A recent study (CR Collins et al. J Pediatr 2019; 206; 240-7) showed that symptoms alone are not able to predict the degree/presence of reflux in infants.

Methods: The authors recruited ‘symptomatic’ infants with median 41 weeks postmenstrual age (median 29 weeks at birth) and employed a combination of 24-hour pH-impedance to determine acid reflux index (ARI) and subsequently used provocative esophageal infusions (with air, water then apple juice) to assess manometry and symptoms. In total, they analyzed 2635 separate esophageal stimula in 74 infants.

The authors considered ARI <3% as normal, 3-7% as indeterminate ARI, and >7% as abnormal ARI.

Symptoms that they recorded included arching, irritability, cough, gag, sneeze, gasp, bradycardia, desaturation, throat clearing, startle, grimace, grunting, mouthing, and yawning.

Key findings:

• “The presence of physical symptoms (ARI <3: 80%; ARI 3-7: 77%; ARI >7: 81%; P=0.4), cardiorespiratory symptoms (ARI <3: 27%; ARI 3-7: 40%; ARI >7: 26%; P=0.4),or sensory symptoms (ARI <3: 26%; ARI 3-7: 22%; ARI >7: 35%; P=0.3) were also not significantly different by ARI groups”
• All infants had a normal symptom index (SI) for acid, nonacid, or total reflex.
• Accepted metrics, SI, SSI, and SAP, had higher association with nonacid events compared with acid events.
• Cardiorespiratory symptoms are more likely to be elicited by esophageal infusions with both water and apple juice than air.  “Symptoms are indicators of esophageal dysmotility and maladaptive aerodigestive protective mechanisms.”
• The authors in their discussion state that “GERD severity plays no role in the generation of symptoms.”

My take: All infants with and without reflux have a lot of “symptoms.”  Nonacid reflux is much more likely to provoke symptoms in this population than acid reflux reinforcing the idea that acid suppression is likely ineffective and potentially harmful.  “The findings of this study challenge the rationale for instituting anti-GERD therapies in neonates based on either symptoms alone or the existing acid-reflux indices or pH-impedance metrics.”

Related blog posts:

• 2018 AAP: Reflux Management in Preterm Infants
• 2018 Pediatric Gastroesophageal Reflux Guidelines
• How Many Kids with Reflux have Reflux?
• Something Useful for ALTEs (BRUEs)
• 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
• 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

Link to article cited below from The Onion: Dog Feels Like He Always Has To Be ‘On’ Around Family Thanks to Jennifer for this reference.

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.