I want to thank the many people who have helped me with this blog –now with 2180 posts over more than 6 years. This includes my wife, my colleagues at GICareforKids, and colleagues from across the country who have provided critical feedback as well as useful publications to review. I hope this blog continues to be a useful resource.
Here are the top dozen most popular blog posts from 2017:
This blog has highlighted several publications which have shown the lack of benefit and potential harm of pharmaceutical agents for gastroesophageal reflux “disease” (GERD) in infancy (see links below). However, in current practice, proton pump inhibitors and histamine receptor antagonists are used frequently. Now, another influential study (J Pediatr 2014; 165: 250-5) has shown the lack of GERD as a causal mechanism in acute life-threatening events (ALTEs) and demonstrated other pathophysiologic mechanisms. However, changing physicians’ practice in this regard may prove to be as difficult as avoiding overprescribing antibiotics, or convincing reluctant parents to vaccinate their children.
So what did this study show?
This study of 20 infants (10 with proven ALTE and 10 healthy controls) had pharyngoesophageal manometry. Key findings:
- Infants with ALTE (vs controls) had delays in restoring aerodigestive normalcy (P=.03). This was indicated by more frequent and prolonged spontaneous respiratory events (SREs)
- Infants with ALTE had a lower magnitude of protective upper esophageal sphincter contractile reflexes (P=.01)
- Infants with ALTE had swallowing as the most frequent esophageal event associated with SREs (84%), a higher proportion of failed esophageal propagation (10% vs 0%, P=.02), an more frequent mixed apnea mechanisms (P=<.01) along with gasping breaths (P=.04)
The associated editorial (pg 225-26) explains some of the limitations of the study, including the fact that the patients had a mean gestational age of 28 weeks.
The authors conclusion: “In infants with ALTE, prolonged SREs are associated with ineffective esophageal motility ,,,suggestive of dysfunctional regulation of swallow-respiratory junction interactions. Hence, treatment should not target gastroesophageal reflux, but rather the proximal aerodigestive tract.”
Take-home message: (from the editorial): “Far too many low birth weight (and term) infants are being unnecessarily treated with a variety of antireflux medications that have serious side effects and few, if any, demonstrable benefits.”
Related blog posts:
While apparent life-threatening events (ALTEs) in infants are quite disturbing, the best management for these events is far from clear. A recent systematic review of ALTEs in infants was undertaken and included studies from 1970-2011 (J Pediatr 2013; 163: 94-9). The authors ultimately identified 37 relevant studies: 18 prospective observational studies and 19 retrospective observational studies.
- None of the 37 studies yielded “a high level of evidence for diagnostic or prognostic investigations.”
- Risk factors for ALTE: prematurity, previous ALTEs, and suspected child maltreatment.
- Routine screening for gastroesophageal reflux, meningitis, bacteremia, and seizures are “highly unlikely to be helpful in patients who are well-appearing and have no other findings suggestive of a diagnosis.”
- Testing for GERD “is unnecessary in children with ALTEs.” “A positive test does not necessarily inform management because causation cannot be established.” Patients with recurrent ALTEs “may benefit from pH monitoring in combination with symptom recording.
NASPGHAN Consensus guidelines on GERD (2009)
Link: Gastroesophageal Reflux Disease in the Pediatric … – NASPGHAN.o
- In premature infants, a relationship between GER (i.e. reflux) and pathologic apnea and/or bradycardia has not been established.Despite a lack of convincing evidence, if pathological apnea occurs in the face of pre- existing reflux, then the following two statements are the most common features:
- Although reflux causes physiologic apnea, it causes pathologic apneic episodes in only a very small number of newborns and infants.
- When reflux causes pathological apnea, the infant is more likely to be awake and the apnea is more likely to be obstructive in nature.
- A diagnosis of an acute life-threatening event (ALTE) warrants consideration of causes other than GER (i.e. reflux).Reflux of gastric acid seems to be related to ALTEs (episodes of combinations of apnea, color change, change in muscle tone, choking, and gagging) in < 5 % of infants with ALTE.
- -J Pediatr 2009; 155: 516. Bradycardia not improved in preemies treated for GER. n=18. Editorial 464 urges not using GER Rx in neonates –outside clinical trials.
- -J Pediatr 2009; 154: 374. Apnea associated with reduction in LES tone in premature infants; therefore, GER may be secondary to apnea rather than the reverse. Small study -12 apneic event in 7 infants.
- -J Pediatr 2008; 152: 365. Compared risk factors with SIDS. One of 153 (0.6%) with ALTE died.
- -Pediatrics 2005; 116: 1059 & 1217 (editorial). Apnea in preemies is unrelated to GER.
- -Pediatrics 2004; 113: e128-132. Apnea is unrelated to GER in most preemies; airway problems due to GERD is hard to establish.
- -J Pediatr 2000; 137: 321 & 298. Poor temporal association between GER & apnea in ALTE patients.
- -J Pediatr 2001; 138: 355. Metoclopropramide/cisapride do not help apnea in preemies with GER
- -Pediatrics 2002; 109: 8-11. GER does not cause apnea of prematurity.