimulation as an adjunctive therapy to help accelerate wound healing. This was a weak recommendation based on moderate-quality evidence. It should be noted that this treatment modality was associated with an increase in adverse events, especially skin irritation, in the elderly population.

Other strategies evaluated for the treatment of pressure ulcers include the use of oxandrolone (an androgen used to promote weight gain), which was found to show no improvement versus placebo in wound healing and to have associated adverse events. Additional therapies evaluated included electromagnetic therapy, therapeutic ultrasound, negative pressure wound therapy, light therapy, and laser therapy, which all showed no improvement in the reduction of wound size, or complete healing, when compared with sham therapies.

Bottom line

For the prevention of pressure ulcers, assess each patient for risk using clinical judgment or a risk assessment tool of your choice. When possible, choose static mattresses or mattress overlays rather than the more costly, and more bothersome, alternating air mattresses. For the treatment of pressure ulcers, use protein or amino acid supplementation to aid in wound healing, use hydrocolloid or foam dressings to help decrease wound size, and consider electrical stimulation as a treatment option in younger patients.

References

Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162[5]:359-69.

Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162[5]:370-9.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Carcia is chief resident in the family medicine program at Abington.

Pressure ulcers affect approximately 3 million adults in the United States and cause significant morbidity, with treatment costs of approximately $11 billion per year. The prevalence varies between 0.4% and 38% in acute care settings and 2%-24% in long-term care settings. Because of the high prevalence and cost associated with pressure ulcers, there has been a push toward prevention and appropriate treatment.

Pressure ulcers are defined as damage to a localized area of skin resulting from pressure or pressure and shear. They are most common in patients who are limited in their mobility. Other risk factors include advanced age, black or Hispanic ethnicity, cognitive and physical impairments, and low body weight. Any comorbid condition that decreases skin integrity or healing may also be considered a risk factor, including fecal or urinary incontinence, diabetes, prolonged edema, a low albumin level, or malnutrition.

The American College of Physicians’s guidelines grade its recommendations by the strength and basis of the supporting data. A strong recommendation is one for which the benefits clearly outweigh the risks and burdens; a weak recommendation is defined as one in which the benefits do not outweigh the risks and burdens. There are three levels of evidence quality: low, moderate, and high.

The first recommendation for the prevention of pressure ulcers is to perform a risk assessment on all patients in order to identify who is at risk. There was no specific recommendation as to which, if any, risk assessment tool should be used. This was a weak recommendation supported by low-quality evidence. There are various scales available for assessing a patient’s risk of pressure ulcer development, including the Braden, Cubbin, Jackson, Norton, and Waterlow scales. There are pitfalls with each tool, and they have all been found to have a low sensitivity and specificity. There has not been any evidence to show that the use of a risk assessment scale is superior to clinical judgment in assessing a patient’s risk for developing pressure ulcers. Although there have been a few studies that directly compared the various risk assessment tools, none of the tools emerged as superior.

The second recommendation for the prevention of pressure ulcers is to use advanced static mattresses or mattress overlays in patients who are at increased risk for developing pressure ulcers. This was a strong recommendation supported by moderate-quality evidence. There are few studies that exist on interventions for pressure ulcer prevention, and the different types of interventions are often each used in only one study. This made comparing the strategies for prevention difficult.

The third recommendation for the prevention of pressure ulcers is not to use alternating air mattresses or air overlays in patients at increased risk for developing pressure ulcers. This weak recommendation is supported by moderate-quality evidence. Most of the studies compared found no significant difference between these and static mattresses; however, air-alternating mattresses were less tolerable to patients and cost more.

It should be noted that the analysis of commonly used methods for the prevention of pressure ulcers – heel support boots, wheelchair cushions, nutritional supplementation, dressings, and repositioning – found no statistically significant difference in the prevention of pressure ulcers. Therefore, they are not part of the recommendations from the ACP. Multicomponent team-based interventions do appear to show a benefit.

The first recommendation for the treatment of pressure ulcers is that protein and amino acid supplementation be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was no recommendation as to what dose of protein supplementation to use, and it should be noted it is unclear whether this is applicable to the entire population or reserved for patients with nutritional deficiencies. There was no evidence to suggest other supplementation with vitamin C should be recommended.

The second recommendation for the treatment of pressure ulcers is that hydrocolloid or foam dressings be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was insufficient evidence to comment on complete wound healing with hydrocolloid or foam dressings, and the relationship between the reduction of wound size and complete healing has not been well defined. The analysis evaluated other dressing types – dextranomer paste, topical collagen, and radiant heat dressings – and did not recommend their use.

The third recommendation for the treatment of pressure ulcers from the ACP is the use of electrical stimulation as an adjunctive therapy to help accelerate wound healing. This was a weak recommendation based on moderate-quality evidence. It should be noted that this treatment modality was associated with an increase in adverse events, especially skin irritation, in the elderly population.

Other strategies evaluated for the treatment of pressure ulcers include the use of oxandrolone (an androgen used to promote weight gain), which was found to show no improvement versus placebo in wound healing and to have associated adverse events. Additional therapies evaluated included electromagnetic therapy, therapeutic ultrasound, negative pressure wound therapy, light therapy, and laser therapy, which all showed no improvement in the reduction of wound size, or complete healing, when compared with sham therapies.

Bottom line

For the prevention of pressure ulcers, assess each patient for risk using clinical judgment or a risk assessment tool of your choice. When possible, choose static mattresses or mattress overlays rather than the more costly, and more bothersome, alternating air mattresses. For the treatment of pressure ulcers, use protein or amino acid supplementation to aid in wound healing, use hydrocolloid or foam dressings to help decrease wound size, and consider electrical stimulation as a treatment option in younger patients.

References

Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162[5]:359-69.

Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162[5]:370-9.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Carcia is chief resident in the family medicine program at Abington.

Pressure ulcers affect approximately 3 million adults in the United States and cause significant morbidity, with treatment costs of approximately $11 billion per year. The prevalence varies between 0.4% and 38% in acute care settings and 2%-24% in long-term care settings. Because of the high prevalence and cost associated with pressure ulcers, there has been a push toward prevention and appropriate treatment.

Pressure ulcers are defined as damage to a localized area of skin resulting from pressure or pressure and shear. They are most common in patients who are limited in their mobility. Other risk factors include advanced age, black or Hispanic ethnicity, cognitive and physical impairments, and low body weight. Any comorbid condition that decreases skin integrity or healing may also be considered a risk factor, including fecal or urinary incontinence, diabetes, prolonged edema, a low albumin level, or malnutrition.

The American College of Physicians’s guidelines grade its recommendations by the strength and basis of the supporting data. A strong recommendation is one for which the benefits clearly outweigh the risks and burdens; a weak recommendation is defined as one in which the benefits do not outweigh the risks and burdens. There are three levels of evidence quality: low, moderate, and high.

The first recommendation for the prevention of pressure ulcers is to perform a risk assessment on all patients in order to identify who is at risk. There was no specific recommendation as to which, if any, risk assessment tool should be used. This was a weak recommendation supported by low-quality evidence. There are various scales available for assessing a patient’s risk of pressure ulcer development, including the Braden, Cubbin, Jackson, Norton, and Waterlow scales. There are pitfalls with each tool, and they have all been found to have a low sensitivity and specificity. There has not been any evidence to show that the use of a risk assessment scale is superior to clinical judgment in assessing a patient’s risk for developing pressure ulcers. Although there have been a few studies that directly compared the various risk assessment tools, none of the tools emerged as superior.

The second recommendation for the prevention of pressure ulcers is to use advanced static mattresses or mattress overlays in patients who are at increased risk for developing pressure ulcers. This was a strong recommendation supported by moderate-quality evidence. There are few studies that exist on interventions for pressure ulcer prevention, and the different types of interventions are often each used in only one study. This made comparing the strategies for prevention difficult.

The third recommendation for the prevention of pressure ulcers is not to use alternating air mattresses or air overlays in patients at increased risk for developing pressure ulcers. This weak recommendation is supported by moderate-quality evidence. Most of the studies compared found no significant difference between these and static mattresses; however, air-alternating mattresses were less tolerable to patients and cost more.

It should be noted that the analysis of commonly used methods for the prevention of pressure ulcers – heel support boots, wheelchair cushions, nutritional supplementation, dressings, and repositioning – found no statistically significant difference in the prevention of pressure ulcers. Therefore, they are not part of the recommendations from the ACP. Multicomponent team-based interventions do appear to show a benefit.

The first recommendation for the treatment of pressure ulcers is that protein and amino acid supplementation be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was no recommendation as to what dose of protein supplementation to use, and it should be noted it is unclear whether this is applicable to the entire population or reserved for patients with nutritional deficiencies. There was no evidence to suggest other supplementation with vitamin C should be recommended.

The second recommendation for the treatment of pressure ulcers is that hydrocolloid or foam dressings be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was insufficient evidence to comment on complete wound healing with hydrocolloid or foam dressings, and the relationship between the reduction of wound size and complete healing has not been well defined. The analysis evaluated other dressing types – dextranomer paste, topical collagen, and radiant heat dressings – and did not recommend their use.

The third recommendation for the treatment of pressure ulcers from the ACP is the use of electrical stimulation as an adjunctive therapy to help accelerate wound healing. This was a weak recommendation based on moderate-quality evidence. It should be noted that this treatment modality was associated with an increase in adverse events, especially skin irritation, in the elderly population.

Other strategies evaluated for the treatment of pressure ulcers include the use of oxandrolone (an androgen used to promote weight gain), which was found to show no improvement versus placebo in wound healing and to have associated adverse events. Additional therapies evaluated included electromagnetic therapy, therapeutic ultrasound, negative pressure wound therapy, light therapy, and laser therapy, which all showed no improvement in the reduction of wound size, or complete healing, when compared with sham therapies.

Bottom line

For the prevention of pressure ulcers, assess each patient for risk using clinical judgment or a risk assessment tool of your choice. When possible, choose static mattresses or mattress overlays rather than the more costly, and more bothersome, alternating air mattresses. For the treatment of pressure ulcers, use protein or amino acid supplementation to aid in wound healing, use hydrocolloid or foam dressings to help decrease wound size, and consider electrical stimulation as a treatment option in younger patients.

References

Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162[5]:359-69.

Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162[5]:370-9.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Carcia is chief resident in the family medicine program at Abington.

Gastroesophageal reflux, defined as passage of gastric contents into the esophagus, is normal and occurs in 66% of healthy infants. Gastroesophageal reflux disease (GERD), defined as reflux associated with worrisome symptoms or complications, is far less common and must be differentiated from simple gastroesophageal reflux (GER) when making decisions about further testing and treatment. A primary emphasis of the American Academy of Pediatrics guidelines is for clinicians to decrease unnecessary diagnostic testing and pharmacologic treatment by distinguishing between GER, which requires relatively mild or no treatment at all, and GERD, which may require more careful intervention.

Clinical presentation

Symptoms associated with GER vary by age group. In infants (younger than 1 year of age), common symptoms include spitting up and vomiting. In school-age children, symptoms may include regurgitation and vomiting. In older children and adults, symptoms include the feeling of "heartburn" and foul-tasting belches. GERD on the other hand has additional symptoms and consequences. GERD symptoms are classified as esophageal or extraesophageal. Esophageal symptoms include poor weight gain, persistent vomiting, dysphagia, severe pain, and esophagitis. Extraesophageal manifestations include respiratory symptoms including cough, laryngitis, pneumonia, wheezing, and dental erosions. In infants less than age 1, the most common presentations of GERD include feeding refusal, poor weight gain, persistent irritability, and sleep disturbances, arching of the back, choking, and respiratory symptoms. In children aged 1-5 years, common symptoms include feeding refusal, vomiting, regurgitation, and abdominal pain. In older children and adolescents, the most common symptoms of GERD include abdominal pain (heartburn), recurrent vomiting, dysphagia, asthma, dental erosions, recurrent pneumonia, and chronic cough.

Diagnostic testing

Diagnostic testing usually is not necessary to make a diagnosis of either GER or GERD. A careful history and physical exam suffice. The diagnostic choices for evaluation of pediatric GERD include upper GI contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy. None of these tests are sufficiently sensitive or specific to serve as a reliable test for GERD. Upper GI series are too short in duration to adequately rule out reflux, and, since reflux can occur normally, the observation of reflux on an upper GI test can lead to false-positive interpretations of the test. Esophageal pH monitoring is also flawed because of similar issues in that there is not a clear cut-off point in changes in esophageal pH that distinguish GER from GERD. Upper endoscopy allows visualization of injury to the esophageal mucosa, but recent data suggest that 25% of infants younger than 1 year have histologic evidence of esophageal inflammation, so the test again suffers from both false-positive and false-negative results. The decision for further diagnostic testing and/or evaluation by specialists is generally determined by failure to respond to pharmacologic treatment or the need to determine with more certainty the diagnosis because of severe consequences of GERD including poor weight gain, unexplained anemia, positive fecal occult blood, recurrent pneumonia, or hematemesis.

Management

Management of GER and GERD should always begin conservatively with lifestyle modifications. Lifestyle modifications in older children and adults include weight loss, as well as avoidance of food triggers such as caffeine, chocolate, alcohol, and spicy foods. Lifestyle modifications vary based on the age of the child. In infants who have uncomplicated GER or GERD, the following treatments can be considered:

• Reducing the volume of feeds and increasing the frequency of feeding.

• Maternal dietary restriction of egg and milk in breastfed children and changing of formula to a non–milk-based formula in bottle-fed infants, because mild protein allergy may mimic GERD. The guidelines reference one study where simply changing to protein hydrolysate formula thickened with 1 tablespoon of rice per 1 ounce of formula, avoiding overfeeding, and emphasizing correct feeding position led to a 24% rate of resolution of symptoms over 2 weeks.

• Formula thickening with 1 tablespoon of rice cereal per 1 ounce of formula. This technique should be recommended to full term infants only, because of an association between thickened feedings and necrotizing enterocolitis in preterm infants. In addition, it is important to realize that thickening a 20 kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the caloric density to 34 kcal/oz. There are commercially available thickened formulas that do not add excess calories per ounce.

• Positioning recommendations include keeping infant upright or placing them prone while supervised and awake. Recently, studies have shown that the semisupine position (such as in a car seat) exacerbates GER and should be avoided in infants especially after feeding.

Pharmacotherapeutic agents are the next line of treatment. The guidelines express concern about overprescription of medications for pediatric GERD and emphasize that medications should be reserved to treat GERD in infants and children who did not respond to lifestyle modifications or who have significant complications of GERD. It is important to understand that medications should not be recommended to healthy children with GER. When medications are chosen the following points should be considered:

• Histamine₂ receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.

• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.

• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.

The bottom line

Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.

Reference

J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.

Gastroesophageal reflux, defined as passage of gastric contents into the esophagus, is normal and occurs in 66% of healthy infants. Gastroesophageal reflux disease (GERD), defined as reflux associated with worrisome symptoms or complications, is far less common and must be differentiated from simple gastroesophageal reflux (GER) when making decisions about further testing and treatment. A primary emphasis of the American Academy of Pediatrics guidelines is for clinicians to decrease unnecessary diagnostic testing and pharmacologic treatment by distinguishing between GER, which requires relatively mild or no treatment at all, and GERD, which may require more careful intervention.

Clinical presentation

Symptoms associated with GER vary by age group. In infants (younger than 1 year of age), common symptoms include spitting up and vomiting. In school-age children, symptoms may include regurgitation and vomiting. In older children and adults, symptoms include the feeling of "heartburn" and foul-tasting belches. GERD on the other hand has additional symptoms and consequences. GERD symptoms are classified as esophageal or extraesophageal. Esophageal symptoms include poor weight gain, persistent vomiting, dysphagia, severe pain, and esophagitis. Extraesophageal manifestations include respiratory symptoms including cough, laryngitis, pneumonia, wheezing, and dental erosions. In infants less than age 1, the most common presentations of GERD include feeding refusal, poor weight gain, persistent irritability, and sleep disturbances, arching of the back, choking, and respiratory symptoms. In children aged 1-5 years, common symptoms include feeding refusal, vomiting, regurgitation, and abdominal pain. In older children and adolescents, the most common symptoms of GERD include abdominal pain (heartburn), recurrent vomiting, dysphagia, asthma, dental erosions, recurrent pneumonia, and chronic cough.

Diagnostic testing

Diagnostic testing usually is not necessary to make a diagnosis of either GER or GERD. A careful history and physical exam suffice. The diagnostic choices for evaluation of pediatric GERD include upper GI contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy. None of these tests are sufficiently sensitive or specific to serve as a reliable test for GERD. Upper GI series are too short in duration to adequately rule out reflux, and, since reflux can occur normally, the observation of reflux on an upper GI test can lead to false-positive interpretations of the test. Esophageal pH monitoring is also flawed because of similar issues in that there is not a clear cut-off point in changes in esophageal pH that distinguish GER from GERD. Upper endoscopy allows visualization of injury to the esophageal mucosa, but recent data suggest that 25% of infants younger than 1 year have histologic evidence of esophageal inflammation, so the test again suffers from both false-positive and false-negative results. The decision for further diagnostic testing and/or evaluation by specialists is generally determined by failure to respond to pharmacologic treatment or the need to determine with more certainty the diagnosis because of severe consequences of GERD including poor weight gain, unexplained anemia, positive fecal occult blood, recurrent pneumonia, or hematemesis.

Management

Management of GER and GERD should always begin conservatively with lifestyle modifications. Lifestyle modifications in older children and adults include weight loss, as well as avoidance of food triggers such as caffeine, chocolate, alcohol, and spicy foods. Lifestyle modifications vary based on the age of the child. In infants who have uncomplicated GER or GERD, the following treatments can be considered:

• Reducing the volume of feeds and increasing the frequency of feeding.

• Maternal dietary restriction of egg and milk in breastfed children and changing of formula to a non–milk-based formula in bottle-fed infants, because mild protein allergy may mimic GERD. The guidelines reference one study where simply changing to protein hydrolysate formula thickened with 1 tablespoon of rice per 1 ounce of formula, avoiding overfeeding, and emphasizing correct feeding position led to a 24% rate of resolution of symptoms over 2 weeks.

• Formula thickening with 1 tablespoon of rice cereal per 1 ounce of formula. This technique should be recommended to full term infants only, because of an association between thickened feedings and necrotizing enterocolitis in preterm infants. In addition, it is important to realize that thickening a 20 kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the caloric density to 34 kcal/oz. There are commercially available thickened formulas that do not add excess calories per ounce.

• Positioning recommendations include keeping infant upright or placing them prone while supervised and awake. Recently, studies have shown that the semisupine position (such as in a car seat) exacerbates GER and should be avoided in infants especially after feeding.

Pharmacotherapeutic agents are the next line of treatment. The guidelines express concern about overprescription of medications for pediatric GERD and emphasize that medications should be reserved to treat GERD in infants and children who did not respond to lifestyle modifications or who have significant complications of GERD. It is important to understand that medications should not be recommended to healthy children with GER. When medications are chosen the following points should be considered:

• Histamine₂ receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.

• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.

• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.

The bottom line

Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.

Reference

J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.

Gastroesophageal reflux, defined as passage of gastric contents into the esophagus, is normal and occurs in 66% of healthy infants. Gastroesophageal reflux disease (GERD), defined as reflux associated with worrisome symptoms or complications, is far less common and must be differentiated from simple gastroesophageal reflux (GER) when making decisions about further testing and treatment. A primary emphasis of the American Academy of Pediatrics guidelines is for clinicians to decrease unnecessary diagnostic testing and pharmacologic treatment by distinguishing between GER, which requires relatively mild or no treatment at all, and GERD, which may require more careful intervention.

Clinical presentation

Symptoms associated with GER vary by age group. In infants (younger than 1 year of age), common symptoms include spitting up and vomiting. In school-age children, symptoms may include regurgitation and vomiting. In older children and adults, symptoms include the feeling of "heartburn" and foul-tasting belches. GERD on the other hand has additional symptoms and consequences. GERD symptoms are classified as esophageal or extraesophageal. Esophageal symptoms include poor weight gain, persistent vomiting, dysphagia, severe pain, and esophagitis. Extraesophageal manifestations include respiratory symptoms including cough, laryngitis, pneumonia, wheezing, and dental erosions. In infants less than age 1, the most common presentations of GERD include feeding refusal, poor weight gain, persistent irritability, and sleep disturbances, arching of the back, choking, and respiratory symptoms. In children aged 1-5 years, common symptoms include feeding refusal, vomiting, regurgitation, and abdominal pain. In older children and adolescents, the most common symptoms of GERD include abdominal pain (heartburn), recurrent vomiting, dysphagia, asthma, dental erosions, recurrent pneumonia, and chronic cough.

Diagnostic testing

Diagnostic testing usually is not necessary to make a diagnosis of either GER or GERD. A careful history and physical exam suffice. The diagnostic choices for evaluation of pediatric GERD include upper GI contrast radiography, esophageal pH and/or impedance monitoring, and upper endoscopy. None of these tests are sufficiently sensitive or specific to serve as a reliable test for GERD. Upper GI series are too short in duration to adequately rule out reflux, and, since reflux can occur normally, the observation of reflux on an upper GI test can lead to false-positive interpretations of the test. Esophageal pH monitoring is also flawed because of similar issues in that there is not a clear cut-off point in changes in esophageal pH that distinguish GER from GERD. Upper endoscopy allows visualization of injury to the esophageal mucosa, but recent data suggest that 25% of infants younger than 1 year have histologic evidence of esophageal inflammation, so the test again suffers from both false-positive and false-negative results. The decision for further diagnostic testing and/or evaluation by specialists is generally determined by failure to respond to pharmacologic treatment or the need to determine with more certainty the diagnosis because of severe consequences of GERD including poor weight gain, unexplained anemia, positive fecal occult blood, recurrent pneumonia, or hematemesis.

Management

Management of GER and GERD should always begin conservatively with lifestyle modifications. Lifestyle modifications in older children and adults include weight loss, as well as avoidance of food triggers such as caffeine, chocolate, alcohol, and spicy foods. Lifestyle modifications vary based on the age of the child. In infants who have uncomplicated GER or GERD, the following treatments can be considered:

• Reducing the volume of feeds and increasing the frequency of feeding.

• Maternal dietary restriction of egg and milk in breastfed children and changing of formula to a non–milk-based formula in bottle-fed infants, because mild protein allergy may mimic GERD. The guidelines reference one study where simply changing to protein hydrolysate formula thickened with 1 tablespoon of rice per 1 ounce of formula, avoiding overfeeding, and emphasizing correct feeding position led to a 24% rate of resolution of symptoms over 2 weeks.

• Formula thickening with 1 tablespoon of rice cereal per 1 ounce of formula. This technique should be recommended to full term infants only, because of an association between thickened feedings and necrotizing enterocolitis in preterm infants. In addition, it is important to realize that thickening a 20 kcal/oz infant formula with 1 tablespoon of rice cereal per ounce increases the caloric density to 34 kcal/oz. There are commercially available thickened formulas that do not add excess calories per ounce.

• Positioning recommendations include keeping infant upright or placing them prone while supervised and awake. Recently, studies have shown that the semisupine position (such as in a car seat) exacerbates GER and should be avoided in infants especially after feeding.

Pharmacotherapeutic agents are the next line of treatment. The guidelines express concern about overprescription of medications for pediatric GERD and emphasize that medications should be reserved to treat GERD in infants and children who did not respond to lifestyle modifications or who have significant complications of GERD. It is important to understand that medications should not be recommended to healthy children with GER. When medications are chosen the following points should be considered:

• Histamine₂ receptor antagonists are effective at achieving acid suppression within 30 minutes of administration. There is little clinical difference between different formulations. Tachyphylaxis can develop within 6 weeks of medication use, limiting long-term efficacy.

• Proton pump inhibitors (PPIs) are effective at achieving acid suppression and do not cause tachyphylaxis. They work best when dosed 30 minutes prior to meals. The FDA has approved omeprazole, lansoprazole, and esomeprazole for use in children above 1 year old. It is important to note that randomized trials have shown no improvement with PPIs over placebo for reduction in irritability. PPIs can cause headaches, diarrhea, constipation, and nausea in up to 14% of children. Again, a word of caution is in order because recent evidence suggests that long-term acid suppression may increase the risk of community-acquired pneumonia, gastroenteritis, candidemia, and in preterm infants, necrotizing enterocolitis.

• Antacids and prokinetic agents have insufficient evidence to support their use, as well as significant potential side effects.

The bottom line

Uncomplicated GER is a common entity in family medicine, especially in infants and children. The most important part of the guidelines is to distinguish between GER and GERD. GER requires education and sometimes lifestyle modification. Treatment of GERD starts with lifestyle modification, moving on to medications and referral when needed.

Reference

J.R. Lightdale and G.A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician. (Pediatrics 2013;131:e1684-e95).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is a second-year resident in the family medicine residency program at Abington Memorial Hospital.