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[Expert consensus on enteral nutrition management for preterm infants in special situations (2024)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:665-676. [PMID: 39014941 DOI: 10.7499/j.issn.1008-8830.2402040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
Establishing enteral nutrition after the birth of preterm infants presents numerous challenges, particularly for those in special situations. Various disease factors and medical interventions impede the establishment of enteral feeding, leading to conflicts and controversies regarding feeding goals, feeding methods, and the challenges and solutions faced by these infants. A critical issue for clinical physicians is how to safely and promptly establish enteral nutrition to achieve full enteral feeding as quickly as possible. The consensus formulation working group, based on both domestic and overseas research, adopted the Grading of Recommendations Assessment, Development and Evaluation, and formed an expert consensus on enteral nutrition management for preterm infants in special situations. This consensus provides 14 recommendations for 9 common special situations, aiming to offer guidance on enteral nutrition management for preterm infants to improve their short and long-term outcomes. Citation:Chinese Journal of Contemporary Pediatrics, 2024, 26(7): 665-676.
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Alexander A, Helmick R, Plumb T, Alshaikh E, Jadcherla SR. Characterizing Biomarkers of Continuous Peristalsis and Bolus Transit During Oral Feeding in Infants at pH-Impedance Evaluation: Clinical and Research Implications. J Pediatr 2024; 274:114154. [PMID: 38897379 DOI: 10.1016/j.jpeds.2024.114154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To examine the biomarkers of pharyngoesophageal swallowing during oral feeding sessions in infants undergoing pH-impedance testing and determine whether swallow frequencies are distinct between oral-fed and partially oral-fed infants. STUDY DESIGN One oral feeding session was performed in 40 infants during pH-impedance studies and measurements included swallowing frequency, multiple swallow rate, air and liquid swallow rates, esophageal swallow clearance time, and gastroesophageal reflux (GER) characteristics. Linear and mixed statistical models were applied to examine the swallowing markers and outcomes. RESULTS Infants (30.2 ± 4.4 weeks' birth gestation) were evaluated at 41.2 ± 0.4 weeks' postmenstrual age. Overall, 10 675 swallows were analyzed during the oral feeding sessions (19.3 ± 5.4 minutes per infant) and GER events were noted (2.5 ± 0.3 per study). Twenty-four-hour acid reflux index (ARI) was 9.5 ± 2.0%. Differences were noted in oral-fed and partially oral-fed infants for volume consumption (P < .01), consumption rate (P < .01), and length of hospital stay in days (P < .01). Infants with ARI >7% had greater frequency of swallows (P = .01). The oral-fed group had greater ARI (12.7 ± 3.3%, P = .05). CONCLUSIONS Oropharyngeal swallowing regulatory characteristics decrease over the feeding duration and were different between ARI >7% vs ≤7%. Although GER is less in infants who are partially oral-fed, the neonates with increased acid exposure achieved greater oral intakes and shorter hospitalizations, despite the presence of comorbidities. Pharyngoesophageal stimulation as during consistent feeding or GER events can activate peristaltic responses and rhythms, which may be contributory to the findings.
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Affiliation(s)
- Alexis Alexander
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH; Center for Perinatal Research, The Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Roseanna Helmick
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH; Center for Perinatal Research, The Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Toni Plumb
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH; Center for Perinatal Research, The Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Enas Alshaikh
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH; Center for Perinatal Research, The Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Sudarshan R Jadcherla
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH; Center for Perinatal Research, The Research Institute, Nationwide Children's Hospital, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.
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Sultana Z, O Yildiz V, Jadcherla SR. Characteristics of esophageal refluxate and symptoms in infants compared between pre-treatment and on treatment with proton pump inhibitors. J Perinatol 2024; 44:87-93. [PMID: 37980392 DOI: 10.1038/s41372-023-01825-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To examine longitudinal pH-impedance characteristics from those infants who remained on proton pump inhibitors therapy for gastroesophageal reflux disease (GERD) as parents/providers refused to discontinue therapy after 4 weeks. STUDY DESIGN Eighteen infants with acid reflux index >3% underwent treatment, and pH-impedance data were compared prior to and on proton pump inhibitors at 42 ± 1 and 46 ± 1 weeks' postmenstrual age, respectively. Esophageal acid and bolus exposure, symptoms and swallowing characteristics were examined. RESULTS Proton pump inhibitors reduces the acid-mediated effects of reflux but modifies impedance and clearance mechanisms (P < 0.05). Prolonged therapy did not reduce symptoms (P > 0.05). Infants evaluated while on proton pump inhibitors were 1.8 times more likely to have swallows before and after reflux. CONCLUSIONS Prescription of proton pump inhibitors for objectively determined GERD should have time limits, as prolonged treatment can result in prolonged esophageal bolus clearance time without relieving symptoms.
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Affiliation(s)
- Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vedat O Yildiz
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Njeh M, Sultana Z, Plumb T, Alshaikh E, Jadcherla SR. Comparison of direct effects of rice-thickened formula vs routine feeds on symptoms and gastroesophageal reflux indices: A crossover cohort study. JPEN J Parenter Enteral Nutr 2024; 48:64-73. [PMID: 37850573 DOI: 10.1002/jpen.2566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND We compared the direct effects of routine vs rice-thickened formula on 24-h pH-impedance and symptom characteristics and then examined if dietary effects were modified by acid reflux index severity in infants. METHODS Forty infants under consideration for gastroesophageal reflux disease and therapies were evaluated at 43 ± 1 weeks postmenstrual age. Each infant was equally fed routine diet and thickened formula during evaluations. Postprandial sessions were analyzed for acid reflux index, reflux events, clearance times, distal baseline impedance, and symptoms. RESULTS Thickened formula has no effect (P ≥ 0.05) on acid reflux events' characteristics or overall symptom frequency. However, refluxate height and frequency of weakly acidic events and cough were decreased (P < 0.05). Prolonged bolus clearance and a decrease in distal baseline impedance were noted with thickened feeds (vs routine feeds) when acid reflux index was >7 (P < 0.05). CONCLUSION Our pH-impedance testing protocol identifies direct effects of potential therapies at the point of care. Acutely, thickened formula does not impact acid-specific reflux indices but decreases full-column reflux and cough reflexes. In those with an acid reflux index of >7, thickened formula prolongs the distal esophageal bolus clearance (the mechanisms of which are uncertain). Clinical trials are needed to clarify objective indications and therapeutic use of thickened formulas for infants with gastroesophageal reflux disease, along with short- and long-term side effects.
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Affiliation(s)
- Minna Njeh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Toni Plumb
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Enas Alshaikh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio, USA
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Grossbauer A, Mnatsakanian A, Costeloe A, Thottam PJ. The effects of untreated reflux on the incidence of dysphagia, oral aversion, and feeding difficulty in the NICU population. Int J Pediatr Otorhinolaryngol 2023; 174:111734. [PMID: 37757707 DOI: 10.1016/j.ijporl.2023.111734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES To determine whether late-preterm and full-term neonates in the neonatal intensive care unit (NICU) with diagnosed gastroesophageal reflux (GERD) have an increased incidence of feeding difficulties, dysphagia, and oral aversion. To determine the incidence of reflux medication use in late-preterm and full-term neonates in the NICU. METHODS Neonates greater than 34 weeks gestational age (GA) diagnosed with reflux, who were hospitalized for at least five days, were included in the study. Neonates with anatomical anomalies that interfere with feeding are excluded. The control group included neonates greater than 34 weeks GA not diagnosed with reflux. The key outcome variables were subjective ease of feeding, oral aversion, and placement on nasogastric (NG), orogastric (OG), or requirement of total parenteral nutrition (TPN). Statistical analysis was performed using chi-squared and t-test to compare incidence of feeding difficulties between the groups. A p-value <0.05 was considered significant. RESULTS In neonates with a diagnosis of reflux, 42.02% had feeding difficulties (66 patients). In the control group, 30.49% of neonates had feeding difficulties (218 patients). Feeding difficulties in neonates with reflux was 11.55% higher than in the control group (p = 0.001). CONCLUSION Late-preterm and full-term neonates diagnosed with reflux have a higher incidence of feeding difficulties than those who did not have reflux. Only 0.86% of neonates diagnosed with reflux were treated with anti-reflux medications at this large tertiary care children's hospital.
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Affiliation(s)
- Anne Grossbauer
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Ani Mnatsakanian
- Department of Otolaryngology, Ascension Providence Hospital, Detroit, MI, USA
| | - Anya Costeloe
- Department of Otolaryngology, Ascension Providence Hospital, Detroit, MI, USA
| | - Prasad John Thottam
- Department of Pediatric Otolaryngology, Beaumont Children's Hospital, Detroit, MI, USA; Michigan Pediatric Ear Nose and Throat Associates, West Bloomfield Township, MI, USA.
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [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: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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Pappa A, Muschaweck M, Wenzl TG. Change of Sleep Stage during Gastroesophageal Reflux in Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050836. [PMID: 37238384 DOI: 10.3390/children10050836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/15/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
INTRODUCTION This study intended to explore the existence of a temporal association of changes of sleep stage and gastroesophageal reflux (GER) in infants. MATERIALS AND METHODS Documentation of sleep stage and GER was conducted via the use of synchronized polygraphic recording combined with impedance-pH-metry in 15 infants. The total recording-time (Rt) was divided into GER-"window-time" (five seconds before and after the onset of a GER episode), "remaining GER time", and "GER-free time", and analyzed for changes of sleep stage. RESULTS a total of 462 GER episodes were identified during Rt (151.1 h) in all infants. During 1.3 h of window-time; 61 changes of sleep stage (47/h); during 5.9 h of Remaining GER-time, 139 changes of sleep stage (24/h); and during 143.9 h of GER-free time, 4087 changes of sleep stage (28/h) were documented. Change of sleep stage was strongly associated with the onset of GER (p < 0.02 and p < 0.05, respectively). CONCLUSIONS There is a strong temporal association between sleep irregularities, i.e., changes of sleep and episodes of GER in infants. When dealing with disturbed sleep in infants, GER should be considered by caregivers.
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Affiliation(s)
- Angeliki Pappa
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Moritz Muschaweck
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Tobias G Wenzl
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
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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.
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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] [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,Corresponding author. (E.B. Ortigoza)
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Sultana Z, Hasenstab KA, Moore RK, Osborn EK, Yildiz VO, Wei L, Slaughter JL, Jadcherla SR. Symptom Scores and pH-Impedance: Secondary Analysis of a Randomized Controlled Trial in Infants Treated for Gastroesophageal Reflux. GASTRO HEP ADVANCES 2022; 1:869-881. [PMID: 36310566 PMCID: PMC9615096 DOI: 10.1016/j.gastha.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS To evaluate and compare gastro-esophageal reflux (GER) symptom scores with pH-impedance and test the effects of acid-suppressive medications with or without feeding modifications on pH-impedance in high-risk infants. METHODS Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and 24-hour pH-impedance data were analyzed from 94 infants evaluated in a tertiary care setting for GER disease. Longitudinal data from 40 infants that received randomized GER therapy (proton pump inhibitor [PPI] with or without feeding modifications) for 4 weeks followed by 1-week washout were analyzed. Relationships between I-GERQ-R and pH-impedance metrics (acid reflux index, acid and bolus GER events, distal baseline impedance, and symptoms) were examined and effects of treatments compared. RESULTS (A) Correlations between I-GERQ-R and pH-impedance metrics were weak. (B) I-GERQ-R sensitivity, specificity, and positive predictive values were suboptimal when correlated with pH-impedance metrics. I-GERQ-R negative predictive value (NPV) was high for acid symptom-association probability (NPV = 84%) and distal baseline impedence (NPV = 86%) thresholds. (C) PPI with feeding modifications (vs PPI alone) did not alter pH-impedance metrics or symptom scores (P > .05); however, bolus clearance metrics worsened for both treatment groups (P < .05). CONCLUSIONS In high-risk infants (1) I-GERQ-R may be a helpful clinical screening tool to exclude acid-GER disease diagnosis and minimize unnecessary acid-suppressive treatment, but further testing is needed for diagnosis. (2) Acid-suppressive therapy with feeding modifications has no effect on symptom scores or pH-impedance metrics. Clearance of refluxate worsened despite PPI therapy, which may signal development of pharyngoesophageal dysmotility and persistence of symptoms. (3) Placebo-controlled trials are needed in high-risk infants with objective pH-impedance criteria to determine efficacy, safety, and underlying mechanisms. Clinicaltrials.gov ID: NCT02486263.
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Affiliation(s)
- Zakia Sultana
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Rebecca K. Moore
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Erika K. Osborn
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Vedat O. Yildiz
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lai Wei
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan L. Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, The Ohio State University College of Medicine, Columbus, Ohio
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Jadcherla SR, Helmick R, Hasenstab KA, Njeh M, Alshaikh E. Impact of esophageal mucosal permeability markers on provocation-induced esophageal reflexes in high-risk infants. Physiol Rep 2022; 10:e15366. [PMID: 35757907 PMCID: PMC9234750 DOI: 10.14814/phy2.15366] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/25/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023] Open
Abstract
Esophageal distal baseline impedance (DBI) is an indicator of mucosal integrity; lower values suggest increased permeability. Aims were to characterize the (1) effect of DBI category (<900 Ω, 900-2000 Ω, and >2000 Ω) on sensory-motor characteristics of mid-esophageal provocation-induced motility reflexes, and (2) clinical outcomes among high-risk human infants evaluated for gastroesophageal reflux disease. Symptomatic infants (N = 49, 41 ± 3 weeks postmenstrual age) underwent pH-impedance testing to characterize acid reflux index (ARI) and DBI, and pharyngo-esophageal manometry to examine upper esophageal sphincter (UES), peristaltic, and lower esophageal sphincter (LES) functions. Sensory-motor response characteristics included response threshold (ml), occurrence (%), latency (s), duration (s), and magnitude (mmHg) upon mid-esophageal stimulations (0.1-2.0 ml of air, water, and apple juice). Motility and clinical outcomes were compared among DBI groups. In infants with DBI <900 Ω and 900-2000 Ω (vs. >2000 Ω): (a) Long-term feeding milestones did not differ (p > 0.05); (b) complete peristaltic propagation decreased in 900-2000 Ω (p < 0.05), polymorphic waveforms increased in <900 Ω and 900-2000 Ω (p < 0.05); (c) media effects were noted with liquids (vs. air) wherein UES and esophageal contractility were prolonged in <900 Ω and 900-2000 Ω (p < 0.05), and esophageal sensitivity heightened for <900 Ω with water and for 900-2000 Ω with air (both p < 0.05). ARI was not correlated with DBI in infants with chronic lung disease (r = 0.05, p = 0.82). We conclude that pharyngo-esophageal motility sensory-motor characteristics in infants are modified by DBI category. These preliminary findings pave-the-way for further physiological testing in convalescing high-risk infants to ascertain potential mechanisms of airway-digestive reflex interactions and symptom generation, which may lead to targeted therapies.
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Affiliation(s)
- Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research ProgramNationwide Children's HospitalColumbusOhioUSA
- Center for Perinatal ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhioUSA
- Division of NeonatologyNationwide Children's Hospital ColumbusOhioUSA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of PediatricsThe Ohio State University College of MedicineColumbusOhioUSA
| | - Roseanna Helmick
- Innovative Infant Feeding Disorders Research ProgramNationwide Children's HospitalColumbusOhioUSA
- Center for Perinatal ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research ProgramNationwide Children's HospitalColumbusOhioUSA
- Center for Perinatal ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Minna Njeh
- Innovative Infant Feeding Disorders Research ProgramNationwide Children's HospitalColumbusOhioUSA
- Center for Perinatal ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Enas Alshaikh
- Innovative Infant Feeding Disorders Research ProgramNationwide Children's HospitalColumbusOhioUSA
- Center for Perinatal ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhioUSA
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Abstract
BACKGROUND Current recommendations do not support the use of anti-reflux medications to treat gastro-oesophageal reflux disease (GORD) among preterm infants. OBJECTIVE To describe the prevalence of GORD and the use of anti-reflux medications amongst very preterm infants (<32 weeks' gestational age (GA)) in neonatal units in England and Wales. DESIGN Retrospective cohort study using the National Neonatal Research Database. RESULTS Among 58,108 infants [median GA (IQR) 29 (27-30) weeks], 15.8% (n = 9191) had a diagnosis of GORD and 36.9% (n = 12,446) received anti-reflux medications. Those who received anti-reflux medications were more preterm [GA, median (IQR): medications, 28 (26-30) vs. no medications, 30 (28-31); p < 0.001] and had lower birth weight [mean (SD): medications, 1124 g (354) vs. no medications, 1265 g (384); p < 0.001]. Most (57%, n = 12,224) received Gaviscon, or Histamine-2 Receptor Antagonist (H2RA) (56%, n = 11,959). Over time, prokinetic use has declined substantially, the use of H2RAs and Gaviscon has reduced although they continue to be used frequently, whilst the use of PPIs has increased. CONCLUSIONS Anti-reflux medications are frequently prescribed in very preterm infants, despite evidence to suggest that they are not effective and may be harmful. Clear guidelines for diagnosing GORD and the use of anti-reflux medications are required to rationalise the pharmacological management of GORD in preterm infants. IMPACT Anti-reflux medications are frequently prescribed, often without a diagnosis of gastro-oesophageal reflux disease, to very preterm infants while in the neonatal unit and at discharge. Half of the infants born at <28 weeks' gestational age receive anti-reflux medications in hospital and a quarter are discharged home on them. Although the use of prokinetics declined following alerts of adverse events, histamine2-receptor antagonists and alginates such as Gaviscon continue to be used and the use of proton-pump inhibitors has increased more than 2-fold.
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Viswanathan S, Batchu S, Osborn E, Jadcherla S. Diagnostic utility of impedance-pH monitoring in infants of diabetic mothers with oral feeding difficulties. J Perinatol 2021; 41:1886-1892. [PMID: 32981928 DOI: 10.1038/s41372-020-00832-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/21/2020] [Accepted: 09/17/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the diagnostic utility of impedance-pH monitoring in infants of diabetic mothers (IDM) with oral feeding difficulties. STUDY DESIGN Retrospective review of a consecutive sample of 50 IDM who had impedance-pH monitoring for objective gastroesophageal reflux disease (GERD) diagnosis. Acid reflux index (ARI) ≥ 7 was considered pathological (ARI+). RESULTS Impedance-pH monitoring was performed at 42.1-week postmenstrual age. Twenty infants (40%) with ARI+ compared to 30 with ARI < 7 (ARI-). ARI+ had lower weight at study vs. ARI- (p < 0.05). ARI+ had significantly higher reflux parameters but had similar symptom burden and symptom-association scores vs. ARI-. All ARI+ received proton-pump inhibitors (PPI) vs. 7 (23.3%) in ARI- (p < 0.05), but oral feeding outcomes, gastrostomy rate, growth, and hospital length of stay were similar in both groups. CONCLUSIONS The diagnostic yield of impedance-pH monitoring in IDM is about 40%. However, GERD diagnosis or treatment with PPI did not modify short-term clinical outcomes.
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Affiliation(s)
- Sreekanth Viswanathan
- Division of Neonatology, Department of Pediatrics, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, FL, USA. .,Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
| | - Sahithee Batchu
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Erika Osborn
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sudarshan Jadcherla
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
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14
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Rodgers A. Gastro-oesophageal reflux in preterm infants: American Academy of Pediatrics guideline 2018. Arch Dis Child Educ Pract Ed 2021; 106:107. [PMID: 32546563 DOI: 10.1136/archdischild-2020-319375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/05/2020] [Accepted: 05/10/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Anna Rodgers
- Paediatrics, North Middlesex University Hospital NHS Trust, London N18 1QX, UK
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15
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Shelly CE, Filatava EJ, Thai J, Pados BF, Rostas SE, Yamamoto H, Fichorova R, Gregory KE. Elevated Intestinal Inflammation in Preterm Infants With Signs and Symptoms of Gastroesophageal Reflux Disease. Biol Res Nurs 2021; 23:524-532. [PMID: 33541135 DOI: 10.1177/1099800420987888] [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: 01/03/2023]
Abstract
OBJECTIVES Reflux is common in infancy; however, persistent signs and symptoms of gastrointestinal distress are often attributed to gastroesophageal reflux disease (GERD). In this pilot study, we aimed to characterize associations between signs and symptoms of suspected GERD and noninvasive markers of intestinal inflammation in preterm infants. METHODS We reviewed Electronic Medical Record (EMR) data to identify clinical signs and symptoms among case patients (n = 16). Controls (n = 16) were matched on gestational age. Univariate and multivariate regression analyses were used to compare fecal calprotectin and urinary intestinal fatty acid binding protein (I-FABP) levels between cases and controls. RESULTS We found no differences in baseline characteristics between cases and controls. In the multivariate regression analysis controlling for the proportion of mother's milk, cases had higher fecal calprotectin levels than controls, with no differences in I-FABP levels between cases and controls. CONCLUSION Our findings suggest that preterm infants with signs and symptoms of GERD have higher levels of intestinal inflammation as indicated by fecal calprotectin compared to their controls. Further studies are needed to evaluate the role of intestinal inflammation in signs and symptoms of gastrointestinal distress and whether fecal calprotectin might have predictive value in diagnosing GERD.
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Affiliation(s)
- Colleen E Shelly
- Department of Nursing, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Evgenia J Filatava
- Department of Pediatric Newborn Medicine, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Thai
- 1811Harvard Medical School, Boston, MA, USA
| | - Britt F Pados
- 15712W.F. Connell School of Nursing, Boston College, MA, USA
| | - Sara E Rostas
- Department of Pediatric Newborn Medicine, 1861Brigham and Women's Hospital, Boston, MA, USA.,1811Harvard Medical School, Boston, MA, USA
| | - Hidemi Yamamoto
- 1811Harvard Medical School, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Raina Fichorova
- 1811Harvard Medical School, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Katherine E Gregory
- Department of Nursing, 1861Brigham and Women's Hospital, Boston, MA, USA.,Department of Pediatric Newborn Medicine, 1861Brigham and Women's Hospital, Boston, MA, USA.,1811Harvard Medical School, Boston, MA, USA
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16
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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
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17
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Differentiating esophageal sensitivity phenotypes using pH-impedance in intensive care unit infants referred for gastroesophageal reflux symptoms. Pediatr Res 2021; 89:636-644. [PMID: 32375162 PMCID: PMC7644596 DOI: 10.1038/s41390-020-0930-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/24/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND To identify esophageal sensitivity phenotypes relative to acid (SAcid), bolus (SBolus), acid and bolus (SAcid+Bolus), and none (SNone) exposures in infants suspected with gastroesophageal reflux disease (GERD). METHODS Symptomatic infants (N = 279) were evaluated for GERD at 42 (40-45) weeks postmenstrual age using 24-h pH-impedance. Symptom-associated probability (SAP) for acid and bolus components defined esophageal sensitivity: (1) SAcid as SAP ≥ 95% for acid (pH < 4), (2) SBolus as SAP ≥ 95% for bolus, (3) SAcid+Bolus as SAP ≥ 95% for acid and bolus, or (4) SNone as SAP < 95% for acid and bolus. RESULTS Esophageal sensitivity prevalence (SAcid, SBolus, SAcid+Bolus, SNone) was 28 (10%), 94 (34%), 65 (23%), and 92 (33%), respectively. Emesis occurred more in SBolus and SAcid+Bolus vs SNone (p < 0.05). Magnitude (#/day) of cough and emesis events increased with SBolus and SAcid+Bolus vs SNone (p < 0.05). SAcid+Bolus had increased acid exposure vs SNone (p < 0.05). Distributions of feeding and breathing methods were distinct in infants with SBolus vs SNone (both, p < 0.05). Multivariate analysis revealed that arching and irritability events/day were lesser at higher PMAs (p < 0.001) and greater for infants on NCPAP (p < 0.01) with SBolus and SAcid+Bolus (p < 0.05). Coughs/day was greater at higher PMAs (p < 0.001) for infants with gavage and transitional feeding methods (p < 0.02) with SBolus and SAcid+Bolus (p < 0.05) but lesser with Trach (p < 0.001). Number of emesis events/day were greater with SBolus and SAcid+Bolus (p < 0.001). Sneezes/day decreased for infants on Trach (p = 0.02). CONCLUSIONS Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. We differentiated esophageal sensitivity phenotypes in NICU infants referred for GERD symptoms using pH-impedance. Acid sensitivity alone was rare, which may explain poor response to acid suppressives; aerodigestive symptoms were predominantly linked with bolus spread. Magnitude of esophageal acid exposure and esophageal sensitivity to bolus spread may explain the pathophysiological basis for symptoms. IMPACT Objective GERD diagnosis and reasons for symptoms in NICU infants remains unclear. Differentiation of esophageal sensitivities by acid and bolus components of GER reveal distinct symptom profiles, specifically the bolus component of GER significantly contributes to symptom occurrence. Acid only sensitivity to GER is rare, and acid-suppressive therapy alone may not improve symptoms in a majority of NICU infants. Magnitude of esophageal acid exposure and esophageal sensitivity to any bolus spread may explain the pathophysiological basis for symptoms. Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. GERD treatments should be individualized to the patient's GERD phenotype and likely also target the bolus component of GER.
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18
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Role of feeding strategy bundle with acid-suppressive therapy in infants with esophageal acid reflux exposure: a randomized controlled trial. Pediatr Res 2021; 89:645-652. [PMID: 32380509 PMCID: PMC7647955 DOI: 10.1038/s41390-020-0932-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To test the hypothesis that a feeding bundle concurrent with acid suppression is superior to acid suppression alone in improving gastroesophageal reflux disease (GERD) attributed-symptom scores and feeding outcomes in neonatal ICU infants. METHODS Infants (N = 76) between 34 and 60 weeks' postmenstrual age with acid reflux index > 3% were randomly allocated to study (acid-suppressive therapy + feeding bundle) or conventional (acid-suppressive therapy only) arms for 4 weeks. Feeding bundle included: total fluid volume < 140 mL/kg/day, fed over 30 min in right lateral position, and supine postprandial position. Primary outcome was independent oral feeding and/or ≥6-point decrease in symptom score (I-GERQ-R). Secondary outcomes included growth (weight, length, head circumference), length of hospital stay (LOHS, days), airway (oxygen at discharge), and developmental (Bayley scores) milestones. RESULTS Of 688 screened: 76 infants were randomized and used for the primary outcome as intent-to-treat, and secondary outcomes analyzed for 72 infants (N = 35 conventional, N = 37 study). For study vs. conventional groups, respectively: (a) 33% (95% CI, 19-49%) vs. 44% (95% CI, 28-62%), P = 0.28 achieved primary outcome success, and (b) secondary outcomes did not significantly differ (P > 0.05). CONCLUSIONS Feeding strategy modifications concurrent with acid suppression are not superior to PPI alone in improving GERD symptoms or discharge feeding, short-term and long-term outcomes. IMPACT Conservative feeding therapies are thought to modify GERD symptoms and its consequences. However, in this randomized controlled trial in convalescing neonatal ICU infants with GERD symptoms, when controlling for preterm or full-term birth and severity of esophageal acid reflux index, the effectiveness of acid suppression plus a feeding modification bundle (volume restriction, intra- and postprandial body positions, and prolonged feeding periods) vs. acid suppression alone, administered over a 4-week period was not superior in improving symptom scores or feeding outcomes. Restrictive feeding strategies are of no impact in modifying GERD symptoms or clinically meaningful outcomes. Further studies are needed to define true GERD and to identify effective therapies in modifying pathophysiology and outcomes. The improvement in symptoms and feeding outcomes over time irrespective of feeding modifications may suggest a maturational effect. This study justifies the use of placebo-controlled randomized clinical trial among NICU infants with objectively defined GERD.
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Gewolb IH, Vice FL. Use of a non-invasive accelerometric method for diagnosing gastroesophageal reflux in premature infants. J Perinatol 2021; 41:1879-1885. [PMID: 33758392 PMCID: PMC8342305 DOI: 10.1038/s41372-021-01034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the clinical usefulness of a non-invasive accelerometric device to diagnose GER in preterm babies. STUDY DESIGN An accelerometer was taped over the sub-xiphoid process in 110 preterm (GA 29.6 ± 3.3 wk) infants (133 studies). Low frequency, sub-audible signals were captured via digital recording (sampling rate 200 Hz), then re-sampled (rate = 60 Hz) to create a spectrogram (focused range 0-30 Hz). Mean amplitude in the focused range was calculated. RESULTS Of 85 studies with simultaneous pH-metry and accelerometry, 18 had concurrent positive and 23 had concurrent negative scores, 42 had negative pH scores when accelerometry was positive (≥1 µV), consistent with non-acid reflux. Eleven infants at high risk of aspiration received surgical interventions. All but 1 had negative pH scores while 10/11 had positive accelerometry. CONCLUSIONS The non-invasiveness of this accelerometric technique allows for GER screening and for repeated testing to assess efficacy of interventions.
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Affiliation(s)
- Ira H. Gewolb
- grid.17088.360000 0001 2150 1785Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI USA
| | - Frank L. Vice
- grid.17088.360000 0001 2150 1785Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI USA
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20
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Jadcherla SR, Hasenstab KA, Gulati IK, Helmick R, Ipek H, Yildiz V, Wei L. Impact of Feeding Strategies With Acid Suppression on Esophageal Reflexes in Human Neonates With Gastroesophageal Reflux Disease: A Single-Blinded Randomized Clinical Trial. Clin Transl Gastroenterol 2020; 11:e00249. [PMID: 33259163 PMCID: PMC7643906 DOI: 10.14309/ctg.0000000000000249] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Aims were to test hypothesis that esophageal provocation-induced reflexes are superior with acid suppression plus feeding modifications vs acid suppression alone among infants treated for gastroesophageal reflux disease (GERD). METHODS Infants (N = 49, 41.3 ± 2.6 of postmenstrual age) with acid reflux index >3% underwent longitudinal motility testing (weeks 0 and 5) with graded midesophageal provocation to test randomly allocated therapies (4 weeks' proton pump inhibitor [PPI] ± feeding modifications) on sensory-motor aerodigestive reflexes. Feeding modification included restricted fluid volume <140 mL/kg per day, fed over 30 minutes in right lateral position and supine postprandial position. Primary motility outcome was frequency-occurrence of peristaltic reflex. Secondary outcomes included upper esophageal sphincter contractile reflex, lower esophageal sphincter (LES) relaxation reflex, respiratory change, and symptom characteristics. RESULTS Treatment groups did not differ for primary outcome (odds ratio = 0.8, 95% confidence interval 0.4-1.6, P = 0.99) or secondary outcomes (all P > 0.05). For both treatment groups at follow-up, distal esophageal contraction and LES tone decreased, and LES relaxation reflex occurrence is less frequent (all P < 0.05). In a subgroup analysis, comparing infants with PPI washout (N = 40) vs with continued (N = 9) PPI therapy, no differences were noted for aerodigestive reflex response frequency-occurrence (all P > 0.05). DISCUSSION In infants with GERD, feeding modification with acid suppression is not superior to acid suppression alone in modifying aerodigestive reflexes (frequency, sensation, or magnitude). Contiguous areas targeted by GER, i.e., LES and distal esophageal functions, worsened at follow-up for both groups despite PPI therapy. Maturation is likely the key factor for GERD resolution in infants, justifying the use of placebo in clinical trials for objectively determined GERD.
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Affiliation(s)
- Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital Columbus, Ohio, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ish K. Gulati
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital Columbus, Ohio, USA
| | - Roseanna Helmick
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Haluk Ipek
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Vedat Yildiz
- Biostatistics Resource at Nationwide Children's Hospital (BRANCH), Columbus, Ohio, USA
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Jensen EA, Zhang H, Feng R, Dysart K, Nilan K, Munson DA, Kirpalani H. Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding. Arch Dis Child Fetal Neonatal Ed 2020; 105:399-404. [PMID: 31685527 PMCID: PMC7453998 DOI: 10.1136/archdischild-2019-317148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 09/26/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Compare rates of hypoxaemia during transpyloric and gastric feedings in very preterm infants with severe bronchopulmonary dysplasia. DESIGN N-of-1 multiple crossover trials with individual patient and pooled data analyses. SETTING Level IV intensive care nursery. PATIENTS Infants receiving positive airway pressure between 36 and 55 weeks postmenstrual age were enrolled between December 2014-July 2016. INTERVENTION N-of-1 trial consisting of two blocks, each with a 4-day gastric and 4-day transpyloric feeding period assigned in random order. MAIN OUTCOME MEASURES The primary outcome was the frequency of daily intermittent hypoxaemic events (SpO2 ≤80% lasting 10-180 s). Secondary outcomes included the daily proportion of time with an SpO2 ≤80% and mean daily fraction of inspired oxygen. RESULTS Of 15 infants, 13 completed the trial and 2 stopped early for transient worsening in respiratory status during gastric feedings. In the intention-to-treat analyses, transpyloric feedings resulted in increased rates of intermittent hypoxaemia in five infants, greater time per day in hypoxaemia in three infants and more supplemental oxygen use in three infants. One infant received more supplemental oxygen during gastric feedings. The remaining study outcomes were similar between the feeding routes in all other infants. Pooling all data, transpyloric feedings resulted in a higher frequency of intermittent hypoxaemic events (median 7.5/day (IQR 1-23.5) vs 3/day (1-11); adjusted incidence rate ratio 1.8, 95% CI 1.3 to 2.5) and a greater proportion of daily hypoxaemia time (median 0.8% (IQR 0.1-2.3) vs 0.4% (0.07-1.8); adjusted mean difference 1.6, 95% CI 1.1 to 2.5). CONCLUSIONS Transpyloric compared with gastric feedings modestly increased rates of hypoxaemia among study participants. TRIAL REGISTRATION NUMBER NCT02142621.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Huayan Zhang
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rui Feng
- Department of Biostatistics and Epidemiology, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Kevin Dysart
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen Nilan
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David A Munson
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Prolonging gavage feeds for reduction of gastroesophageal reflux in infants. J Perinatol 2020; 40:916-921. [PMID: 32086438 DOI: 10.1038/s41372-020-0630-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 01/29/2020] [Accepted: 02/11/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine if prolonging gavage feedings in infants for ≥60 min is associated with decreased gastroesophageal reflux (GER) compared with bolus feeding using multiple-channel intraluminal impedance with pH probe (MII-pH). STUDY DESIGN Retrospective analysis of infants who underwent MII-pH between October 2009 and July 2018 and received gavage feedings. Infants were divided into two groups: bolus (<30 min) or prolonged (≥60 min). Symptoms, number of reflux events and percent time pH < 4 was compared. RESULT Fifty-eight infants underwent evaluation. Thirty-one (54%) received bolus gavage feedings and 27 (46%) received prolonged feedings. Groups differed in postmenstrual age. Total reflux episodes were significantly lower with prolonged feeding (median 19 vs. 28 episodes, p = 0.015), with no difference in acid exposure time. There was no significant difference in GER symptoms between the two groups. CONCLUSION Prolongation of gavage feedings was associated with decreased total numbers of GER events without reduction in GER symptoms.
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Gulati IK, Sultana Z, Jadcherla SR. Approach to Feeding Difficulties in Neonates and Infants: A Comprehensive Overview. Clin Perinatol 2020; 47:265-276. [PMID: 32439111 DOI: 10.1016/j.clp.2020.02.006] [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: 10/25/2022]
Abstract
Deglutition disorders (DD) can be transient and considered as physiologic during normal maturation. However, when oral feeding milestones are impaired and bothersome symptoms and aerodigestive consequences are associated, it is interpreted as DD with varying specific entities, such as feeding difficulties, swallowing disorders, aerodigestive illness, and aspiration syndromes. Symptoms related to DD are heterogeneous and managed empirically. This article clarifies current controversies, explains the potential role of safe feeding and physiologic and pathophysiologic perspectives, and highlights current advances in the field. Evidence basis for diagnostic strategies is discussed, and involves evaluation for structure and function tests, and nutrition and feeding assessment.
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Affiliation(s)
- Ish K Gulati
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, College of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA.
| | - Zakia Sultana
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, OH, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, College of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA; Division Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
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Abstract
Aerodigestive disorders, those affecting the upper and lower airway or upper gastrointestinal tract, are interrelated anatomically during fetal development and functionally after birth. Successful respiration and feeding requires careful coordination to promote effective swallowing and prevent aspiration. I describe the epidemiology, including the prevalence of the most common aerodigestive disorders. The ability of an infant to feed by mouth at discharge, without a surgically placed feeding tube, is an important neurodevelopmental marker. Therefore, aerodigestive disorders have a high potential for lifelong morbidities and health care expenditures. When available, published research on related medical costs for these disorders is provided.
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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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Badran EF, Jadcherla S. The enigma of gastroesophageal reflux disease among convalescing infants in the NICU: It is time to rethink. Int J Pediatr Adolesc Med 2020; 7:26-30. [PMID: 32373699 PMCID: PMC7193076 DOI: 10.1016/j.ijpam.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Gastroesophageal reflux (GER) can be a normal physiological process, or can be bothersome, when aerodigestive consequences are associated; the latter is often interpreted as GER disease (GERD). However, the distinction between these two entities remains an enigma among infants surviving after neonatal intensive care (NICU) care. Symptoms related to GERD are heterogeneous, and are often managed with changes in diet, feeding methods, and acid suppressive therapy. However, none of these approaches have been well-tested in neonates; hence practice variation is very high world-wide. In this paper, we explain the variation in diagnosis, pathophysiology of the clinical presentation, and highlight approaches to diagnosis and management.
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Affiliation(s)
- Eman F. Badran
- Department of Pediatrics, School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Sudarshan Jadcherla
- Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Childrens’ Hospital and The Ohio State University College of Medicine, Columbus, OH, 43215, USA
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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.].
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Ryan PM, Mondal T. Does domperidone prolong QTc in a clinically relevant manner in infants with GORD? Arch Dis Child 2020; 105:202-205. [PMID: 31594778 DOI: 10.1136/archdischild-2019-318183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 11/04/2022]
Affiliation(s)
| | - Tapas Mondal
- Division of Cardiology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Jadcherla SR. Challenges to Eating, Swallowing, and Aerodigestive Functions in Infants: A Burning Platform That Needs Attention! J Pediatr 2019; 211:7-9. [PMID: 31176454 DOI: 10.1016/j.jpeds.2019.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/10/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Sudarshan R Jadcherla
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
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Casar Berazaluce AM, Gibbons AT, Hanke RE, Ponsky TA, Harmon CM. It Is a Wrap! Or Is It?: The Role of Fundoplication in Infant Feeding Intolerance. J Laparoendosc Adv Surg Tech A 2019; 29:1315-1319. [PMID: 31264917 DOI: 10.1089/lap.2019.0076] [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: 11/12/2022] Open
Abstract
Purpose: Fundoplication is one of the most common procedures performed by pediatric surgeons, frequently for gastroesophageal reflux with feeding intolerance. No consensus exists in its management, with multiple institutions opting for medical therapy over surgical intervention. Methods: A case-based survey was administered at a national pediatric surgery conference. Clinical vignettes described former-premature infants with reflux and feeding intolerance with or without failure to thrive (FTT), neurological impairment, complex cardiopathy, and respiratory symptoms. Odds ratios (ORs) for fundoplication were calculated from participants' responses. Results: Surgeons elected to perform fundoplication in 14%-74% of cases. The OR for performing fundoplication in the presence of FTT was 1.84 (confidence interval [CI] 1.34-2.54, P = .0002) overall, achieving significance in subgroup analysis for cardiopathy (OR 3.56, CI 1.88-6.71, P = .0001) and neurological impairment (OR 1.79, CI 1.04-3.07, P = .04), but not in the absence of these comorbidities (OR 1.05, CI 0.61-1.83, P = .86). The OR for fundoplication in the presence of neurological impairment was 1.97 (CI 1.34-2.90, P = .0005) and that for cardiopathy was 1.70 (CI 1.20-2.40, P = .003), independent of FTT status. In subgroup analysis, the greatest predictors for fundoplication were neurological impairment with FTT (OR 2.63, CI 1.55-4.48, P = .0004) and complex cardiopathy with FTT and cough/syncope (OR 7.14, CI 4.05-12.58, P < .0001). Presence of cardiopathy without FTT had the overall lowest odds of fundoplication (OR 0.40, CI 0.21-0.78, P = .006). Conclusion: Surgeons tend to perform fundoplication in the presence of FTT and other comorbidities, particularly when these are concurrent. Respiratory symptoms are a strong predictor for fundoplication in patients with complex cardiopathies.
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Affiliation(s)
- Alejandra M Casar Berazaluce
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander T Gibbons
- Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Rachel E Hanke
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd A Ponsky
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Carroll M Harmon
- Department of Surgery, Division of Pediatric Surgery, Kaleida Health, John R. Oishei Children's Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Nobile S, Marchionni P, Noviello C, Carnielli VP. Correlation between cardiorespiratory events and gastro-esophageal reflux in preterm and term infants: Analysis of predisposing factors. Early Hum Dev 2019; 134:14-18. [PMID: 31112857 DOI: 10.1016/j.earlhumdev.2019.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The association between cardiorespiratory events (CRE) and gastro-esophageal reflux (GER) among neonates is still controversial. AIMS To test such an association in preterm and term infants. STUDY DESIGN Prospective observational study. SUBJECTS Forty-seven infants with suspected GER and recurrent CRE admitted at a neonatal intensive care unit, who underwent simultaneous and synchronized 24-hour recording of heart rate (HR), peripheral oxygen saturation (SpO2) and pH-impedance monitoring (MII-pH). HR/SpO2 data were filtered to avoid artefactual episodes of hypoxia and hypoperfusion. OUTCOME MEASURES The main outcome measure was the symptom association probability (SAP), with a 2-minute time window. Infants with positive (>95%) and negative (≤95%) SAP index tests were compared by univariate and multivariate statistics. RESULTS Median gestational age at birth was 294/7 weeks, median age at study 36 days. We recorded 3341 GER events and 4936 CRE (4710 desaturations, 226 bradycardias); 609/4936 (12%) CRE were temporally associated with GER episodes: 338 preceded and 271 followed GER events. The SAP index was significant in 5/47 (11%) patients. The SAP index including only CRE following GER events was significant in 3/47 (6%). There was no significant difference in the number of acid, weakly acid, non-acid, pH-only events preceding or following CRE between infants with SAP-positive and SAP-negative tests. Infants with positive SAP-index tests compared to those with SAP-negative tests had lower weight gain in the three days preceding the test and tended to have lower birth weight. CONCLUSIONS GER and CRE were associated in <11% of patients. The evaluation of ponderal growth might be helpful in predicting such an association.
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Affiliation(s)
- S Nobile
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy; Department of Woman and Child Health and Public Health, Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy.
| | - P Marchionni
- Department of Industrial Engineering and Mathematical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - C Noviello
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | - V P Carnielli
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
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Gulati IK, Jadcherla SR. Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Infant: Who Needs to Be Treated and What Approach Is Beneficial? Pediatr Clin North Am 2019; 66:461-473. [PMID: 30819348 PMCID: PMC6400306 DOI: 10.1016/j.pcl.2018.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastroesophageal reflux (GER) and GER disease (GERD) pertaining to infants in the neonatal intensive care unit (NICU) are reviewed, based on research in this specific population. The developmental biology of the gastroesophageal junction, physiology of GER, and pathophysiology of GERD in this setting are summarized, and risk factors for GER and GERD identified. The epidemiology, economic burden, and controversies surrounding GERD in NICU infants are addressed, and an approach to GER and GERD in these patients formulated. Recent advancements in individual assessment of GER and GERD in the NICU infant are examined, and evidence-based guidelines for their adoption provided.
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Affiliation(s)
- Ish K Gulati
- Innovative Research Program in Neonatal Feeding Disorders; The Neonatal and Infant Feeding Disorders Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Research Program in Neonatal Feeding Disorders; The Neonatal and Infant Feeding Disorders Program, Nationwide Children's Hospital, Columbus, OH, USA; Division of Neonatology, Department of Pediatrics, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 575 Children's Cross Roads, Columbus, OH 43215, USA; Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 575 Children's Cross Roads, Columbus, OH 43215, USA.
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Collins CR, Hasenstab KA, Nawaz S, Jadcherla SR. Mechanisms of Aerodigestive Symptoms in Infants with Varying Acid Reflux Index Determined by Esophageal Manometry. J Pediatr 2019; 206:240-247. [PMID: 30466790 PMCID: PMC6389384 DOI: 10.1016/j.jpeds.2018.10.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To test whether symptom generation in infants is related to the severity of gastroesophageal reflux disease (GERD) symptoms as determined by the Acid Reflux Index (ARI), stimulus media, and stimulus volume during provocative esophageal manometry. STUDY DESIGN Symptomatic neonates (n = 74) born at a median of 28.9 weeks gestation (range, 23.4-39.4 weeks) were studied at a median of 41.0 weeks (range, 34.6-48.0 weeks) postmenstrual age using 24-hour pH-impedance methods to determine ARI severity, followed by provocative esophageal manometry with graded mid-esophageal infusions (0.1-5.0 mL) of air, water, and apple juice. Peristaltic reflexes and symptom characteristics were compared among ARI severity categories using linear mixed models and generalized estimating equations. RESULTS The effects of 2635 separate esophageal stimuli on reflexes and symptoms were analyzed. Peristaltic reflexes occurred in 1880 infusions (71%), and physical, cardiorespiratory, sensory symptoms were seen in 439 infusions (17%). Symptom prevalence did not differ across the ARI severity categories (ARI <3, 18%; ARI 3-7, 17%; ARI >7, 16%; P = 1.0). Symptom and peristaltic responses increased with incremental stimulus volumes (all media, P < .001). CONCLUSIONS Symptoms and peristaltic reflexes are manifestations of the recruitment of several neurosensory and neuromotor pathways evoked by mid-esophageal infusions. ARI severity grade plays no role in symptom generation, indicating that GERD should not be diagnosed and severity should not be assigned based on symptoms alone. An increase in symptom occurrence was noted with increasing stimulus volumes, which provided increased activation of receptors, afferents, and efferents in evoking peristaltic clearance reflexes.
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Affiliation(s)
- Carissa R. Collins
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Saira Nawaz
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Center for Perinatal Research, Division of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Jadcherla SR, Hanandeh N, Hasenstab KA, Nawaz S. Differentiation of esophageal pH-impedance characteristics classified by the mucosal integrity marker in human neonates. Pediatr Res 2019; 85:355-360. [PMID: 30467343 PMCID: PMC6377827 DOI: 10.1038/s41390-018-0237-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/22/2018] [Accepted: 10/24/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND In adults, distal baseline impedance (BI) is a determinant of esophageal mucosal integrity with values <900 Ω indicating inflammation. Relationships between acid gastroesophageal reflux (GER) and BI in neonates are unclear. METHODS NICU infants (N = 198, 30.4 ± 0.3 weeks gestation) were evaluated at 43 ± 0.4 weeks postmenstrual age using 24-h pH-impedance. Ten randomly selected 1-min windows during rest from the distal impedance channel (Z6) were averaged. Chi-square, t-tests, and ANOVA were used to compare pH-impedance and symptom characteristics by BI severity (BI < 900 Ω, BI 900-2000 Ω, BI > 2000 Ω). Regression analysis was used to identify potential contributing factors of BI. RESULTS In BI < 900 Ω: (1) pH-impedance characteristics were increased (acid reflux event frequency, duration, and severity, all P < 0.05 vs. BI > 2000 Ω), and (2) positive symptom correlations were noted with bolus (73%) and acid events (55%). Significant predictors of BI included chronological age, acid reflux index, and BPD diagnosis (all P < 0.05). CONCLUSIONS Low BI is associated with prolonged acid exposure, delayed clearance, and greater aerodigestive symptom prevalence, likely associated with inflammation and or increased mucosal permeability. BI > 2000 Ω likely involves little or no inflammation because acid exposure is minimal. Combination of SAP, pH-impedance metrics, and BI along with the clarification of dysmotility mechanisms provides the rationale for personalized anti-reflux therapies as needed.
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Affiliation(s)
- Sudarshan R. Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH,Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
| | - Nour Hanandeh
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Kathryn A Hasenstab
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Saira Nawaz
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
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Jadcherla SR. Understanding the neonatal oesophageal mysteries of gastro-oesophageal reflux disease using baseline impedance. Acta Paediatr 2018; 107:1486-1487. [PMID: 29883517 DOI: 10.1111/apa.14402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sudarshan R Jadcherla
- Professor of Pediatrics & Associate Division Chief of Neonatology, Academics, Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, The Neonatal and Infant Feeding Disorders Program, Innovative Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Rossor T, Lingam I, Douiri A, Bhat R, Greenough A. Detection of gastro-oesophageal reflux in the neonatal unit. Acta Paediatr 2018; 107:1535-1540. [PMID: 29532506 DOI: 10.1111/apa.14315] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/29/2018] [Accepted: 03/07/2018] [Indexed: 12/17/2022]
Abstract
AIM To determine whether a pH probe or multichannel intraluminal impedance (MII) more frequently detected gastro-oesophageal reflux and test the hypothesis that acid reflux was associated with lower baseline impedance. METHODS A prospective study of infants in whom reflux was suspected and evaluated using combined pH and multichannel impedance. Studies were considered abnormal if the acid index was >10% or there were >79MII reflux events in 24 hours. The acid index was the percentage of total study time with a pH RESULTS Forty-two infants [median gestational age 31 (range 23-42) weeks] were assessed. Only nine infants (21%) had abnormal studies, seven detected by pH monitoring, one by MII monitoring and one by both techniques (p = 0.04). After correcting for gestational age and post-natal age, baseline impedance remained negatively correlated with the acid index (r = -0.34, p = 0.038) and the maximum ACT (r = -0.44, p = 0.006). CONCLUSION Clinical suspicion of reflux was frequently incorrect, and reflux was more frequently detected by a pH probe. The inverse relationship of acid reflux to baseline impedance suggests that mucosal disruption may result from acid reflux in this population.
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Affiliation(s)
- Thomas Rossor
- MRC Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ingran Lingam
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Abdel Douiri
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- MRC Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
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Eichenwald EC, Cummings JJ, Aucott SW, Goldsmith JP, Hand IL, Juul SE, Poindexter BB, Puopolo KM, Stewart DL. Diagnosis and Management of Gastroesophageal Reflux in Preterm Infants. Pediatrics 2018; 142:peds.2018-1061. [PMID: 29915158 DOI: 10.1542/peds.2018-1061] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Gastroesophageal reflux (GER), generally defined as the passage of gastric contents into the esophagus, is an almost universal phenomenon in preterm infants. It is a common diagnosis in the NICU; however, there is large variation in its treatment across NICU sites. In this clinical report, the physiology, diagnosis, and symptomatology in preterm infants as well as currently used treatment strategies in the NICU are examined. Conservative measures to control reflux, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of GER in the preterm infant. In addition, preterm infants with clinically diagnosed GER are often treated with pharmacologic agents; however, a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in preterm infants.
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Affiliation(s)
| | - James J. Cummings
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Wright Aucott
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay P. Goldsmith
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ivan L. Hand
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandra E. Juul
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Karen M. Puopolo
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dan L. Stewart
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Cooper CA, Urso PP. Gastroesophageal Reflux in the Intensive Care Unit Patient. Crit Care Nurs Clin North Am 2017; 30:123-135. [PMID: 29413207 DOI: 10.1016/j.cnc.2017.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The incidence of gastroesophageal reflux disease (GERD) in the critically ill patient in the intensive care unit is unknown. Interventions used in critically ill patients, such as sedation, tracheal tubes, mechanical ventilation, enteral feedings, positioning, and medications, along with specific patient characteristics and comorbid conditions contribute to an increased risk for gastroesophageal reflux (GER) in this population. Critical care nurses have an integral role in helping identify critically ill patients at risk for GER or with known GERD, in preventing complications associated with these conditions.
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Affiliation(s)
- Cathy A Cooper
- Middle Tennessee State University, School of Nursing, 1301 East Main Street, Murfreesboro, TN 37132, USA.
| | - Patti P Urso
- Nursing Education, Walden University, School of Nursing, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
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Pharmacological management of gastroesophageal reflux disease in infants: current opinions. Curr Opin Pharmacol 2017; 37:112-117. [DOI: 10.1016/j.coph.2017.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
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Abstract
RATIONALE Tracheobronchomalacia is a common comorbidity in neonates with bronchopulmonary dysplasia. However, the effect of tracheobronchomalacia on the clinical course of bronchopulmonary dysplasia is not well-understood. OBJECTIVE We sought to assess the impact of tracheobronchomalacia on outcomes in neonates with bronchopulmonary dysplasia in a large, multi-center cohort. METHODS We preformed a cohort study of 974 neonates with bronchopulmonary dysplasia admitted to 27 neonatal intensive care units participating in the Children's Hospital Neonatal Database who had undergone bronchoscopy. In hospital morbidity for neonates with bronchopulmonary dysplasia and tracheobronchomalacia (N=353, 36.2%) was compared to those without tracheobronchomalacia (N=621, 63.8%) using mixed-effects multivariate regression. RESULTS Neonates with tracheobronchomalacia and bronchopulmonary dysplasia had more comorbidities, such as gastroesophageal reflux (OR=1.65, 95%CI 1.23- 2.29, P=0.001) and pneumonia (OR=1.68, 95%CI 1.21-2.33, P=0.002) and more commonly required surgeries such as tracheostomy (OR=1.55, 95%CI 1.15-2.11, P=0.005) and gastrostomy (OR=1.38, 95%CI 1.03-1.85, P=0.03) compared with those without tracheobronchomalacia. Neonates with tracheobronchomalacia were hospitalitized (118 ± 93 vs 105 ± 83 days, P=0.02) and ventilated (83.1 ± 91.1 vs 67.2 ± 71.9 days, P=0.003) longer than those without tracheobronchomalacia. Upon discharge, neonates with tracheobronchomalacia and BPD were more likely to be mechanically ventilated (OR=1.37, 95CI 1.01-1.87 P=0.045) and possibly less likely to receive oral nutrition (OR=0.69, 95%CI 0.47-1.01, P=0.058). CONCLUSIONS Tracheobronchomalacia is common in neonates with bronchopulmonary dysplasia who undergo bronchoscopy and is associated with longer and more complicated hospitalizations.
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Effects of Esophageal Acidification on Troublesome Symptoms: An Approach to Characterize True Acid GERD in Dysphagic Neonates. Dysphagia 2017; 32:509-519. [PMID: 28365873 DOI: 10.1007/s00455-017-9792-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
To quantify and compare maximal extent (height) of acid reflux events (AREs) on symptom generation in dysphagic neonates. Dysphagic neonates (N = 53), born at 30 ± 5.3 weeks gestation, underwent 24-hour pH-impedance study for the evaluation of troublesome symptoms purported to be due to gastroesophageal reflux disease (GERD). AREs (pH < 4 for >4 s) detected by impedance (Z) were categorized by maximal extent as refluxate reaching distal (Z6, Z5), middle (Z4, Z3), or proximal (Z2, Z1) impedance channels. AREs reaching the pH sensor only were categorized as distal. Symptom correlation (%, symptom index, symptom sensitivity index, and symptom associated probability) and temporal characteristics (clearance times) of AREs were analyzed using linear mixed and GEE models comparing height categories presented as mean ± SEM, median (IQR), and OR (95% CI). Of the 2003 AREs, 1) distal extent AREs (n = 1642) had increased frequency (p < 0.05), decreased ACT (p < 0.05), and decreased acidity (p < 0.05); 2) in middle and proximal AREs, acid clearance was longer than bolus clearance, (p < 0.01); and 3) the odds of having cardiorespiratory (cough or sneeze) symptoms are increased with proximal and middle AREs (p < 0.05). Most proximal ascent of AREs into middle or proximal esophagus likely activates protective aerodigestive reflexes (peristalsis) or vigilant states to facilitate bolus and chemical clearance. Heightened esophageal sensitivity, acid neutralization delays, or clearance mechanism delays may accentuate multi-systemic troublesome symptoms.
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Sankaran J, Qureshi AH, Woodley F, Splaingard M, Jadcherla SR. Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events. J Pediatr 2016; 179:42-48.e1. [PMID: 27692861 PMCID: PMC5206757 DOI: 10.1016/j.jpeds.2016.08.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/01/2016] [Accepted: 08/19/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state. STUDY DESIGN Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state. RESULTS Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups. CONCLUSIONS Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.
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Affiliation(s)
- Janani Sankaran
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide sChildren’s Hospital, Columbus, Ohio
| | - Aslam H. Qureshi
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide sChildren’s Hospital, Columbus, Ohio
| | - Frederick Woodley
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
| | - Mark Splaingard
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,Division of Pulmonary Medicine, Sleep Laboratory, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sudarshan R Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Pediatric Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.
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D’Agostino JA, Passarella M, Martin AE, Lorch SA. Use of Gastroesophageal Reflux Medications in Premature Infants After NICU Discharge. Pediatrics 2016; 138:peds.2016-1977. [PMID: 27940703 PMCID: PMC5127072 DOI: 10.1542/peds.2016-1977] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To describe the epidemiology and management of gastroesophageal reflux (GER) medications started in the first year of life for premature infants. METHODS Retrospective review of a cohort of infants ≤35 weeks' gestation presenting for care by 168 days of age to a 30-site network between 2005 and 2009 (n = 2217) and followed to 3 years of age. Medication frequency, types, and duration of use were assessed. Logistic regression identified factors associated with treatment. RESULTS Thirty-seven percent (812) were prescribed GER medications with 77% begun after NICU discharge. Ninety percent (727) received histamine-2 receptor antagonists, 33% (269) proton pump inhibitors, 22% (182) prokinetics; 40% (325) received >1 medication. Outpatient medication was initiated at 95 ± 69 days of life for total of 294 ± 249 days (interquartile ratio: 117-359). Feeding issues (adjusted odds ratio [aOR] 2.05, 95% confidence interval [CI]: 1.24-3.39) were associated with outpatient initiation. Forty-three percent (322) of infants started before 6 months were still on at 1 year of age associated with gestational age <32 weeks (aOR 1.76, 95% CI: 1.16-2.67), chronic lung disease (aOR 2.59, 95% CI: 1.29-5.22), and reactive airways disease (aOR 1.67, 95% CI: 1.05-2.65). CONCLUSIONS Of the 37% of the cohort on GER medications, 77% were started after NICU discharge with prolonged use of medications. Feeding difficulties were associated with starting medication and markers of chronic lung disease with continuation of treatment. With uncertain evidence of efficacy, use of these medications in a high-risk population should be carefully evaluated.
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Affiliation(s)
- Jo Ann D’Agostino
- Department of Pediatrics,,Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Molly Passarella
- Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Ashley E. Martin
- Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Scott A. Lorch
- Department of Pediatrics,,Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,The University of Pennsylvania School of Medicine and,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Neonatal Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Treatment at United States Children's Hospitals. J Pediatr 2016; 174:63-70.e3. [PMID: 27131401 PMCID: PMC4925209 DOI: 10.1016/j.jpeds.2016.03.059] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/23/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine treatment frequency and duration of histamine-2 receptor antagonist (H2RA)/proton pump inhibitor (PPI) use among infants hospitalized within US children's hospital neonatal intensive care units and evaluate diagnoses/demographic factors associated with use. STUDY DESIGN We retrospectively analyzed a cohort of neonatal intensive care unit infants admitted to 43 US children's hospitals within the Pediatric Health Information System database between January 2006 and March 2013 to determine H2RA/PPI treatment frequency, timing/duration of treatment, factors associated with use, percent of infants remaining on treatment at discharge, and interhospital prescribing variation. We used a modified Poisson regression to calculate the adjusted probability of infants ever receiving H2RAs/PPIs in relation to diagnosis, gestation, and sex. RESULTS Of the 122 002 infants evaluated, 23.8% (n = 28 989) ever received an H2RA or PPI; 19.0% received H2RAs (n = 23 187), and 10.5% (n = 12 823) received PPIs. Extremely preterm infants and term infants were the most likely to receive H2RA and PPI treatment. Infants with gastroesophageal reflux disease (relative risk [RR] = 3.13) and congenital heart disease (RR = 2.41) had the highest H2RA/PPI treatment probabilities followed by those with an ear, nose, and throat diagnosis (RR = 2.34; P < .05). The majority of treated infants remained treated at discharge. CONCLUSIONS Despite limited evidence and increasing safety concerns, H2RAs/PPIs are frequently prescribed to extremely preterm neonates and those with congenital anomalies and continued through discharge. Our findings support the need for innovative studies to examine the comparative effectiveness and safety of H2RA/PPIs vs no treatment in these high-risk neonatal populations.
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The Role of Sleep in the Modulation of Gastroesophageal Reflux and Symptoms in NICU Neonates. Pediatr Neurol 2015; 53:226-32. [PMID: 26149107 PMCID: PMC4590781 DOI: 10.1016/j.pediatrneurol.2015.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/22/2015] [Accepted: 05/23/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Newborns sleep about 80% of the time. Gastroesophageal reflux disease is prevalent in about 10% of neonatal intensive care unit infants. Concurrent polysomnography and pH-impedance studies clarify the relationship of gastroesophageal reflux with sleep. AIMS To characterize spatiotemporal and chemical characteristics of impedance-positive gastroesophageal reflux and define symptom associations in sleep and wake states in symptomatic neonates. We hypothesized that frequency of impedance-positive gastroesophageal reflux events and their association with cardiorespiratory symptoms is greater during sleep. METHODS Eighteen neonates underwent concurrent polysomnography with a pH-impedance study. Impedance-positive gastroesophageal reflux events (weakly acidic or acidic) were categorized between sleep versus wake states: Symptom Index = number of symptoms with gastroesophageal reflux/total symptoms*100; Symptom Sensitivity Index = number of gastroesophageal reflux with symptoms/total gastroesophageal reflux*100; Symptom Association Probability = [(1 - probability of observed association between reflux and symptoms)*100]). RESULTS We analyzed 317 gastroesophageal reflux events during 116 hours of polysomnography. During wake versus sleep, respectively, the median (interquartile range) frequency of impedance-positive gastroesophageal reflux was 4.9 (3.1-5.8) versus 1.4 (0.7-1.7) events/hour (P < 0.001) and the proximal migration was 2.6 (0.8-3.3) versus 0.2 (0.0-0.9) events/hour (P < 0.001). The Symptom Index for cardiorespiratory symptoms for impedance-positive events was 22.5 (0-55.3) versus 6.1 (0-13), P = 0.04, whereas the Symptom Sensitivity Index was 9.1 (0-23.1) versus 18.4 (0-50), P = 0.04, although Symptom Association Probability was similar (P = 0.68). CONCLUSIONS Contrary to our hypothesis, frequency of gastroesophageal reflux in sleep is lower; however, spatiotemporal and chemical characteristics of gastroesophageal reflux and symptom-generation mechanisms are distinct. For cardiorespiratory symptoms during sleep, a lower Symptom Index entails evaluation for etiologies other than gastroesophageal reflux disease, a higher Symptom Sensitivity Index implies heightened esophageal sensitivity, and similar Symptom Association Probability indicates other mechanistic possibilities.
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Jadcherla SR, Dail J, Malkar MB, McClead R, Kelleher K, Nelin L. Impact of Process Optimization and Quality Improvement Measures on Neonatal Feeding Outcomes at an All-Referral Neonatal Intensive Care Unit. JPEN J Parenter Enteral Nutr 2015; 40:646-55. [DOI: 10.1177/0148607115571667] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/18/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Sudarshan R. Jadcherla
- The Neonatal and Infant Feeding Disorders Program
- Center for Perinatal Research
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - James Dail
- Neonatal Quality Improvement Service, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Manish B. Malkar
- The Neonatal and Infant Feeding Disorders Program
- Center for Perinatal Research
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Richard McClead
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Neonatal Quality Improvement Service, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Kelly Kelleher
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Innovative Pediatric Health, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Leif Nelin
- Center for Perinatal Research
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Singendonk MMJ, Rommel N, Omari TI, Benninga MA, van Wijk MP. Upper gastrointestinal motility: prenatal development and problems in infancy. Nat Rev Gastroenterol Hepatol 2014; 11:545-55. [PMID: 24890279 DOI: 10.1038/nrgastro.2014.75] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Deglutition, or swallowing, refers to the process of propulsion of a food bolus from the mouth into the stomach and involves the highly coordinated interplay of swallowing and breathing. At 34 weeks gestational age most neonates are capable of successful oral feeding if born at this time; however, the maturation of respiration is still in progress at this stage. Infants can experience congenital and developmental pharyngeal and/or gastrointestinal motility disorders, which might manifest clinically as gastro-oesophageal reflux (GER) symptoms, feeding difficulties and/or refusal, choking episodes and airway changes secondary to micro or overt aspiration. These problems might lead to impaired nutritional intake and failure to thrive. These gastrointestinal motility disorders are mostly classified according to the phase of swallowing in which they occur, that is, the oral preparatory, oral, pharyngeal and oesophageal phases. GER is a common phenomenon in infancy and is referred to as GERD when it causes troublesome complications. GER is predominantly caused by transient relaxation of the lower oesophageal sphincter. In oesophageal atresia, oesophageal motility disorders develop in almost all patients after surgery; however, a congenital origin of disordered motility has also been proposed. This Review highlights the prenatal development of upper gastrointestinal motility and describes the most common motility disorders that occur in early infancy.
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Affiliation(s)
- Maartje M J Singendonk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Nathalie Rommel
- Department of Neurosciences, ExpORL, KU Leuven, O&N II Herenstraat 49, Box 721, 3000 Leuven, Belgium
| | - Taher I Omari
- Gastroenterology Unit, Women's and Children's Health Network, 72 King William Street, 5006 SA, Australia
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Michiel P van Wijk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Hasenstab KA, Jadcherla SR. Respiratory events in infants presenting with apparent life threatening events: is there an explanation from esophageal motility? J Pediatr 2014; 165:250-255.e1. [PMID: 24681180 PMCID: PMC4112005 DOI: 10.1016/j.jpeds.2014.02.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/10/2014] [Accepted: 02/03/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To test the hypothesis that proximal aerodigestive clearance mechanisms mediated by pharyngoesophageal motility during spontaneous respiratory events (SREs) are distinct in infants with apparent life threatening events (ALTEs). STUDY DESIGN Twenty infants (10 with proven ALTE, 10 healthy controls) had pharyngoesophageal manometry to investigate motility changes concurrent with respiratory events detected by respiratory inductance plethysmography and nasal thermistor methods. We measured changes in resting upper esophageal and lower esophageal sphincter pressures, esophageal peristalsis characteristics, and gastroesophageal reflux. Statistical analysis included mixed models; data presented as mean±SD, median (range), or percentage. RESULTS Infants with ALTE (vs controls) had: (1) delays in restoring aerodigestive normalcy as indicated by more frequent (P=.03) and prolonged SREs (P<.01); (2) a lower magnitude of protective upper esophageal sphincter contractile reflexes (P=.01); (3) swallowing as the most frequent esophageal event associated with SREs (84%), with primary peristalsis as the most prominent aerodigestive clearance mechanism (64% vs 38%, P<.01); (4) a higher proportion of failed esophageal propagation (10% vs 0%, P=.02); and (5) more frequent mixed apneic mechanisms (P<.01) and more gasping breaths (P=.04). CONCLUSIONS In infants with ALTE, prolonged SREs are associated with ineffective esophageal motility characterized by frequent primary peristalsis and significant propagation failure, thus suggestive of dysfunctional regulation of swallow-respiratory junction interactions. Hence, treatment should not target gastroesophageal reflux, but rather the proximal aerodigestive tract.
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Affiliation(s)
- Kathryn A Hasenstab
- Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus, OH
| | - Sudarshan R Jadcherla
- Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus, OH; Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.
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