AAP Issues Guidance on Reflux in Preterm Infants

Diana Swift

June 18, 2018

The American Academy of Pediatrics (AAP) has issued a clinical report on the diagnosis and management of gastroesophageal reflux (GER) in preterm infants. The report, compiled by the AAP's Committee on Fetus and Newborn, was published online today in Pediatrics.

The authors conclude that GER is a normal developmental condition, is usually asymptomatic, and typically resolves itself as the preterm infant matures.

GER, in which the contents of the stomach back up into the esophagus, is "an almost universal phenomenon" in preterm infants, explain Eric C. Eichenwald, MD, professor of pediatrics at Perelman School of Medicine, University of Pennsylvania, Philadelphia, and chief of neonatology at the Children's Hospital of Philadelphia, in Philadelphia Pennsylvania, and colleagues.

According to Eichenwald, the impetus for issuing the guideline at the present time was twofold. "Research has shown that there is large variability between hospitals in how GER is diagnosed and treated, and many signs attributed to reflux in preterm infants in reality are not related to reflux," he told Medscape Medical News. Furthermore, accumulating evidence suggests that commonly used medications, such as H2 blockers and proton pump inhibitors, may cause harm.

"The best take-away message for all physicians who care for preterm infants is that GER is a normal developmental phenomenon in infants that will usually resolve on its own with maturation. Diagnosis and treatment are almost always unnecessary," Eichenwald said.

He added that gastroenterologists separate GER from GERD, or gastroesophageal reflux disease, in which babies have symptoms or evidence of esophageal irritation from acid reflux.

GER's principal mechanism is transient relaxation of the lower esophageal sphincter, with a sudden reflexive drop in lower esophageal sphincter pressure to levels at or below pressure in the stomach that is not associated with swallowing. Precipitating triggers may include body position and a large volume of liquid in the stomach.

The condition is often diagnosed by trial-and-error response to medication, as well as clinical and behavioral indicators such as bradycardia, desaturation, feeding aversion, wakefulness, and irritability. However, previous research suggests that most suspected behaviors do not correlate with reflux events, as measured by the gold standard of multichannel intraluminal impedance (MII-pH). Hence, treatment should not be based solely on clinical and behavioral signs.

"There is little evidence that clinically diagnosed reflux based on behavioral signs such as irritability and wakefulness or apnea of prematurity are due to GER," Eichenwald said.

Nevertheless, a diagnosis of GER in the neonatal intensive care unit is significant because preterm infants with GER stay in hospital longer and incur higher healthcare costs, the report notes.

In the United States, the diagnosis and treatment of reflux can vary by as much as 13-fold across different sites, probably because of the lack of definitive testing and the reliance on signs and symptoms.

Given the absence of data to support the efficacy of antireflux medications, even though their use is increasing, "the committee recommended that antireflux medications be used rarely, if at all, in preterm infants due to questions about efficacy and potential for harm," Eichenwald said.

Medications may cause harm by reducing acidification in the stomach, which may adversely alter the microbiological flora in the gut, although that explanation is speculative, Eichenwald continued.

Moreover, previous research has reported that reflux episodes do not decrease in newborns treated with esomeprazole.

The AAP report notes that nonpharmacologic treatments also need further study and may not reduce clinical signs commonly interpreted as GER. These approaches include positioning babies on their left sides, elevating their heads, and giving lower-volume feedings.

Asked whether the recommendations would apply to full-term infants, Eichenwald said the guidance report is specific to the hospitalized preterm infant. "Although some of the recommendations may be relevant to term infants, that issue was beyond the scope of the guideline and is usually dealt with by pediatricians or gastroenterologists."

Among statements from the report:

  • Most GER episodes in preterm babies are only mildly acidic because their gastric pH is rarely <4, and in combination with frequent exposure to milk, this low acidity is not likely to injure the lower esophageal mucosa.

  • The most accurate method for detecting GER in preterm infants is MII, often combined with simultaneous pH sensoring. MII tracks the movement of fluids, solids, and air and can show whether a fluid bolus is moving antegrade (swallowing) or retrograde (reflux), and how high in the esophagus it is. Measuring lower-esophageal pH alone is a not a reliable method. Although contrast fluoroscopy images episodes of reflux, it cannot distinguish between clinically significant and insignificant GER.

  • Infants of more than 32 weeks' postmenstrual age require sleep measures such as placement in the supine position on a firm flat surface. Devices designed to hold up the head should not be used. These approaches should be demonstrated to parents in hospital before infants are discharged.

  • A potential association between GER and worsening lung disease is not supported by adequate data, and further research into this connection is needed.

The author has disclosed no relevant financial relationships.

Pediatrics. Published online June 18, 2018. Full text

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