Eric C. Eichenwald
Gastroesophageal reflux, a common and normal condition among preterm neonates, should be diagnosed using signs of the condition such as feeding intolerance and irritability, and treated without the use of pharmacologic agents, according to a clinical report issued by the AAP Committee on Fetus and Newborn.
This condition, according to Eric C. Eichenwald, MD, FAAP, chief of the division of neonatology at the Children’s Hospital of Philadelphia, is usually a condition that will resolve as the infant matures.
“The impetus for issuing the guidelines was two-fold,” he told Infectious Diseases in Children. “Research has shown that there is large variability between hospitals in how [gastroesophageal reflux] GER is diagnosed and treated, and there is accumulating evidence that common medications used for treatment may be associated with harm. The committee believed that the guidelines would provide information for neonatologists about the best way to diagnose reflux and reassurance that, in most cases, no treatment is necessary.”
In the report, Eichenwald addresses the physiology of the condition, its diagnosis based on signs associated with GER and the safety of varying treatment methods.
GER is caused by transient lower esophageal sphincter relaxation (TLESR), which is defined as a sudden decrease in lower esophageal pressure to a one that matches or falls below intragastric pressure. This change is unrelated to swallowing and is common among preterm infants. According to Eichenwald, these episodes can occur several times daily and is normal considering the liquid-based diet and body positioning of neonates.
Gastric distension may increase the likelihood of GER immediately after feeding, but episodes can be affected by the positioning of the infant. More TLESR episodes and liquid reflux are reported in neonates who are placed on their right-side-down lateral position compared with infants who are placed in a left-side-down lateral position; however, infants placed right side down have better gastric emptying. Additionally, infants placed in a prone position have fewer GER episodes compared with those placed in a supine position.
Eichenwald noted that diagnostic tests for GER, such as lower esophageal pH monitoring, have been used in older children and adults, but testing for GER in preterm infants is not recommended. The pH observed in the stomachs of preterm infants is infrequently less than 4 because their diet primarily consists of milk and their baseline pH is generally higher. Fluoroscopy cannot distinguish between clinically significant and insignificant episodes, although it can be used to observe episodes of reflux.
According to Eichenwald, the most precise method of testing for GER in the preterm population includes multichannel intraesophageal impedance (MII) monitoring, sometimes used alongside measuring the infant’s pH. Fluids, solids and air traveling through the esophagus are tracked using an esophageal catheter. This catheter can detect changes in electrical impedance between several electrodes.
Although diagnostic testing is an option for preterm infants, most cases of GER can be diagnosed using behavioral signs or responses to various interventions. Signs of GER in this population include feeding intolerance, inadequate growth, apnea, desaturation and worsening of existing pulmonary conditions, including bronchopulmonary dysplasia. Furthermore, behavioral signs may be observed in infants with GER, such as arching, irritability and perceived discomfort with feeding. No evidence currently supports that these signs are temporally related to measured episodes.
The author recommended that pharmacologic treatments for GER, such as prokinetic agents, sodium alginate and histamine-2 receptor blockers, are not sufficiently supported with research regarding their safety and efficacy. He also mentions that in previous trials, proton pump inhibitors did not demonstrate efficacy in limiting signs of GER and had higher rates of adverse events.
Eichenwald and the AAP Committee on Fetus and Newborn suggest the following for the diagnosis and treatment of preterm infants with GER:
- The development of GER is normal in preterm infants and will resolve as the infant ages.
- Pathologic GER is caused by the reflux of acidic gastric contents. This reflux causes damage to the lower esophageal mucosa. Most GER cases in preterm infants involve weakly acidic episodes due to the lessened acidity of the neonatal gastric system and frequent milk feedings. Esophageal injury is unlikely in this population.
- Diagnostic signs of GER in preterm infants generally include feeding intolerance or food aversion, poor weight gain, frequent regurgitation, apnea, desaturation and bradycardia. Preterm infants may also demonstrate irritability and perceived postprandial discomfort. Perceived signs of reflux are not supported by MII or pH. These signs can usually improve without treatment.
- Clinically observed signs of GER have not demonstrated reflux improvement by using measures such as left lateral body position or head elevation or by changing feeding regimens. Eichenwald recommends that for infants older than 32 weeks’ postmenstrual age, safe sleep practices should be promoted for these neonates.
- Pharmacologic approaches to treating GER in preterm neonates should be used in moderation, if at all. The efficacy of these drugs has not been sufficiently supported, and significant harm has been associated with their use, especially regarding gastric acid blockade. – by Katherine Bortz
Disclosure: Eichenwald reports no relevant financial disclosures.