Tag Archives: irritability

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

Is Gabapentin a Good Idea for Neonates with Irritability?

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A recent case report (CM Cotten, et al. J Pediatr 2016; 169: 310-2) retrospectively reviewed 11 neonates (8 preterm) who received gabapentin mainly for “visceral hyperalgesia/agitation.”  The starting doses generally ranged from a low of 5 mg/kg/dose every 24 hrs to 5 mg/kg/dose every 8 hrs.  Generally, there were improved symptoms and lower need for opioids and benzodiazepines; the most frequent adverse reaction noted was bradycardia.  The authors caution against abrupt withdrawal of gabapentin.

My take: Like most medications, gabapentin has not been adequately evaluated in neonates, but it would not surprise me if it were useful for irritability.

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.

Old San Juan

Old San Juan

No Effect of Proton Pump Inhibitors and Irritability on Crying in Infants

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While the title of this blog will come as no surprise to most pediatric gastroenterologists, many parents would be surprised that a systemic review of randomized controlled trials (RCTs) showed` that proton pump inhibitors (PPI) are ineffective for crying infants (J Pediatr 2015; 166: 767-70).

In this review, only five trials (with 430 infants) met the prespecified inclusion criteria.  While some trials showed a decrease in crying/irritability form baseline to the end of the intervention, a similar effect was evident in the control group.  The authors found that one trial reported a higher risk of lower respiratory tract infections in the PPI group and note that “administration of PPIs is not without risk.”

Take-home message: “the limited data available suggest that PPIs are not effective for the management of crying/irritability in infants.”

Another PPI citation: Rosen R et al. J Pediatr 2015; 166: 917-23.  In this study, the authors prospectively showed that PPI use was associated with differences in gastric, lung, and oropharyngeal microflora (n=116 children with 59 receiving PPIs)

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