M Njeh, S Jadcherla et al. J Pediatr 2024; 264: 113760. The Irritable Infant in the Neonatal Intensive Care Unit: Risk Factors and Biomarkers of Gastroesophageal Reflux Disease
This study analyzed “pH impedance testing in the NICU in 516 infants with symptoms of arching and irritability. A nurse was assigned to document episodes of arching and irritability during the study.”
Key findings:
- Acid reflux and impedance bolus characteristics were not significantly different between infants with >72 and ≤72 arching/irritability events (P ≥ .05)
- Arching/irritability events had an 8% sensitivity for reflux (3062/39,962). The specificity of arching/irritability for NOT being reflux was 94% (246,462/262,534)
- Oral feeding was associated with more arching and irritability than tube feeding
R-A Deregenier. J Pediatr 2024; 264; 113844 (commentary) Rethinking Infant Irritability and Arching
“The study found that <10% of the clinical episodes were associated with acid reflux but episodes of arching and irritability were more common in infants with preterm birth, neurologic injury, or chronic lung disease.”
My take (in part, borrowed from authors): “Acid GER disease is unlikely the primary cause of arching/irritability and empiric treatment should not be used when arching/irritability is present.” Unfortunately, getting physicians to curtail the use of ineffective acid blockers in infants is a not making headway (Unfavorable Trends in Reflux Management of Infants) There is definitely enough material with reflux to devote a whole MythBusters show.
In addition to not being the main reason for arching,
- Reflux is not a frequent reason for BRUEs
- Reflux cannot be reliably-identified by ENTs. Red airway appearance is NOT indicative of reflux (poor specificity, poor sensitivity)
- Reflux in infants does not improve with PPIs (more than placebo)
- Fundoplication does not result in fewer hospitalizations or improve pulmonary outcomes
- Treating reflux does not improve asthma and probably does not help throat symptoms either
- Many kids (and adults) with “reflux” don’t have reflux
Related blog posts:
- Which Symptom is Best for Indicating Reflux in Infants?
- Is Reflux Really a Disease in Premature Infants?
- Incredible Review of GERD, BRUE, Aspiration, and Gastroparesis
- Acid Suppression for Laryngomalacia -Handed This Article to My ENT Colleagues
- Unfavorable Trends in Reflux Management of Infants & Update on USNWR Rankings
- How Many Kids with Reflux have Reflux?
- Better to do a coin toss than an ENT exam to determine reflux
- Treating reflux does not help asthma | gutsandgrowth
- How Likely is Reflux in Infants with “Reflux-like … – gutsandgrowth
- No Effect of Proton Pump Inhibitors and Irritability on … – gutsandgrowth
- Gastroesophageal Reflux: I know it when I see it | gutsandgrowth
- 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
- Reflux Management in Preterm Infants
- Good Episode of Bowel Sounds on Reflux
- Does Reflux Therapy Help Chronic Throat Symptoms? (Probably Not)
- Blaming Reflux for BRUEs -Not Changing Despite Guideline Recommendations
- Something Useful for Apparent Life-Threatening Events (ALTEs)=BRUEs
gutsandgrowth 
Orally-fed infants with a weak suck-swallow-breathe synchrony for any reason will arch. The reasons include neurological impairment, respiratory compromise, oral weakness, cervical or thoracic instability/poor caregiver handling technique, and oral apraxia. I have never worked with a nurse that can evaluate most of it. Any pediatric feeding specialist (OTR, SLP) is able to do so.
There are a lot of potential reasons for arching. Many (not all) OTR and SLP, in my experience, also tell families that the infant’s symptoms (arching, fussiness) are due to reflux when this is usually not the case.