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De Rose DU, Maggiora E, Maiocco G, Morniroli D, Vizzari G, Tiraferri V, Coscia A, Cresi F, Dotta A, Salvatori G, Giannì ML. Improving growth in preterm infants through nutrition: a practical overview. Front Nutr 2024; 11:1449022. [PMID: 39318385 PMCID: PMC11421391 DOI: 10.3389/fnut.2024.1449022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 08/30/2024] [Indexed: 09/26/2024] Open
Abstract
The primary purpose of this practical overview is to provide a practical update on appropriate nutritional strategies to improve growth in preterm infants. Current recommendations for improving preterm growth concern both macronutrients and micronutrients, with tailored nutrition since the first days of life, particularly when fetal growth restriction has been reported. Human milk is undoubtedly the best nutrition for all newborns, but, in some populations, if not adequately fortified, it does not adequately support their growth. In all preterms, growth should be correctly monitored weekly to intercept a negative trend of growth and implement nutritional strategies to avoid growth restriction. Similarly, growth should be accurately supported and monitored after discharge to improve long-term health consequences.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
- Faculty of Medicine and Surgery, “Tor Vergata” University of Rome, Rome, Italy
| | - Elena Maggiora
- Neonatology Unit of the University, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Giulia Maiocco
- Neonatology Unit of the University, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Daniela Morniroli
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Vizzari
- Dipartimento di Scienze Cliniche e di Comunità, Dipartimento di Eccellenza 2023–2027, University of Milan, Milan, Italy
| | - Valentina Tiraferri
- Dipartimento di Scienze Cliniche e di Comunità, Dipartimento di Eccellenza 2023–2027, University of Milan, Milan, Italy
| | - Alessandra Coscia
- Neonatology Unit of the University, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Francesco Cresi
- Neonatology Unit of the University, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Guglielmo Salvatori
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
- Human Milk Bank, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Maria Lorella Giannì
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Dipartimento di Eccellenza 2023–2027, University of Milan, Milan, Italy
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2
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Bor S, Kalkan İH, Çelebi A, Dinçer D, Akyüz F, Dettmar P, Özen H. Alginates: From the ocean to gastroesophageal reflux disease treatment. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:109-136. [PMID: 31624050 DOI: 10.5152/tjg.2019.19677] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Serhat Bor
- Division of Gastroenterology, Department of Internal Medicine, Ege University School of Medicine, Ege Reflux Study Group, İzmir, Turkey
| | - İsmail Hakkı Kalkan
- Department of Gastroenterology, TOBB University of Economics and Technology School of Medicine, Turkey
| | - Altay Çelebi
- Division of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Dinç Dinçer
- Division of Gastroenterology, Department of Internal Medicine, Akdeniz University School of Medicine, Antalya, Turkey
| | - Filiz Akyüz
- Division of Gastroenterology, Department of Internal Medicine İstanbul School of Medicine, Istanbul University, İstanbul, Turkey
| | - Peter Dettmar
- RD Biomed Limited, Castle Hill Hospital, Cottingham, UK
| | - Hasan Özen
- Department of Pediatrics, Hacettepe University School of Medicine, Ankara, Turkey
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3
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Quitadamo P, Giorgio V, Zenzeri L, Baldassarre M, Cresi F, Borrelli O, Salvatore S. Apnea in preterm neonates: what's the role of gastroesophageal reflux? A systematic review. Dig Liver Dis 2020; 52:723-729. [PMID: 32423847 DOI: 10.1016/j.dld.2020.03.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
A causal relationship between gastro-esophageal reflux (GER) and apnea in preterm infants has been frequently hypothesized and is currently debated. The present study aims at reviewing the currently available scientific evidence, in order to clarify the role of GER on the occurrence of apnea and to help improving the clinical management of apneic preterm neonates. We performed a systematic literature search to identify all the clinical studies on preterm neonates that properly assessed the relationship between apnea and GER. Two-hundred and fifty-two papers, including 32 reviews and meta-analysis, were screened. Out of them, only 7 were included in the final analysis according to the selected criteria. Among them, 3 studies reported an increased frequency of apnea after reflux compared to reflux-free period and 4 denied a significant temporal relation. In conclusion, a minority of apneic events occurs soon after GER episodes. Whether this happens by chance or because of a causal relationship is still impossible to define. Based on the available data, empirical treatment with acid inhibitors is not recommended in neonates with apnea unless a proven temporal relation is shown by simultaneous esophageal pH-impedance and polysomnography or cardiorespiratory monitoring and in the absence of a clear clinical benefit.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy.
| | - Valentina Giorgio
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italy
| | - Letizia Zenzeri
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy
| | - Mariella Baldassarre
- Department of biomedical science and human oncology- neonatology and Nicu section. University "Aldo Moro", Bari, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
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4
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Hasenstab KA, Jadcherla SR. Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Neonate: Controversies, Current Understanding, and Future Directions. Clin Perinatol 2020; 47:243-263. [PMID: 32439110 DOI: 10.1016/j.clp.2020.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Gastroesophageal reflux (GER) is considered physiologic and is a normal process; whereas, when aerodigestive consequences are associated, it is often interpreted as GER disease (GERD). However, the distinction between them remains a challenge in infants in the NICU. Reflux-type of symptoms are heterogeneous, and often managed with changes in diet, feeding methods, and acid-suppressive therapy; all these empiric therapies lack objectivity; hence, practice variation is universal. We clarify the current controversies, explain the potential role of GERD in causing symptoms and complications, and highlight current advances. The evidence basis for the diagnostic strategies is discussed.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute, 575 Children's Crossroads, Columbus, OH 43215, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute, 575 Children's Crossroads, Columbus, OH 43215, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA; Division Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, College of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
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5
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Yousaf M, Nirwan JS, Smith AM, Timmins P, Conway BR, Ghori MU. Raft‐forming polysaccharides for the treatment of gastroesophageal reflux disease (GORD): Systematic review. J Appl Polym Sci 2019. [DOI: 10.1002/app.48012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Maria Yousaf
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Jorabar Singh Nirwan
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Alan M. Smith
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Peter Timmins
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
| | - Muhammad Usman Ghori
- Department of Pharmacy, School of Applied ScienceUniversity of Huddersfield Huddersfield HD1 3DH United Kingdom
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Maier T, Kerbs A, Fruk L, Slater NKH. Iron delivery from liquid-core hydrogels within a therapeutic nipple shield. Eur J Pharm Sci 2019; 131:119-126. [PMID: 30710620 DOI: 10.1016/j.ejps.2019.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/19/2019] [Accepted: 01/28/2019] [Indexed: 12/28/2022]
Abstract
To aid oral therapeutic administration to infants, a novel delivery technology, referred to as a Therapeutic Nipple Shield (TNS), was previously developed. It consists of a silicone nipple shield device and a dosage form containing a therapeutic (or Active Pharmaceutical Ingredient (API)) to enable delivery during breastfeeding. A range of dosage forms were investigated in past literature, but sufficient API release into human milk had not been achieved. The presented work illustrates the delivery of iron sulphate pentahydrate from liquid-core sodium alginate hydrogels, inserted into a commercially available ultra-thin silicone nipple shield into human milk during in-vitro breastfeeding simulation. Release of iron was quantified employing absorbance measurements of a salicylic assay. An absolute recovery of 44.35 ± 5.43% of loaded iron(III)sulphate pentahydrate was obtained after 10.58 ± 0.09 g of human milk had passed through the nipple shield. This finding is superior to previous investigations involving the delivery of zinc from rapidly disintegrating tablets and non-woven fibres within a TNS. Due to their superior delivery properties, ease of fabrication and cost-efficiency, liquid-core sodium alginate hydrogels consequently represent a promising dosage form for use as part of the TNS. Further improvements can be made to enhance handling stability and shelf-life characteristics.
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Affiliation(s)
- Theresa Maier
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom; University of Cambridge, Department of Paediatrics, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom.
| | - Antonina Kerbs
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom
| | - Ljiljana Fruk
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom
| | - Nigel K H Slater
- University of Cambridge, Department of Chemical Engineering and Biotechnology, West Cambridge Site, Philippa Fawcett Drive, Cambridge CB3 0AS, United Kingdom
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Ciciora SL, Woodley FW. Optimizing the Use of Medications and Other Therapies in Infant Gastroesophageal Reflux. Paediatr Drugs 2018; 20:523-537. [PMID: 30198060 DOI: 10.1007/s40272-018-0311-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroesophageal reflux (GER) is the retrograde movement of gastric (and sometimes duodenal) contents into the esophagus. While the majority of GER is physiologic, for patients, it can be associated with symptoms. While some symptoms are merely bothersome (crying), others can be life threatening (cough, gagging, choking). The main driver of GER in infants is the frequent feedings that produce increased intra-abdominal pressure, which is known to trigger transient relaxations of the lower esophageal sphincter. The recent 2018 clinical practice guidelines reported by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN/ESPGHAN) have recommended non-pharmacologic management initially with subsequent consideration of brief trials with acid suppressants. The main target for these acid suppressants is the gastric parietal cells. Our review of the literature has revealed a paucity of data regarding the use of histamine-2 receptor antagonists and proton pump inhibitors in infants. Despite the absence of well-controlled clinical studies, the prescription rate of these medications has increased internationally. Risks to patients of all ages have become increasingly recognized, with new associations being reported all too often. Here we report our review of all pharmacologic modalities as well as some non-surgical options.
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Affiliation(s)
- Steven L Ciciora
- Division of Gastroenterology, Hepatology and Nutrition, Center for Functional Motility Disorders, Nationwide Children's Hospital, Columbus, OH, 43205, USA.,Department of Pediatrics, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Frederick W Woodley
- Division of Gastroenterology, Hepatology and Nutrition, Center for Functional Motility Disorders, Nationwide Children's Hospital, Columbus, OH, 43205, USA. .,Department of Pediatrics, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
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8
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Cresi F, Martinelli D, Maggiora E, Locatelli E, Liguori SA, Baldassarre ME, Cocchi E, Bertino E, Coscia A. Cardiorespiratory events in infants with gastroesophageal reflux symptoms: Is there any association? Neurogastroenterol Motil 2018; 30:e13278. [PMID: 29266638 DOI: 10.1111/nmo.13278] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/04/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cardiorespiratory (CR) events (apnea, bradycardia, oxygen desaturation) and gastroesophageal reflux (GER) symptoms often coexist in infants admitted to Neonatal Intensive Care Unit, leading to over-prescription of drugs and delayed discharge. We aimed to evaluate the relationships between CR and GER events. METHODS The temporal associations between CR and GER events were analyzed in symptomatic infants who underwent synchronized CR and pH-impedance monitoring. The symptom association probability (SAP) index was used to identify infants with a significant number of temporal associations. Gastroesophageal reflux characteristics and the chronological sequence of CR and GER events occurring within 30 seconds of each other were evaluated according to SAP index. KEY RESULTS Of the 66 infants enrolled, aged 29 (18-45) days, 58 had CR events during monitoring. From these 58 patients, a total of 1331 CR events and 5239 GER (24% acidic) were detected. The SAP index was positive in seven (12%) infants. These infants had greater GER frequency, duration, and proximal extent (P < .05). The number of temporal associations was 10 times greater in the positive SAP group. Gastroesophageal reflux events preceded CR events in 83% of these associations. These GER events had a higher proximal extent (P = .004), but showed no differences in pH values. CONCLUSIONS & INFERENCES The simultaneous evaluation of CR and GER events could be useful to identify infants with severe GER and significant temporal associations between these events. Treatment of GER could be indicated in these infants, but as the GER events involved are mainly non-acidic, empirical treatment with antacids is, often, inappropriate.
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Affiliation(s)
- F Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - D Martinelli
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, Bari, Italy
| | - E Maggiora
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - E Locatelli
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - S A Liguori
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - M E Baldassarre
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, Bari, Italy
| | - E Cocchi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - E Bertino
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - A Coscia
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
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Salvatore S, Ripepi A, Huysentruyt K, van de Maele K, Nosetti L, Agosti M, Salvatoni A, Vandenplas Y. The Effect of Alginate in Gastroesophageal Reflux in Infants. Paediatr Drugs 2018; 20:575-583. [PMID: 30182358 PMCID: PMC6267531 DOI: 10.1007/s40272-018-0314-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Guidelines are contradictory regarding the use of alginate in infants with persisting gastroesophageal reflux (GER). While The British National Institute for Health and Care (NICE) guidelines consider alginate as a treatment option, the guidelines of the European and North-American Societies for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN, NASPGHAN) do not recommend alginates. AIMS We assessed the efficacy of alginate to reduce GER episodes in infants. METHODS In a prospective, observational study, we consecutively enrolled all infants referred for pH-multiple intraluminal impedance (pH-MII) recording because of persisting GER symptoms not responsive to behavior and dietetic modifications. A 48-h pH-MII was performed in all infants; a baseline recording was performed during the first 24 h while magnesium or sodium alginate was administered during the second 24 h. The primary endpoint was the difference in the total number of GER episodes per 24 h between the baseline day and the second day during which the alginate was administered. The secondary outcome was the difference in symptoms between each period. We also compared other pH-MII data from before and during alginate administration. RESULTS We recruited 43 infants (median age 68 days, range 25-306); three pH-MII tracings were excluded because of artifacts. The median number of all MII reflux episodes was significantly reduced during alginate administration (76.0 vs 69.5; p < 0.001). Crying-fussiness, cough and regurgitation episodes all significantly improved during alginate administration (p = 0.00012; p = 0.005 and p = 0.04, respectively). The following MII parameters also decreased during the alginate administration: acid (19.0 vs 14.5; p < 0.04), non-acid (52.0 vs 49.5; p < 0.004), proximal GER episodes (46.0 vs 41.4; p < 0.007), and bolus exposure index (1.9 vs 1.6; p = 0.002). At least three out of seven pH-MII parameters decreased by > 10% during the alginate period in 31/40 infants (77.5%), without a significant difference between magnesium and sodium alginate. CONCLUSION These results suggest that alginate significantly decreases the number and extension of both acid and non-acid reflux episodes and associated symptoms in infants.
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Affiliation(s)
- Silvia Salvatore
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Antonio Ripepi
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Koen Huysentruyt
- 0000 0001 2290 8069grid.8767.eKidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, 101, 1090 Brussels, Belgium
| | - Kristel van de Maele
- 0000 0001 2290 8069grid.8767.eKidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, 101, 1090 Brussels, Belgium
| | - Luana Nosetti
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Massimo Agosti
- Division of Neonatology and Neonatal Intensive Care Unit, “F. Del Ponte” Hospital, Varese, Italy
| | - Alessandro Salvatoni
- 0000000121724807grid.18147.3bDivision of Pediatrics, “F. Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Yvan Vandenplas
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, 101, 1090, Brussels, Belgium.
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Dermyshi E, Mackie C, Kigozi P, Schoonakker B, Dorling J. Antacid therapy for gastroesophageal reflux in preterm infants: a systematic review. BMJ Paediatr Open 2018; 2:e000287. [PMID: 30019019 PMCID: PMC6045735 DOI: 10.1136/bmjpo-2018-000287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Gastro-oesophageal reflux is prevalent in preterm infants. Despite widespread use in clinical practice, there is still much controversy over the efficacy and safety of drug interventions, particularly antacid therapy. OBJECTIVE To systematically review the effects of antacid therapy on preterm infants with symptoms of gastro-oesophageal reflux, and to assess the safety of these interventions. METHODS We carried out an electronic search of the Cochrane central register of controlled trials (CENTRAL, The Cochrane Library), MEDLINE (1966-present), EMBASE (1980-present) and CINAHL (1982-present) as well as other online sources. Participants were preterm infants (<37 weeks gestation) with gastro-oesophageal reflux disease who were receiving care on a neonatal unit. We assessed the effects of histamine-2 receptor antagonists, proton pump inhibitors and alginates against placebo, primarily to see if they reduced the symptoms of reflux. RESULTS Six studies were included in this review. Meta-analysis could not be carried out due to a lack of studies assessing the same intervention with the same outcomes. Omeprazole therapy significantly reduced the oesophageal acid exposure percentage time with pH<4 (p<0.01) and sodium alginate significantly decreased gastro-oesophageal reflux episodes (p=0.024). Metoclopramide and ranitidine showed a significant increase in gastro-oesophageal reflux disease symptoms versus placebo (p<0.04). No significant results were found for the use of esomeprazole or lansoprazole versus placebo. CONCLUSIONS There is insufficient evidence available to conclude whether antacid therapy is effective or safe when treating gastro-oesophageal reflux disease in preterm infants. Further research is needed into this topic and caution should be taken when administering antacids to preterm infants. TRIAL REGISTRATION NUMBER CRD42017078778.
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Affiliation(s)
- Elda Dermyshi
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Charley Mackie
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Phoebe Kigozi
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Bernard Schoonakker
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
| | - Jon Dorling
- Neonatal Intensive Care Unit, Nottingham University Hospitals, Nottingham, UK
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11
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Rossor T, Andradi G, Bhat R, Greenough A. Investigation and management of gastro-oesophageal reflux in United Kingdom neonatal intensive care units. Acta Paediatr 2018; 107:48-51. [PMID: 28901635 DOI: 10.1111/apa.14073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/30/2017] [Accepted: 09/08/2017] [Indexed: 11/30/2022]
Abstract
AIM In 2004, wide variation in the investigation and management of gastro-oesophageal reflux (GOR) of infants on UK major neonatal units was demonstrated. Our aim was to resurvey neonatal practitioners to determine current practice and whether it was now evidence based. METHODS A questionnaire was sent to all 207 UK neonatal units. RESULTS Responses were obtained from 84% of units. The most frequent 'investigation' was a trial of therapy (83% of units); pH studies were used in 38%, upper GI contrast studies in 19% and multichannel intraluminal impedance (MII)/pH studies in 5%. Only six units suggested a threshold for an abnormal pH study and two units for an abnormal MII study. Infants were commenced on antireflux medication without investigation always in 32% of units, often in 29%, occasionally in 19% and only never in 1%. Gaviscon was used as first line treatment in 60% of units, and other medications included ranitidine in 53%, thickening agents in 27%, proton pump inhibitors in 23%, domperidone in 22% and erythromycin in 6%. CONCLUSION There remains a wide variation in diagnostic and treatment strategies for infants with suspected GOR on neonatal intensive care units, emphasising the need for randomised trials to determine appropriate GOR management.
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Affiliation(s)
- Thomas Rossor
- Division of Asthma, Allergy and Lung Biology; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
| | - Gwendolyn Andradi
- Division of Asthma, Allergy and Lung Biology; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
- NIHR Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London; London UK
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12
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Kwok TC, Ojha S, Dorling J. Feed thickener for infants up to six months of age with gastro-oesophageal reflux. Cochrane Database Syst Rev 2017; 12:CD003211. [PMID: 29207214 PMCID: PMC6485971 DOI: 10.1002/14651858.cd003211.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is common in infants, and feed thickeners are often used to manage it in infants as they are simple to use and perceived to be harmless. However, conflicting evidence exists to support the use of feed thickeners. OBJECTIVES To evaluate the use of feed thickeners in infants up to six months of age with GOR in terms of reduction in a) signs and symptoms of GOR, b) reflux episodes on pH probe monitoring or intraluminal impedance or a combination of both, or c) histological evidence of oesophagitis. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed (1966 to 22 November 2016), Embase (1980 to 22 November 2016), and CINAHL (1982 to 22 November 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials. SELECTION CRITERIA We included randomised controlled trials if they examined the effects of feed thickeners as compared to unthickened feeds (no treatment or placebo) in treating GOR in term infants up to six months of age or six months of corrected gestational age for those born preterm. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible studies from the literature search. Two review authors independently performed data extraction and quality assessments of the eligible studies. Differences in opinion were resolved by discussion with a third review author, and consensus was reached among all three review authors. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS Eight trials recruiting a total of 637 infants met the inclusion criteria for the systematic review. The infants included in the review were mainly formula-fed term infants. The trials were of variable methodological quality. Formula-fed term infants with GOR on feed thickeners had nearly two fewer episodes of regurgitation per day (mean difference -1.97 episodes per day, 95% confidence interval (CI) -2.32 to -1.61; 6 studies, 442 infants, moderate-certainty evidence) and were 2.5 times more likely to be asymptomatic from regurgitation at the end of the intervention period (risk ratio 2.50, 95% CI 1.38 to 4.51; number needed to treat for an additional beneficial outcome 5, 95% CI 4 to 13; 2 studies, 186 infants, low-certainty evidence) when compared to infants with GOR on unthickened feeds. No studies reported failure to thrive as an outcome. We found low-certainty evidence based on 2 studies recruiting 116 infants that use of feed thickeners improved the oesophageal pH probe parameters of reflux index (i.e. percentage of time pH < 4), number of reflux episodes lasting longer than 5 minutes, and duration of longest reflux episode. No major side effects were reported with the use of feed thickeners. Information was insufficient to conclude which type of feed thickener is superior. AUTHORS' CONCLUSIONS Gastro-oesophageal reflux is a physiological self resolving phenomenon in infants that does not necessarily require any treatment. However, we found moderate-certainty evidence that feed thickeners should be considered if regurgitation symptoms persist in term bottle-fed infants. The reduction of two episodes of regurgitation per day is likely to be of clinical significance to caregivers. Due to the limited information available, we were unable to assess the use of feed thickeners in infants who are breastfeeding or preterm nor could we conclude which type of feed thickener is superior.
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Affiliation(s)
| | - Shalini Ojha
- University of NottinghamDivision of Medical Sciences and Graduate Entry Medicine, School of MedicineNottinghamUK
- Derby Teaching Hospitals NHS Foundation TrustChildren’s HospitalDerbyUK
| | - Jon Dorling
- Neonatal Unit, Queen's Medical CentreSchool of Medicine, University of NottinghamDerby RoadNottinghamUKNG7 2UH
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Abstract
OBJECTIVES Gastroesophageal reflux (GER) is a frequently occurring condition in infants capable of causing distressing symptoms. The aim of our study is to evaluate the efficacy of Mg alginate plus simethicone (Gastrotuss Baby, DMG Italia SRL, Pomezia, Italy), compared with rice-starch-thickened formula or with reassurance alone, in the treatment of GER in infants. METHODS The present randomized controlled trial was conducted in full-term infants affected by symptoms suggestive of GER, evaluated through a validated questionnaire (Infant Gastroesophageal Reflux Questionnaire Revised). The patients were randomized into 3 groups according to treatment (group A: Mg alginate plus simethicone; group B: thickened formula; group C: reassurance with lifestyle changes). Evaluation of symptom scores was performed after 1 month (T1) and 2 months (T2). RESULTS A total of 64 (85.3%) of 75 enrolled infants (median age 5 months; range 1-10) concluded the study. After 1 month of treatment (T1), infants treated with Mg alginate plus simethicone showed a statistically significant improvement in symptoms compared with the thickened formula and reassurance (P < 0.03, <0.0001, respectively). At the end of the study, all 3 groups of patients showed a significant reduction in symptom scores (P < 0.002, <0.038, <0.03, respectively). Median symptom score values were more significantly reduced in group A than in group B and in group C (group A vs group B P < 0.002; group A vs group C P < 0.0001; group B vs group C P < 0.001). CONCLUSIONS Mg alginate plus simethicone seems to be more efficacious on GER symptom scores than thickened formula and reassurance with lifestyle changes alone.
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Abstract
PURPOSE OF REVIEW Gastroesophageal reflux (GER) remains a common, challenging problem for clinicians, with differentiation of normal development from disease a particular issue. This review updates clinicians on advances in diagnosis of GER, relationship to other problems, and current practice in management. RECENT FINDINGS Development and understanding of multichannel intraluminal impedance-pH monitoring has given insights into the relationship of GER to symptoms. Medical treatment has changed little. Avoidance of overmedicalizing normal development is the major issue for clinicians. Laparoscopic fundoplication is established as equivalent to open fundoplication. Newer endoscopic techniques have only limited use in children to date. SUMMARY Major changes in pediatric GER relate to understanding of physiology and relationship of GER to symptoms. The major challenge for clinicians involve differentiation of normal from abnormal GER, and applying the most relevant management.
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Corvaglia L, Monari C, Martini S, Aceti A, Faldella G. Pharmacological therapy of gastroesophageal reflux in preterm infants. Gastroenterol Res Pract 2013; 2013:714564. [PMID: 23878533 PMCID: PMC3710644 DOI: 10.1155/2013/714564] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 05/22/2013] [Accepted: 06/12/2013] [Indexed: 02/07/2023] Open
Abstract
Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.
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Affiliation(s)
- Luigi Corvaglia
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
| | - Caterina Monari
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Silvia Martini
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Arianna Aceti
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Giacomo Faldella
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
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Cresi F, Locatelli E, Marinaccio C, Grasso G, Coscia A, Bertino E. Prognostic values of multichannel intraluminal impedance and pH monitoring in newborns with symptoms of gastroesophageal reflux disease. J Pediatr 2013; 162:770-5. [PMID: 23146428 DOI: 10.1016/j.jpeds.2012.10.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 08/29/2012] [Accepted: 10/03/2012] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate the relationship between multichannel intraluminal impedance and pH monitoring (MII/pH) values in newborns with symptoms of gastroesophageal reflux disease (GERD) and clinical history in their first 3 years of life. STUDY DESIGN Sixty-four newborns with GERD symptoms who underwent MII/pH in the first weeks of life were enrolled into a clinical follow-up program. Follow-up visits were programmed at 1, 3, 6, 9, 12, 18, 24, and 36 months. Patients were divided into 3 groups according to duration of symptoms: short (1-3 months), medium (4-9 months), and long (>9 months), and MII/pH values in these groups were compared. RESULTS Fifty-three patients completed the 3-year follow-up. The number of patients with GERD symptoms decreased each month. A comparison of MII/pH values of the 3 lifetime symptom groups revealed differences in the impedance bolus exposure index (F = 83; P = .012) and proximal reflux frequency (F = 410; P = .022). These 2 MII variables showed an increasing trend from the short lifetime symptom group to the long lifetime symptom group. Weakly acidic reflux events, but not acidic events, were responsible for these differences. CONCLUSION MII/pH in newborns has prognostic value regarding the duration of GERD symptoms and provides useful information that clinicians may give parents about the prognosis of symptomatic infants. Impedance bolus exposure index and proximal reflux frequency seem to be the variables with the highest predictive value. Weakly acidic reflux events play an important role in determining the duration of GERD symptoms in newborns.
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Affiliation(s)
- Francesco Cresi
- Neonatal Intensive Care Unit, S. Anna-Regina Margherita Children's Hospital, Department of Pediatrics, University of Turin, Turin, Italy.
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