A recent review (EC Eichenwald, AAP  COMMITTEE ON FETUS AND NEWBORN. Pediatrics. June 2018) on reflux in pretern infants reinforces several important issues:

1. Reflux medicines have not been shown to be effective and can cause harm
2. Feeding regimen manipulation is not effective

Diagnosis/Testing:

• The report asserts that pH monitoring is not reliable “to diagnose GER in preterm infants¹⁹ because their stomach pH is rarely <4 owing to frequent milk feedings and a higher baseline pH. In addition, abnormal esophageal pH does not correlate well with symptom severity…Currently, the most accurate method for detecting GER is MII monitoring, which is frequently combined with simultaneous measurement of pH.² ”  There are problems with impedance testing as well, including sparse normative data.

Apnea, Bradycardia and Desaturations:

• “Researchers examining the timing of reflux episodes in relation to apneic events have found that they are rarely temporally related^14,27 and that GER does not prolong or worsen apnea… there is no evidence that pharmacologic treatment of GER with agents that decrease gastric acidity or promote gastrointestinal motility decrease the risk of recurrent apnea or bradycardia in preterm infants.^30,31“

Feeding problems:

• “Feeding-associated arching or irritability and oral feeding aversion, are not temporally associated with MII or lower pH documented reflux events and, thus, are not reliable markers of clinically significant reflux.”^20,24

Lung disease/BPD:

• “Data regarding the possible association between worsening lung disease attributable to GER and microaspiration in mechanically ventilated preterm infants are sparse.”

Full Text: Diagnosis and Management of Gastroesophageal Reflux in Preterm Infants

Abstract: Gastroesophageal reflux (GER), generally defined as the passage of gastric contents into the esophagus, is an almost universal phenomenon in preterm infants. It is a common diagnosis in the NICU; however, there is large variation in its treatment across NICU sites. In this clinical report, the physiology, diagnosis, and symptomatology in preterm infants as well as currently used treatment strategies in the NICU are examined. Conservative measures to control reflux, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of GER in the preterm infant. In addition, preterm infants with clinically diagnosed GER are often treated with pharmacologic agents; however, a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in preterm infants.

My take: The information and recommendations in this review will not come with any surprises for most pediatric gastroenterologists.  Nevertheless, I think it may influence the care of neonatologists (and others) to use acid blockers less often in this population.

Related blog posts:

• 2018 Pediatric Gastroesophageal Reflux Guidelines
• How Many Kids with Reflux have Reflux?
• Esophageal Diseases Special
• pH Probe Testing: Rumors of My Death are Premature
• Better to do a coin toss than an ENT exam to determine reflux
• PPI Webinar NAPSPGHAN
• Treating reflux does not help asthma | gutsandgrowth
• Salivary Pepsin Doesn’t Pass Muster for Reflux
• Does Reflux Lead to Increased Aspiration Pneumonia? | gutsandgrowth
• How Likely is Reflux in Infants with “Reflux-like … – gutsandgrowth
• No Effect of Proton Pump Inhibitors and Irritability on … – gutsandgrowth
• Even the Experts Agree: pH-MII is a “Flawed Test” | gutsandgrowth
• Why didn’t patient with documented reflux get better with PPI?
• Gastroesophageal Reflux: I know it when I see it | gutsandgrowth

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.