Despite evidence that an outsized number of pediatricians globally are prescribing medical treatments for gastroesophageal reflux (GER) in infants, one pediatric researcher and clinician said the consensus is to hold back on proton pump inhibitors (PPIs) and other interventions.

During European Academy of Paediatrics (EAP) 2025 in Warsaw, Poland, Sandra Trapani, a pediatrician at Meyer University in Florence, Italy, was featured in an EAP Choosing Wisely webinar on treating gastrointestinal issues in infants. Trapani referred to several studies, including an Italian one, which found that, despite multiple recommendations against it, pediatricians have been found to overtreat GER.

“The study showed that protein pump inhibitors had been significantly overprescribed, by as much as 80%,” Trapani said. “Another study from Australia said PPIs were being prescribed without indication.”

Trapani said it is important to distinguish whether a child has GER or GER disease (GERD), the difference being that the latter creates debilitating symptoms such as anemia, failure to thrive, and refusal to eat. Both conditions present with irritability, excessive crying, and arching of the back.

Referencing guidelines from the American Academy of Pediatrics, the EAP, and other pediatric groups from Canada and Italy, among others, Trapani gave three criteria for gauging how to treat GER in infants:

1. Do not use H2 blockers or PPIs for crying or distress.
2. Do not use H2 blockers or PPIs for treatment of visible regurgitation.
3. Do not use H2 blockers or PPIs in patients with extra-esophageal symptoms such as cough or wheezing.

Further, Trapani recommended that it is helpful to reassure parents and caregivers of infants with GER by telling them that the condition is not uncommon and that most children will outgrow it without complications, within a few months. She also recommended explaining to families that the cause of GER is the incomplete maturation of the gastrointestinal system.

To help manage GER, Trapani recommended keeping the infant upright for a while during and after feeding, taking breaks while feeding, and reducing the amount fed. The time to refer the patient to a pediatric gastroenterologist is when the child develops difficulty breathing, experiences weight loss, and cries inconsolably.

For Joshua Wechsler, MD, MSCI, who directs the Eosinophilic Gastrointestinal Diseases Program at the Lurie Children’s Hospital of Chicago, actual GER in infants should be thought of as rare. “It is really, really, really rare. It can happen in some populations, but it’s not likely.”

“I try not to call it GER, but to move it away from thinking about acid and more toward regurgitation. When babies spit up it’s mostly a mechanical problem,” Wechsler told Medscape Medical News in an interview.

He noted that in the jointly issued pediatric GER guidelines from the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition “they worked really hard to clarify what to do when a baby is spitting up a lot, and what makes sense to address that.” Now that adult GERD is defined, people naturally assume it is the same in kids. “But adults are not little kids,” Wechsler said.

Wechsler disclosed that he is currently a speaker and medical advisor for Regeneron and Sanofi. He is the head of a data monitoring committee at AstraZeneca, and has previously, but not currently, provided consulting for Allakos, Bristol Myers Squibb, and Ellodi. Trapani disclosed no conflicts of interest.