Does Positioning Help Infants with Reflux?

IM Paul et al. JPGN Reports 2023; 4(2):p e312. Open Access! Pilot Study of Inclined Position and Infant Gastroesophageal Reflux Indicators

Methods: Healthy infants aged 1–5 months with gastroesophageal reflux disease (GERD) (N = 25) and controls (N = 10) were enrolled into one post-feed observation. Infants were monitored in a prototype reclining device for consecutive 15-minute periods in supine position with head elevations of 0°, 10°, 18°, and 28° in random order. Continuous pulse oximetry assessed hypoxia (O2 saturation <94%) and bradycardia (heart rate <100).

Key findings:

  • Overall, 17 (68%) infants had 80 episodes of hypoxia (median 20 seconds duration), 13 (54%) had 33 episodes of bradycardia (median 22 seconds duration), and 15 (60%) had 28 episodes of regurgitation.
  • For all 3 outcomes, incident rate ratios were not significantly different between positions, and no differences were discovered for observed symptoms or infant comfort.

Limitations: This was a one-feeding study with a small number of infants

My take: This study shows a high frequency of transient hypoxia and bradycardia in healthy infants with regurgitation. In addition, there was not improvement in reflux parameters in the inclined position.

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Tucson Botanical Gardens

Incredible Review of GERD, BRUE, Aspiration, and Gastroparesis

Recently, Rachel Rosen gave a terrific review of reflux and reflux-related entities as part of our annual William (Billy) Meyers lectureship.  This lecture information would be helpful for every pediatric gastroenterologist as well as every pediatrician, pediatric ENT, pediatric pulmonologist, pediatric SLP and lactation specialist.  It puts to rest many obsolete ideas about reflux and its management. Some of her points have been covered by this blog previously (see links below) and by her bowel sounds podcast (see link below).   Some errors of omission and transcription may have occurred as I took notes during this lecture. 

Main points:


  1. Using the label “GERD” increases the likelihood that an infant will be prescribed acid blockers; this phenomenon is noted as well with SLP and lactation specialist team members.  Everyone needs to be careful about ascribing infant symptoms to “reflux disease”
  2. AR formulas need acid to increase their viscosity (don’t use PPIs in infants taking AR formulas). Also, AR formula viscosity is hindered when mixed with breastmilk (don’t mix with breastmilk)
  3. Most infants with reflux have nonacid reflux.  PPIs do not help nonacid reflux
  4. PPIs are associated with increased aspiration and infection risks.  Acid suppression has been associated with increased risk of allergic diseases
  5. Rumination can look a lot like reflux on pH probe studies
  6. Reflux hypersensitivity, and functional heartburn can result in similar symptoms as reflux (can be distinguished with pH testing)
  7. Pepsin can increase lung inflammation and can be increased by PPI use
  8. Red airway appearance is NOT indicative of reflux (poor specificity, poor sensitivity)
  9. If having symptoms with transpyloric feedings, this indicates that the symptoms are NOT due to reflux; transpyloritc feedings have similar efficacy as a fundoplication
  10. Avoid fundoplication.  It does not result in fewer hospitalizations or improve pulmonary outcomes.  It can result in a number of complications
  11. Consider genotyping for CYP2C19 pharmacogenetics in patients receiving chronic PPI.  Those with rapid metabolism could benefit from higher doses.  Those with slow metabolism could benefit from lower doses.  Higher doses of PPIs increase risk for infections
  12. Bolus feedings result in fewer problems than continuous feedings

Delayed Gastric Emptying (Gastroparesis)

  1. Delayed GE is associated with increased lung bile acids.  This is important in lung transplant recipients and increased lung bile acids is seen more commonly in those with frequent admissions for respiratory issues
  2. In Dr. Rosen’s experience, prucalopride is currently the most useful promotility agent in documented gastroparesis


  1.  Infants with BRUE need to be tested for aspiration, not prescribed PPIs.
  2.  VSS (aka OPMS) has the highest yield of any test in infants with BRUE (~72% abnormal testing in one study). 
  3. Silent aspiration is common -don’t rely on SLP bedside assessment.
  4. Even with this diagnosis, many infants are still prescribed PPIs which increase the risk of complications (more hospitalizations, more infections, possible increase in allergies)


  1. There are a number of potential etiologies, though most infants have aspiration due to neurological reasons (most transitory and improved by 7 months of age)
  2. In Boston, less than 5% with aspiration on VSS required GT placement
  3. Thickeners can be very helpful.  Practitioners need to know the differences (don’t use Simply Thick in 1st year of life due to NEC risk)

Chronic Cough:

  1. ~10% of kids with chronic cough have eosinophilic esophagitis (who have seen GI in Boston)

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Cacti at Tucson Botanical Gardens

ACG Adult GERD Guidelines 2022

PO Katz et al The American Journal of Gastroenterology: January 2022 – Volume 117 – Issue 1 – p 27-56doi: 10.14309/ajg.0000000000001538. Open Access: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

Related blog post: 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines

Does Reflux Therapy Help Chronic Throat Symptoms? (Probably Not)

A recent study (J O’Hara et al. BMJ 2021;372:m4903. Full text: Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial) will probably be another thorn in the side of our ENT colleagues who frequently assert that reflux is likely causing a persistent sore throat. This study is likely to influence empiric treatment by GI physicians as well.


  • Random blinded allocation (1:1) to either 30 mg lansoprazole (n=172) twice daily or matched placebo (n=174) twice daily for 16 weeks of patients with persistent throat symptoms.
  • Eligible patients had persistent (>6 weeks) unexplained throat symptoms—principally hoarseness, throat pain, globus sensation, throat clearing, postnasal secretions or excess mucus, cough, or choking sensation
  • Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score.

Key finding:

  • No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up.
  • Improvements (reduction in RSI score) were observed in both groups—score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms. Furthermore, “no trends were in favour of lansoprazole.”
  • Limitation: “Our trial could be criticised for lacking any objective measure of GORD within the methodology or for employing any such test as an inclusion criteria. However, we did address the use of PPIs in an empirical setting, which was a near universal practice at the time of our study.”

My take (borrowed in part from authors): “No evidence supports the empirical use of PPIs to treat persistent throat and voice symptoms.” Despite this finding, “old habits die hard” and I predict that it will be a long time before this finding is widely adopted into clinical practice.

Related blog posts:

New Agent for Refractory Reflux

In the June issue of Gastroenterology (158: 2015-16), a tribute to George Sachs (1935-2019) recognizes his work in the field of gastroenterology and his development of proton pump inhibitors (PPIs).

Much more work remains as ~30% of patients with gastroesophageal reflux remain symptomatic despite PPI therapy.   In the same issue, IW-3718, a bile acid sequestrant colsevelam with a gastric-retentive formulation was studied in 280 patients (MF Vaez et al. Gastroenterol 2020; 158: 2017-19).

Methods: The authors performed a multicenter, double-blind, placebo-controlled 8-weel treatment trial (2016-17); patients received the study drug (500, 1000, 1500 mg) or placebo twice daily.  The authors enrolled symptomatic patients (≥4 times per week) with erosive esophagitis or pathologic reflux based on Bravo study (pH<4 for ≥4.2% during at least one 24-hour period). They continued PPI therapy which they had been receiving for a minimum of 8 weeks prior to starting study medication.

Key findings:

  • Improvement in heartburn severity scores for placebo, 500, 1000, and 1500 mg groups: 46%, 49%, 55%, and 58%.  The 11.9% difference between 1500 mg group compared to placebo reached statistical significance (P=.04)
  • There was an improvement in weekly regurgitation frequency score as well from baseline to week 8 in 1500 mg group of 17.5% compared to placebo.
  • No serious drug related serious adverse events were identified.  Constipation was noted in 8% of study drug recipients compared 7% for placebo recipients.

Limitations: lack of a centralized review for endoscopy images, high placebo response rate, once daily use of PPI in study, and problems with overlap of functional symptoms

My take: This study shows why a placebo control is needed in reflux studies.  While IW-3718 at higher doses was effective, its response appears much less notable when compared with placebo-recipients.

Job Security Study: Lots of People Have Reflux Symptoms & COVID-19 Due To Singing

A recent study (SD Delshad, CV Almario et al. Gastroenterol 2020; 158: 1250-61) used survey data from an APP, MyGiHealth, to assess prevalence of reflux symptoms and symptoms that had not responded to proton pump inhibitor treatment.

Key findings:

  • In 2015, among 71,812 participants, 32,878 (44.1%) reported reflux symptoms previously and 23,039 (30.9%) reported reflux symptoms in previous week
  • 35% with reflux symptoms were currently receiving treatment: 55% PPIs, 24% H2RAs, and 24% antacids
  • Of the 3229 taking daily PPIs, 54% reported persistent reflux symptoms (≥2 days per week)
  • Age range of respondents was 33% for 18-29, 27% for 30-39, 17% for 40-49, 15% for 50-59, and 8% ≥60


  • Potential selection bias as there was only a 5.5% response rate among the entire eligible population of 1.3 million
  • Reflux symptoms frequently is not due to reflux disease

My take: There are a lot of folks with reflux symptoms and many have ongoing symptoms despite treatment; hence, lots of opportunity to help (and job security)

Related blog posts:

Also from NY Times: Coronavirus Ravaged a Choir. But Isolation Helped Contain It.

“One sick singer attended choir practice, infecting 52 others, two of whom died. A study released by the C.D.C. shows that self-isolation and tracing efforts helped contain the outbreak.”  Only 8 of the 61 choir members did not get sick.

Graphical Abstract

Impedance May Help in Borderline Reflux Disease Assessment

A recent retrospective study (A Rengarajan et al. Clin Gastroenterol Hepatol 2020; 18: 589-95), with a cohort of 371 patients (mean age 54 years) shows how impedance testing may help identify patients who are likely to respond to reflux management when pH probe testing is equivocal.  The cohort included adults with persistent reflux symptoms.  Response to antireflux therapy was defined as >50% improvement in esophageal symptoms.

Key points:

  • 107 (28.8%) had pathologic acid exposure time (AET) (pH<4 for >6%)
  • 234 (63.1%) had abnormal mean nocturnal baseline impedance (MNBI) (<2292 ohms). MNBI was calculated using baseline values at 10-minute periods between 1-3 am from the 5 cm channel to correspond to total distal AET.
  • Figure 1, shows the combined use of AET and MNBI.  Only 106/107 patients with AET>6, had an abnormal MNBI.  In the borderline category of AET 4-6%, 62/68 (91.2%) had abnormal MNBI values. In those with AET <4, MNBI was abnormal in 66/196 (33.7%)

Response to Treatment:

  • Among patients with AET >6, 66/89 (74%) responded to medical therapy and 18/23 (78%) responded to surgical therapy; among patients with AET 4-6%, 37/56 (66%) responded to medical therapy and 14/17 (82%) responded to surgical therapy. In those with AET <4, 39/185 (21%) responded to medical therapy and 16/23 (70%) responded to surgical therapy
  • Among patients with a low MNBI, 119/198 (60%) responded to medical therapy and 41/50 (82%) to surgical therapy.  In those with a normal MNBI, 23/132 (17%) responded to medical therapy and 7/13 (54%) responded to surgical treatment
  • In those with AET >6, 84/111 (76%) responded to treatment. For those with AET 4-6%, of those with low MNBI, 49/67 (73%), responded (similar to those with AET >6%).  In those with low MNBI and AET <4, 27/70 (39%) responded to treatment
  • 28/138 (20.2%) with normal AET <4 and with normal MNBI responded to treatment

My take: The big takeaway is that all of our tests for pathologic reflux are highly flawed; impedance may (to a small degree) help stratify patients with equivocal evaluation based on AET.  Normal tests do not exclude response treatment (especially surgery).

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Island Ford, Sandy Springs


Does Reflux Really Worsen After Gastrostomy Placement in Children?

A recent prospective longitudinal cohort study (J Franken et al. JPGN 2020; 70: e41-47) examined the development of gastroesophageal reflux (GER) in 50 children  who underwent gastrostomy tube (GT) placement between 2012-2014.

Key findings:

  • GER symptoms were present before and after GT placement: in 44% and 40% respectively.

Among the 25 who underwent pre- and post-operative impedance-pH analysis

  • there was not a significant change in acid exposure: 6.2% vs. 6.1%
  • there was not a significant change in reflux episodes
  • Prior to GT placement, 18 of 25 (72%) had pathologic reflux.  Afterwards, 18 of 25 (72%) had pathologic reflux –though this included 4 with new onset reflux and 4 with resolved reflux

My take: This study shows that reflux symptoms and documented reflux are commonplace in children undergoing GT placement.  Based on this limited sample size, it appears that GER does not appreciably change following GT placement.

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Island Ford, Sandy Springs

How helpful is a pH-Impedance Study in Identifying Reflux-Induced Symptoms?

In both kids and adults, individuals presenting with complaints of reflux more often have other problems like functional heartburn or reflux hypersensitivity (see posts below).  A recent prospective, cross-sectional study (LB Mahoney et al. JPGN 2020; 70: 31-36) provides data that further shows that abnormal pH-impedance (pH-MII) testing does NOT predict reduced quality of life (QOL) in children with reflux symptoms (n=82).

Key findings:

  • 38% had abnormal pH-MII testing; however, there were no significant differences in QOL scores on any of the tested questionairres between those with normal or abnormal pH-MII studies.
  • Subjects with gross esophagitis on EGD reported significantly worse QOL scores. Microscopic esophagitis was not associate with differences in QOL scores.

The implication of this study is that reflux without esophagitis is NOT a driver of abnormal QOL parameters; instead, functional GI disorders are likely more important.

My take: This study makes it clear that gross endoscopic findings are much more consequential than abnormal pH-MII studies.

Related blog posts:

Another Study Questions the Efficacy of Drip Feeds for Reflux

Several years ago, a small study showed that bolus feeds were as well-tolerated in premature infants as drip feeds: Which is Safer -Drip Feeds of Bolus Feeds for Preterm Infants?

Now, a retrospective study (LB Mahoney, E Liu, R Rosen. JPGN 2019; 69: 678-81) found no difference in the rate of reflux in 18 children who were with gastrostomy-tube dependent.

In this study, 24-hour multichannel intraluminal impedance with pH monitoring (MII-pH) examine reflux events in children receiving exclusive enteral nutrition with a combination of daytime bolus feeds and overnight continuous feeds; each patient served as their own control.  this included 6 with prior fundoplication.

Key finding:

  • There was no difference in rate of reflux events when comparing bolus feedings and drip (aka continuous) feedings.

The limitations in this study include the small sample size and retrospective design.  The authors estimate that to achieve adequate power (80% power) to detect a risk ratio of 1.2 would require 211 patients.

My take: This study and other small studies challenge the assumption that drip feedings are safer. Though, until a larger prospective study is performed, we will not know.

Quebec City

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