Gastroesophageal Reflux: A Critical Review of Its Role in Preterm Infants

Title: Gastroesophageal Reflux: A Critical Review of Its Role in Preterm Infants

Author: Christian F. Poets, M

Published: Pediatrics Vol. 113 No. 2 February 2004

Summary Information:
The author states: "GER is common in infants, which is related to their large fluid intake (corresponding to 14 L/day in an adult) and supine body position, resulting in the gastroesophageal junction's being constantly "under water." pH monitoring, the standard for reflux detection, is of limited use in preterm infants whose gastric pH is >4 for 90% of the time."

The author states "After the recent withdrawal of cisapride, there is now increasing interest in the use of erythromycin, which binds to neural motilin receptors and stimulates antral contractions and, in lower doses, induces antral migrating motor complexes, which are important for gastric emptying (8)."

The author also calls into question the use of Pro-kinetics.

The author states "Gastroesophageal reflux (GER) is common in preterm infants, occurring on average 3 to 5 tmes per hour (1,2), but to what extent is it a clinical problem? A recent survey of current practice estimated that 19% of preterm infants admitted to U.S. teaching hospitals received cisapride(3). Thus, many neonatologists seem to consider GER indeed a problem, but what is the evidence?"

In Pathogenesis of GER in Infants the author states "Reflux may occur when the lower esophageal sphincter relaxes. In an upright adult, gas will exit the stomach during these transient lower esophageal sphincter relaxations (TLESRs), causing belching. In a subject lying supine, however, the gastroesophageal junction is constantly under water, and liquid instead of gas will enter the esophagus. The quantity of the reflux depends on the fluid volume inside the stomach. The volume of fluid given to an infant (180 mL/kg per day) would correspond to a daily intake of ~14 L/day in an adult. GER, in an otherwise healthy infant may simply serve as a pop-off valve to cope with this high volume (4)."

The author states in the Apnea section "Problems that are frequently cited in conjunction with GER are apnea, failure to thrive, and airway problems such as recurrent aspiration or wheezing (26)."

Evidence from animal studies "show that apnea can be induced by the instillation of small amounts of liquid into the larynx, resulting in stimulation of laryngeal chemoreceptors (28), and the observation that apneas are mor likely to occur after episodes of regurgitation (29)."

The author states "Several issues remain unclear from these studies. First, assuming a causal relationship, is GER cause or effect of the respiratory symptoms, i.e., does it result in airway narrowing via stimulation of airway receptors and/or recurrent aspiration, or do the large intrathoracic pressure swings caused by the upper airway narrowing facilitate GER? Although the respiratory response to GER treatment described above supports the first option, it cannot prove it."

the author concludes "Thus, despite the above data from older infants, there is currently no evidence that GER is a significant contributor to chronic airway problems in preterm infants. Why then treat it?"