1
|
Tan J, Jeffries S, Carr R. A Review of Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Therapy for Gastroesophageal Reflux Disease in Neonates and Infants. Paediatr Drugs 2023; 25:557-576. [PMID: 37458926 DOI: 10.1007/s40272-023-00580-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 08/11/2023]
Abstract
Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are commonly used medications in neonates and infants for the treatment of gastroesophageal reflux disease (GERD), especially in neonatal intensive care units (NICUs). A literature review was conducted to evaluate the efficacy and safety of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) in preterm neonates, term neonates, and infants. A total of 27 studies were included in this review. Antacid medications in studies have consistently shown positive pharmacodynamic effects, including increasing gastric pH, reducing the reflux index, and reducing the number of acidic reflux events. The benefit found in placebo-controlled trials are limited exclusively to these surrogate outcomes. The actual clinically salient outcomes which H2RAs and PPIs are used for, such as reduction in GERD symptoms, especially irritability and improved feed tolerance and weight gain, have consistently shown no clinical benefit. H2RAs and PPIs appear to be extremely well tolerated by the neonatal and infant populations, which would mimic our experience with these medications in our unit. The available data from large, retrospective cohort and case-control studies paint a much more concerning picture regarding the potential for an increased risk in the development of allergies, anaphylactic reactions, necrotizing enterocolitis (NEC), other nosocomial infections, and lower respiratory tract infections. Given the risks associated with and lack of clinical effectiveness of both H2RAs and PPIs, use of these medications should be limited to specific clinical situations. Further studies are required to determine whether antacid pharmacologic therapy might benefit certain neonates and infants, such as those with complex medical issues.
Collapse
Affiliation(s)
- Jason Tan
- BC Children's and Women's Hospital, Pharmacy, Vancouver, BC, Canada.
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada.
| | - Sonia Jeffries
- BC Children's and Women's Hospital, Pharmacy, Vancouver, BC, Canada
| | - Roxane Carr
- BC Children's and Women's Hospital, Pharmacy, Vancouver, BC, Canada
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| |
Collapse
|
2
|
Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review. CHILDREN 2023; 10:children10030583. [PMID: 36980141 PMCID: PMC10047907 DOI: 10.3390/children10030583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023]
Abstract
Purpose: Pediatric laryngopharyngeal reflux (P-LPR) is associated with the development of common otolaryngological symptoms and findings. In the present study, the findings about epidemiology, clinical presentation, diagnostic and therapeutic outcomes of pediatric population were reviewed. Methods: A PubMed, Cochrane Library, and Scopus literature search was conducted about evidence-based findings in epidemiology, clinical presentation, diagnostic and therapeutic outcomes of P-LPR. Findings: The prevalence of LPR remains unknown in infant and child populations. The clinical presentation depends on age. Infants with LPR symptoms commonly have both gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux and related digestive, respiratory and ear, nose and throat symptoms. The GERD prevalence appears to decrease over the growth, and the clinical picture is increasingly associated with LPR symptoms and findings without GERD. The prevalence of LPR and proximal acid and nonacid esophageal reflux events may be high in some prevalent otolaryngological conditions (chronic otitis media, laryngolomalacia and apnea). However, the lack of use of hypopharyngeal–esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) limits the establishment of etiological associations. Proton pump inhibitors are less effective in P-LPR patients compared to GERD populations, which may be related to the high prevalence of weakly or nonacid reflux events. Conclusions: Many gray areas persist in P-LPR and should be not resolved without the establishment of diagnostic criteria (guidelines) based on HEMII-pH. The unavailability of HEMII-pH and the poor acid-suppressive therapeutic response are all issues requiring future investigations. Future controlled studies using HEMII-pH and enzyme measurements in ear, nose or throat fluids may clarify the epidemiology of P-LPR according to age and its association with many otolaryngological conditions.
Collapse
|
3
|
Sawyer C, Sanghavi R, Ortigoza EB. Neonatal gastroesophageal reflux. Early Hum Dev 2022; 171:105600. [PMID: 35716649 PMCID: PMC9983357 DOI: 10.1016/j.earlhumdev.2022.105600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christopher Sawyer
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Rinarani Sanghavi
- Division Pediatric Gastroenterology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Eric B Ortigoza
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States of America.
| |
Collapse
|
4
|
Conlon S, Di Fiore JM, Martin RJ. Are we over-treating hypoxic spells in preterm infants? Semin Fetal Neonatal Med 2021; 26:101227. [PMID: 33736905 DOI: 10.1016/j.siny.2021.101227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.
Collapse
Affiliation(s)
- Steven Conlon
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Richard J Martin
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| |
Collapse
|
5
|
Rayasam S, Johnson R, Lenahan D, Abijay C, Mitchell RB. Obstructive Sleep Apnea in Children Under 3 Years of Age. Laryngoscope 2021; 131:E2603-E2608. [PMID: 33764521 DOI: 10.1002/lary.29536] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/14/2021] [Accepted: 03/17/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To identify predictors of severe obstructive sleep apnea (OSA) in children under 3 years of age and to compare demographics, comorbidities, and polysomnographic characteristics of infants and toddlers with OSA. STUDY DESIGN Retrospective case series. METHODS We examined children under 3 years of age who had polysomnogram between August 2012 and March 2020. Demographics, clinical, and polysomnographic parameters were compared in children age 0-1 versus 1-3 years and 0-2 versus 2-3 years and severe versus mild-moderate OSA. Univariate analysis was used to compare age groups; multiple logistic regression for predictors of severe OSA. Significance was set at P < .05. RESULTS Of the 413 children, 267 (65%) were male and 131 (32%) obese. The population included Hispanic (41%), African American (28%), and Caucasian (25%) children. A total of 98.5% had OSA and 35% had severe OSA. Children under 1 year of age more commonly had gastroesophageal reflux disease (GERD) (38% vs. 23%; P = .014); tonsillar hypertrophy was more common in children over 2 years of age (56% vs. 34%, P = .001). Down syndrome (odds ratio (OR): 3.16, 95% confidence interval (CI) = 1.14-8.68, P = .026) and tonsillar hypertrophy (OR: 1.97, 95% CI = 1.28-3.02, P = .002) were predictors of severe OSA. CONCLUSION Children under 3 years of age with OSA are more likely to be male and have GERD. Down syndrome and tonsillar hypertrophy are predictors of severe OSA, and children with these conditions should be prioritized for polysomnography. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2603-E2608, 2021.
Collapse
Affiliation(s)
| | - Romaine Johnson
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, UT Southwestern and Children's Medical Center, Dallas, Texas, U.S.A
| | - Danielle Lenahan
- University of Southern California Medical Center, Los Angeles, California, U.S.A
| | - Claire Abijay
- UT Southwestern Medical School, Dallas, Texas, U.S.A
| | - Ron B Mitchell
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, UT Southwestern and Children's Medical Center, Dallas, Texas, U.S.A
| |
Collapse
|
6
|
Decreasing Inappropriate Use of Antireflux Medications by Standardizing Gastroesophageal Reflux Disease Management in NICU. Pediatr Qual Saf 2021; 6:e394. [PMID: 33718749 PMCID: PMC7952116 DOI: 10.1097/pq9.0000000000000394] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/04/2020] [Indexed: 11/26/2022] Open
Abstract
Gastroesophageal reflux (GER) is a functional self-limiting condition in neonates. When pathologic, it is called GER disease (GERD). There are wide variations in the management of signs, symptoms, and complications associated with GERD in the neonatal intensive care unit (NICU). Evidence does not support an empiric trial of GERD medications as a diagnostic tool or therapy in premature infants. Methods A multidisciplinary team developed evidence-based clinical practice guidelines (CPG) for GERD management. Process improvement included developing a GERD management algorithm, electronic order sets, and education for all providers. Multiple plan-do-study-act cycles done. Results Implementation of standardized GERD management guideline, decreased the overall use of antireflux medications from baseline, 15.1%-6.8% [χ2 (1, N = 1259) = 12.98, P < 0.001]. There was elimination of GERD medication use in preterm from baseline of 19.3% [χ2 (1, N = 220) = 12.18, P < 0.001]. The most frequently used GERD medication was lansoprazole, with an incorrect initial dosing rate of 55.0% that deceased to zero [χ2 (1, N = 33) = 10.73, P = 0.001]. Appropriate testing with PH probe with 24-hour multichannel impedance was observed (17.1%-28.0%) identifying patients with correct GERD diagnosis [χ2 (1, N = 101) = 1.41, P = 0.236]. Length of stay for GERD patient's improved from a median of 89-53 days. Conclusion Standardizing clinical management leads to best practices for GERD management with appropriate diagnostic testing, eliminating incorrect medication dosing, and improved patient safety with value-based outcomes.
Collapse
|
7
|
Sanchez JB, Jadcherla SR. Gastroesophageal Reflux Disease in Neonates: Facts and Figures. Neoreviews 2021; 22:e104-e117. [PMID: 33526640 DOI: 10.1542/neo.22-2-e104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jenny Bellodas Sanchez
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Sudarshan R Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
8
|
Effects on Gastroesophageal Reflux of Donkey Milk-Derived Human Milk Fortifier Versus Standard Fortifier in Preterm Newborns: Additional Data from the FortiLat Study. Nutrients 2020; 12:nu12072142. [PMID: 32708446 PMCID: PMC7400944 DOI: 10.3390/nu12072142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/11/2020] [Accepted: 07/16/2020] [Indexed: 02/08/2023] Open
Abstract
Background: Feeding intolerance is a frequent diagnosis in very preterm infants. As seen in the FortiLat trial, human milk fortification with the new donkey milk-derived human milk fortifier (DF) seems to improve feeding tolerance in these infants. The aim of this study was to evaluate the effects of using the DF compared with bovine milk-derived fortifier (BF) on gastroesophageal reflux (GER) in very low birth weight (VLBW) infants. Methods: Over a total of 156 preterm infants were enrolled into the FortiLat trial (GA <32 weeks and birth weight <1500 g) and randomized into the BF arm or DF arm, and we selected all infants with clinical signs of GER and cardiorespiratory (CR) symptoms. All the infants underwent CR and multichannel intraluminal impedance and pH (MII/pH) monitoring associated with gastric ultrasound to evaluate GER and gastric emptying time. Results: 10 infants were enrolled, and 5 were in the DF arm. At MII/pH, infants enrolled into the DF arm showed a lower GER frequency than BF arm infants (p = 0.036). Half gastric emptying time was similar in DF and BF arm infants (p = 0.744). Conclusion: The use of donkey-derived human milk fortifier reduced the GER frequency and consequently should be recommended in infants with feeding intolerance.
Collapse
|
9
|
Reducing Antacid Use in a Level IV NICU: A QI Project to Reduce Morbidity. Pediatr Qual Saf 2020; 5:e303. [PMID: 32607459 PMCID: PMC7297399 DOI: 10.1097/pq9.0000000000000303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/22/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Gastroesophageal reflux is a physiologic occurrence in infants. Clinicians caring for neonates use histamine-2 receptor antagonists (H2As) or proton pump inhibitors (PPIs) for symptomatic reflux, apnea/bradycardia/desaturations, or irritability. Recent studies have shown that there is an increased incidence of infection, fracture, and mortality in neonates who receive antacids. Methods A multidisciplinary team aimed to decrease nonindicated antacid use in the NICU by 50% by April 2019. Outcome measures include the median number of inappropriate antacid prescriptions and patient-days on acid-suppressants. Interventions include education regarding use and risks of antacids, development of a list of indications deemed "appropriate" for starting an H2A or PPI, mandatory discussion on rounds when considering antacids, documentation of treatment goal, and indication, and an automatic drop-off in the electronic medical record. Results Baseline data (June-December 2017) showed 19 prescriptions of H2As or PPIs. Of those, 10 orders were deemed "inappropriate," according to our indicated uses. There were 407 total patient-days of medication-use (median: 51 patient-days). After the implementation of the interventions (October 2018-May 2019), there were 11 prescriptions of antacid medications, 3 of which were deemed "inappropriate." There were 206 total days of medication-use (median: 18.5 patient-days). Conclusions A multidisciplinary agreement on indications for antacid use in neonates stimulates discussion and creates more purposeful use. Overall, we successfully decreased nonindicated antacid prescriptions in the NICU. For the next steps, we hope to educate physicians on the risks of antacid use and reduce prescriptions in other areas of the hospital and the outpatient setting.
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
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.
| |
Collapse
|
12
|
Abstract
Gastroesophageal reflux is the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation and is considered a normal physiologic process, occurring daily in greater than one-third of all infants. Gastroesophageal reflux disease (GERD) is pathologic reflux associated with poor weight gain, irritability, dysphagia and often requires evaluation and treatment. No gold-standard testing for GERD exists. Measurements made by pH probe or multichannel intraesophageal impedance may provide insight into the quantity and character of reflux. Those events do not correlate well with clinical symptoms. Most cases of GERD can be treated conservatively with alterations in the infant's environment and/or feeding pattern. Proton pump inhibitors remain the mainstay for pharmacotherapy of GERD, although these have been associated with increased rates of infection, especially in the preterm population. Neonatal GERD remains a difficult entity to define and manage, and additional studies to aid in the clinical diagnosis and management are needed. [Pediatr Ann. 2020;49(2):e77-e81.].
Collapse
|
13
|
Jarasvaraparn C, Belen Rojas Gallegos M, Wang B, Crissinger KD, Gremse DA. The Characteristics of Esophageal Multichannel Intraluminal Impedance-PH Measurements in Infants Experiencing Brief Resolved Unexplained Events. ANNALS OF GASTROENTEROLOGY AND DIGESTIVE DISORDERS 2018; 1:1-8. [PMID: 31119217 PMCID: PMC6527118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Brief Resolved Unexplained Events (BRUE) is defined as a sudden, brief and now resolved episode characterized by color change, altered respirations, change in tone, and altered level of responsiveness. This study aims to identify the characteristics of esophageal Multichannel Intraluminal Impedance-pH (MII-pH) monitoring in infants who have experienced a BRUE. METHODS This study was a retrospective review of records of infants younger than 12 months who presented to the University of South Alabama Children's and Women's Hospital with an admission diagnosis of BRUE. Patients who underwent esophageal MII-pH monitoring between October 2015 and February 2017 and diagnosed with BRUE were initially included in this study. RESULTS Fifty-three infants (preterm 25, term 28) who experienced a higher risk BRUE were included in our study. The mean age at diagnosis was 2.25 ± 2.07 months. Apnea (41/53; 77.4%) was the most common manifestation of BRUE. Non-acid reflux events were the most common findings in the MII-pH studies (66%). MII-pH results showed 6/53 (11%) acid reflux, 17/53 (32%) non-acid reflux and 12/53 (23%) both acid/nonacid reflux and 18/53 (34%) were normal. There were significant differences in the longest acid reflux episode and the Reflux Symptom Sensitivity Index (RSSI) of coughing/choking/gagging between preterm and term infants. The Reflux Symptom Index (RSI), RSSI and Reflux Symptom Association Probability (RSAP) were significantly correlated with each other in all symptoms (pain/fussiness, coughing/choking/gagging and vomiting). CONCLUSIONS Among infants experiencing a higher risk BRUE, esophageal MII-pH monitoring revealed acid or nonacid reflux in 2/3 of patients.
Collapse
Affiliation(s)
| | | | - Bin Wang
- Department of Mathematics and Statistics, University of South Alabama, Mobile, Alabama, USA
| | - Karen D. Crissinger
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of South Alabama, Mobile, Alabama, USA
| | - David A. Gremse
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of South Alabama, Mobile, Alabama, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Rossor T, Andradi G, Ali K, Bhat R, Greenough A. Gastro-Oesophageal Reflux and Apnoea: Is There a Temporal Relationship? Neonatology 2018; 113:206-211. [PMID: 29262418 DOI: 10.1159/000485173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/10/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) and apnoea are common in infants; whether there is a causal relationship is controversial. OBJECTIVES To determine whether there was a temporal relationship between GOR and apnoea, in particular, the frequency of obstructive apnoeas and if the frequency of GOR episodes correlated with apnoea frequency when maturity at testing was taken into account. METHODS Polysomnography and pH/multichannel intraluminal impedance (MII) studies were performed. Apnoeas were classified as central, obstructive, or mixed. MII events were classified as acidic (pH <4) or weakly acidic (4 < pH < 7). Apnoea frequency in the 5-min period after a reflux event was compared to that in the 5-min period preceding the event and that in a 5-min reflux-free period (control period). RESULTS Forty infants (median gestational age 29 [range 24-42] weeks) were assessed at a post-conceptional age of 37 (30-54) weeks. Obstructive (n = 580), central (n = 900), and mixed (n = 452) apnoeas were identified; 381 acid reflux events were detected by MII and 153 by the pH probe only. Apnoeas were not more frequent following GOR than during control periods. Both the frequency of apnoeas (p = 0.002) and GOR episodes (p = 0.01) were inversely related to post-conceptional age at testing, but were not significantly correlated with each other when controlled for post-conceptional age. CONCLUSIONS These results suggest that GOR does not cause apnoea.
Collapse
Affiliation(s)
- Thomas Rossor
- MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | | | | | | | | |
Collapse
|
16
|
Safe M, Chan WH, Leach ST, Sutton L, Lui K, Krishnan U. Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe? World J Gastrointest Pharmacol Ther 2016; 7:531-539. [PMID: 27867686 PMCID: PMC5095572 DOI: 10.4292/wjgpt.v7.i4.531] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/16/2016] [Accepted: 08/06/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux is a common phenomenon in infants, but the differentiation between gastroesophageal reflux and gastroesophageal reflux disease can be difficult. Symptoms are non-specific and there is increasing evidence that the majority of symptoms may not be acid-related. Despite this, gastric acid inhibitors such as proton pump inhibitors are widely and increasingly used, often without objective evidence or investigations to guide treatment. Several studies have shown that these medications are ineffective at treating symptoms associated with reflux in the absence of endoscopically proven oesophagitis. With a lack of evidence for efficacy, attention is now being turned to the potential risks of gastric acid suppression. Previously assumed safety of these medications is being challenged with evidence of potential side effects including GI and respiratory infections, bacterial overgrowth, adverse bone health, food allergy and drug interactions.
Collapse
|
17
|
Minowa H. Respiratory inhibition after crying or gastroesophageal reflux and feeding hypoxemia in infants. J Matern Fetal Neonatal Med 2015; 29:2301-5. [PMID: 26371580 DOI: 10.3109/14767058.2015.1085011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study is to present information on respiratory inhibition after crying (RIAC), feeding hypoxemia, and respiratory inhibition after gastroesophageal reflux (RIGER) to medical staff caring for infants. METHODS The author reviewed investigations of these conditions. RESULTS These conditions have been observed in full-term healthy infants, and they are accompanied clinically by central cyanosis and a decrease in SpO2 to less than 70%. These conditions are easily diagnosed using pulse oximetry. Among Japanese infants with a gestational age of 36 weeks or older, the incidence of RIAC and feeding hypoxemia is 24% and 32%, respectively. The incidence of RIGER is approximately 4%. Feeding hypoxemia occurs significantly more often during bottle-feeding than during breastfeeding. RIAC, feeding hypoxemia, and RIGER are significantly associated with each other. The risk factors are maternal smoking during pregnancy, threatened premature labor, twin gestation, asymmetric intrauterine growth restriction, and abnormal cranial ultrasound findings. Almost all infants recover from RIAC by day 7 after birth. Some infants with feeding hypoxemia require additional assistance and monitoring by nursing staff until the day of discharge. CONCLUSIONS Medical staff caring for infants should note the presence of RIAC, feeding hypoxemia, and RIGER.
Collapse
Affiliation(s)
- Hideki Minowa
- a Department of Neonatal Intensive Care Unit , Nara Prefecture General Medical Center , Nara , Japan
| |
Collapse
|
18
|
Minowa H, Tamura R, Mima A, Arai I, Yasuhara H, Ebisu R, Ohgitani A. Gastroesophageal reflux related to respiratory inhibition after crying and feeding hypoxemia in infants. J Matern Fetal Neonatal Med 2015; 29:512-5. [DOI: 10.3109/14767058.2015.1009441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
19
|
Neu J. Developmental aspects of maternal-fetal, and infant gut microbiota and implications for long-term health. Matern Health Neonatol Perinatol 2015; 1:6. [PMID: 27057323 PMCID: PMC4772751 DOI: 10.1186/s40748-015-0007-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/08/2015] [Indexed: 11/26/2022] Open
Abstract
Background Early life interactions between the human host and microbes set the stage for future health and disease. Findings In this review, some of the relationship of the human microbiome effects will be discussed as they relate to preterm delivery, early life diseases seen in prematurely delivered infants, and other childhood and adult maladies which include autoimmunity, allergic diseases, obesity or a healthy phenotype. Conclusion Although the data in these areas is just beginning to emerge, this review will provide a brief summary of some of the key research being done and will also speculate on emerging areas where major questions are being raised.
Collapse
Affiliation(s)
- Josef Neu
- College of Medicine, University of Florida, 1600 S.W. Archer Road, Gainesville, Florida 32610 USA
| |
Collapse
|
20
|
Dutta S, Singh B, Chessell L, Wilson J, Janes M, McDonald K, Shahid S, Gardner VA, Hjartarson A, Purcha M, Watson J, de Boer C, Gaal B, Fusch C. Guidelines for feeding very low birth weight infants. Nutrients 2015; 7:423-42. [PMID: 25580815 PMCID: PMC4303848 DOI: 10.3390/nu7010423] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 12/19/2014] [Indexed: 11/16/2022] Open
Abstract
Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.
Collapse
Affiliation(s)
- Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Balpreet Singh
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Lorraine Chessell
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Wilson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Marianne Janes
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Kimberley McDonald
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Shaneela Shahid
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Victoria A Gardner
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Aune Hjartarson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Margaret Purcha
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Watson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Chris de Boer
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Barbara Gaal
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Christoph Fusch
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| |
Collapse
|
21
|
Qubty WF, Mrelashvili A, Kotagal S, Lloyd RM. Comorbidities in infants with obstructive sleep apnea. J Clin Sleep Med 2014; 10:1213-6. [PMID: 25325583 DOI: 10.5664/jcsm.4204] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 06/25/2014] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE The clinical characteristics of obstructive sleep apnea (OSA) in infants have been insufficiently characterized. Our aim was to describe identifiable comorbidities in infants with obstructive sleep apnea, which may assist in recognizing these patients earlier in their disease course and help improve management. METHODS This was a single-center, retrospective study involving infants 0-17 months of age with a diagnosis of OSA on the basis of clinical features and nocturnal polysomnography (PSG) at the Mayo Clinic Center for Sleep Medicine between 2000 and 2011. Patients were excluded if they had central apnea accounting for greater than 50% of respiratory events. OSA severity was determined by the apnea-hypopnea index (AHI). RESULTS One hundred thirty-nine patients were included. Based upon the AHI, they were subdivided into mild (AHI <5; 30%), moderate (AHI 5-9; 30%), or severe (AHI >10; 40%) categories. Comorbidities included gastroesophageal reflux in 95/139 (68%), periodic limb movements in sleep in 59/139 (42%), craniofacial abnormalities in 52/139 (37%), neuromuscular abnormalities in 47/139 (34%), prematurity in 41/139 (29%), genetic syndromes in 41/139 (29%), laryngomalacia / tracheomalacia in 38/139 (27%), and epilepsy in 23/139 (17%) of subjects. Severity of OSA correlated with prematurity, having a genetic syndrome, or neuromuscular abnormality. Multispecialty evaluation was needed for 119/139 (86%). CONCLUSION Comorbidities in infants with OSA differ from those of older children. Based upon the comorbidities identified in our study population, it appears that appropriate management of infants with OSA requires a multidisciplinary approach involving genetics, gastroenterology, pulmonology, otolaryngology, neurology, and general pediatrics.
Collapse
Affiliation(s)
| | | | - Suresh Kotagal
- Division of Child Neurology, Mayo Clinic, Rochester, MN and Center for Sleep Medicine, Mayo Clinic, Rochester, MN
| | - Robin M Lloyd
- Division of Pediatrics, Mayo Clinic, Rochester, MN and Center for Sleep Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
22
|
Smits MJ, van Wijk MP, Langendam MW, Benninga MA, Tabbers MM. Association between gastroesophageal reflux and pathologic apneas in infants: a systematic review. Neurogastroenterol Motil 2014; 26:1527-38. [PMID: 25080836 DOI: 10.1111/nmo.12405] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/27/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND In infants, apneas can be centrally mediated, obstructive or both and have been proposed to be gastroesophageal reflux (GER) induced. Evidence for this possible association has never been systematically reviewed. PURPOSE To perform a systematic review using PubMed, EMBASE and Cochrane databases to determine whether an association between GER and apnea in infants exists. Studies with n ≥ 10 infants, aged <12 months, were included. GER had to be studied by pH-metry or pH-impedancemetry. GER episodes were defined as pH <4 for ≥ 5 s and/or a drop of >50% of baseline in impedance signal in distal channels. An apneic event was defined as a cessation of breathing for >20 s, or ≥ 10 s with hypoxemia or bradycardia. An epoch of ≤ 2 min was used to define temporal relation between GER and apnea. Methodological quality of studies was assessed with Newcastle Ottawa Scale (NOS). Of 1959 abstracts found, 6 articles met the inclusion criteria. All studies had poor methodological quality. A total of 289 infants were included. The temporal association of GER followed by apnea was assessed in all studies, with epochs varying from 10 s to 2 min. One study found an increase of apneic events after GER, the remaining 5 studies did not find an association. Two studies assessed apnea followed by GER as well, but did not find sufficient evidence for association. This systematic review showed insufficient evidence for an association between GER and apneas in infants. High quality studies using uniform inclusion criteria, definitions according to accepted guidelines, and patient relevant outcome measures are needed.
Collapse
Affiliation(s)
- Marije J Smits
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
23
|
Abstract
Apnea of prematurity is a significant problem due to immaturity of the central neural control circuitry responsible for integrating afferent input and central rhythm. In this review, we provide an overview of the pathogenesis of apnea of prematurity--including our current understanding of the role that afferent input to the brain stem plays in synergy with the central pattern generation circuitry in the emergence of apnea of prematurity. We then discuss the interplay of apnea, bradycardia, desaturation, as well as the genesis of central, mixed, and obstructive apnea. Finally, we provide a summary of the physiological basis for current therapeutic approaches to treating apnea of prematurity, and conclude with an overview of proposed long-term consequences of the resultant intermittent hypoxic episodes.
Collapse
Affiliation(s)
- Richard J Martin
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA.
| | | |
Collapse
|
24
|
Epifanio M, Eloi J, Cassiano AS, Pinheiro D, Spolidoro JV. Infants under 3 months old with cyanosis at the emergency room: could it be gastroesophageal reflux? Dis Esophagus 2013; 27:335-9. [PMID: 24006911 DOI: 10.1111/dote.12116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study is to describe the prevalence of gastroesophageal reflux disease (GERD) in infants under 3 months old with a history of cyanotic episodes, who were examined at the emergency room of a university hospital. This descriptive study reviews reports of esophageal pH monitoring from a pediatric gastroenterology service over a period of 5 years. The following data were collected: age, sex, pediatric as well as other specialists' evaluations, and the esophageal pH monitoring reports. This study included 67 infants with a history of cyanotic episodes, with no primary cause determined by pediatrician and pediatric specialists' evaluations, who underwent esophageal pH monitoring. The infants were 6-90 days old, 41 (61.2%) of them male. Fifty infants (74.6%) had at least one esophageal pH monitoring parameter above the normal limit. ZMD index was abnormal in 32 cases (48%) and reflux index was abnormal in 31 cases (46%). When other common causes of cyanosis have been ruled out, a significant proportion of infants presenting cyanosis have abnormal pH study, suggesting the role of GERD in cyanosis. The authors highlight that reflux index is not enough to conclude whether a pH study is normal or not. The ZMD index and the presence of episodes longer than 20 minutes are also important parameters for GERD diagnosis.
Collapse
Affiliation(s)
- M Epifanio
- Department of Pediatric Gastroenterology, Hospital São Lucas (SLH), Porto Alegre, Brazil
| | | | | | | | | |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Abstract
Apnea of prematurity and gastroesophageal reflux (GER) are both common occurrences in preterm infants and widely perceived to be causally related. We seek in this review to provide a potential guideline for neonatal GER non-pharmacologic and pharmacologic therapy. Available physiologic data suggest that when there is a temporal relationship apnea may be more likely to predispose to GER via esophageal sphincter relaxation than vice versa. Measurement of multiple intraluminal impedance via esophageal catheter in addition to esophageal pH has enhanced our understanding of GER, although it also did not demonstrate a causal relationship between apnea and GER. The incidence of GER may be modified by thickening feeds and position change without adverse effects. In contrast, pharmacotherapy including acid suppression therapy may have adverse effects and should only be used in infants with clear evidence of clinical benefit.
Collapse
|
27
|
Apnea of prematurity--perfect storm. Respir Physiol Neurobiol 2013; 189:213-22. [PMID: 23727228 DOI: 10.1016/j.resp.2013.05.026] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 05/17/2013] [Accepted: 05/21/2013] [Indexed: 12/23/2022]
Abstract
With increased survival of preterm infants as young as 23 weeks gestation, maintaining adequate respiration and corresponding oxygenation represents a clinical challenge in this unique patient cohort. Respiratory instability characterized by apnea and periodic breathing occurs in premature infants because of immature development of the respiratory network. While short respiratory pauses and apnea may be of minimal consequence if oxygenation is maintained, they can be problematic if accompanied by chronic intermittent hypoxemia. Underdevelopment of the lung and the resultant lung injury that occurs in this population concurrent with respiratory instability creates the perfect storm leading to frequent episodes of profound and recurrent hypoxemia. Chronic intermittent hypoxemia contributes to the immediate and long term co-morbidities that occur in this population. In this review we discuss the pathophysiology leading to the perfect storm, diagnostic assessment of breathing instability in this unique population and therapeutic interventions that aim to stabilize breathing without contributing to tissue injury.
Collapse
|
28
|
Treatment with Gabapentin Associated with Resolution of Apnea in Two Infants with Neurologic Impairment. J Palliat Med 2013; 16:455-8. [DOI: 10.1089/jpm.2012.0103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
29
|
Carter BM. Feeding Intolerance in Preterm Infants and Standard of Care Guidelines for Nursing Assessments. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.nainr.2012.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
30
|
Malcolm WF, Cotten CM. Metoclopramide, H2 blockers, and proton pump inhibitors: pharmacotherapy for gastroesophageal reflux in neonates. Clin Perinatol 2012; 39:99-109. [PMID: 22341540 DOI: 10.1016/j.clp.2011.12.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pharmacotherapy for gastroesophageal reflux (GER) in neonates, aimed at interfering with this physiologic process and potentially reducing the negative sequelae that providers often attribute to GER, consists primarily of drugs that increase the viscosity of feeds, reduce stomach acidity, or improve gut motility. Medications used to treat clinical signs thought to be from GER, such as apnea, bradycardia, or feeding intolerance, are among the most commonly prescribed medications in neonatal intensive care units in the United States, despite the lack of evidence of safety and efficacy in this population.
Collapse
Affiliation(s)
- William F Malcolm
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University, Durham, NC, USA
| | | |
Collapse
|
31
|
Doheny L, Hurwitz S, Insoft R, Ringer S, Lahav A. Exposure to biological maternal sounds improves cardiorespiratory regulation in extremely preterm infants. J Matern Fetal Neonatal Med 2012; 25:1591-4. [DOI: 10.3109/14767058.2011.648237] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
32
|
Katz ES, Mitchell RB, D'Ambrosio CM. Obstructive sleep apnea in infants. Am J Respir Crit Care Med 2011; 185:805-16. [PMID: 22135346 DOI: 10.1164/rccm.201108-1455ci] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Obstructive sleep apnea in infants has a distinctive pathophysiology, natural history, and treatment compared with that of older children and adults. Infants have both anatomical and physiological predispositions toward airway obstruction and gas exchange abnormalities; including a superiorly placed larynx, increased chest wall compliance, ventilation-perfusion mismatching, and ventilatory control instability. Congenital abnormalities of the airway, such as laryngomalacia, hemangiomas, pyriform aperture stenosis, choanal atresia, and laryngeal webs, may also have adverse effects on airway patency. Additional exacerbating factors predisposing infants toward airway collapse include neck flexion, airway secretions, gastroesophageal reflux, and sleep deprivation. Obstructive sleep apnea in infants has been associated with failure to thrive, behavioral deficits, and sudden infant death. The proper interpretation of infant polysomnography requires an understanding of normative data related to gestation and postconceptual age for apnea, arousal, and oxygenation. Direct visualization of the upper airway is an important diagnostic modality in infants with obstructive apnea. Treatment options for infant obstructive sleep apnea are predicated on the underlying etiology, including supraglottoplasty for severe laryngomalacia, mandibular distraction for micrognathia, tonsillectomy and/or adenoidectomy, choanal atresia repair, and/or treatment of gastroesophageal reflux.
Collapse
Affiliation(s)
- Eliot S Katz
- Division of Respiratory Diseases, Department of Medicine, Children's Hospital, Boston, MA, USA.
| | | | | |
Collapse
|
33
|
Jadcherla SR, Chan CY, Moore R, Malkar M, Timan CJ, Valentine CJ. Impact of feeding strategies on the frequency and clearance of acid and nonacid gastroesophageal reflux events in dysphagic neonates. JPEN J Parenter Enteral Nutr 2011; 36:449-55. [PMID: 22038208 DOI: 10.1177/0148607111415980] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Feeding difficulties and gastroesophageal reflux (GER) are common problems in neonates. The authors hypothesize that GER could be influenced by feeding mechanics by evaluating the effects of feeding volumes, feeding durations, feeding flow rates, and caloric density on the chemical composition and clearance of GER in dysphagic neonates. METHODS Symptomatic dysphagic neonates (n = 35) underwent evaluation for suspected GER using pH-impedance methods. RESULTS The proportions of acid and nonacid GER were different during the first, second, and third postprandial hours (P < .0001). Prolonged feeding duration was significantly associated with decreased total, nonacid GER and BCT (P < .03). Significant positive correlations (P < .05) were detected between feeding flow rate vs frequency of total, nonacid GER and BCT. Significant positive correlation (P = .002) was noted between feeding volume and BCT. BCT decreased with each hourly interval (analysis of variance [ANOVA] P < .05); however, ACT increased with each hourly interval (ANOVA P = .05). Comparison between BCT and ACT at each postprandial hour is remarkable for longer ACT during the second and third hours after the initiation of feed (P ≤ .001). No significant correlation was noted between the milk types (breast milk or formula) or caloric density with regard to the GER characteristics. Oral-fed infants had more GER events than gavage-fed infants. CONCLUSIONS Prolonged feeding durations and slower flow rates are associated with decreased frequency of GER. Modification of feeding duration and flow rate can be a useful adjunct to ameliorate GER in dysphagic neonates.
Collapse
Affiliation(s)
- Sudarshan R Jadcherla
- Section of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio 43205, USA.
| | | | | | | | | | | |
Collapse
|
34
|
Lucchini R, Bizzarri B, Giampietro S, De Curtis M. Feeding intolerance in preterm infants. How to understand the warning signs. J Matern Fetal Neonatal Med 2011; 24 Suppl 1:72-4. [PMID: 21892877 DOI: 10.3109/14767058.2011.607663] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
MESH Headings
- Early Diagnosis
- Feeding Methods/adverse effects
- Gastrointestinal Diseases/diagnosis
- Gastrointestinal Diseases/etiology
- Humans
- Infant Nutrition Disorders/complications
- Infant Nutrition Disorders/diagnosis
- Infant Nutrition Disorders/etiology
- Infant Nutrition Disorders/prevention & control
- Infant, Newborn
- Infant, Premature/physiology
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/pathology
- Infant, Premature, Diseases/prevention & control
Collapse
|