Tag Archives: arching

Arching in Infants Not Due to Reflux

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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

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Lisbon

How Likely is Reflux in Infants with “Reflux-like” Behaviors?

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Another study (Funderburk et al. JPGN 2016; 62: 556-61) has shown that gastroesophageal reflux disease is infrequent in infants with a “strong clinical suspicion for reflux.”  This is a good to know since we also know that pharmacologic therapy for gastroesophageal reflux has not been proven to be effective in infancy either.

This retrospective study with 58 infants, including 40 preterm infants, evaluated for GERD with MII-pH studies.  Characteristics of cohort: median gestational age 31 weeks, median birth wt 1683 gm, and median age at study: 70 days. 10 patients were receiving acid suppression therapy.

Indications for testing:

  • Irritability 55%
  • Bradycardia  34%
  • Desaturation 31%
  • Cough 21%
  • Gagging 12%
  • Difficulty feeding 12%
  • Arching 10%
  • Apnea 5%

Key findings:

  • Only 6 infants (~10%) had abnormal MII-pH studies (defined as >95th percentile for reflux episodes/hours or >95th percentile for acid exposure time)
  • None of the symptom indices correlated with symptoms. SI, SSI, or SAP
  • The majority of reflux episodes did not correlate with clinical “reflux” behaviors
  • Small bore (5 Fr) NG tubes were not associated with increased reflux.

In the related commentary by Rachel Rosen (pgs 517-18), she noted that “there is little to no evidence to show that the 3 indices predict any meaningful clinical outcome…including response to fundoplication, or medications.” “The current literature fails to support the use of symptom indices to prove causality when resolution of symptoms with medical or surgical therapies is used as the criterion standard.”

My take: The vast majority of infants with “reflux behaviors” do not have reflux.  Even if they do, current pharmacologic therapies have not been shown to work.  So, there is little  value in reflux testing in most infants.  Finally, given the failure of symptom indices, does the addition of the impedance data to the pH data add any value?

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