Gastroesophageal reflux (GER) is defined as spontaneous return of gastric contents into the esophagus. It may be regurgitant, with gastric material appearing in the mouth, or non-regurgitant. Non-regurgitant GER may be less obvious, but adverse outcomes may still be present.
Gastroesophageal reflux (GER) and/or aspiration risk appears to be higher in VLBW and LBW infants. While many families report that their infants "spit up," reports of "spitting up" in a preterm infant should not be dismissed out of hand. Pathological reflux or GER disease may be associated with poor growth, esophagitis, irritability, intractable crying, feeding aversions, and respiratory symptoms. Feeding problems due to early experiences with GER may persist beyond the time of resolution of the GER. Aspiration can be a consequence of GER that causes special concern.
In parental focus groups, GER was a common topic brought up by parents. Please see section on What Parents say about Feeding Preterm Infants. It was not uncommon for families to speak of GER type symptoms that impacted feeding and remained undiagnosed for significant periods of time.
It appears reasonable to screen each LBW infant frequently in the first months of life to rule out need for further assessment for GER and/or aspiration.
For more information see Feeding and Swallowing Disorders in Infancy by Wolf and Glass.
Feranchak and colleagues (1994) examined behaviors of infants who were undergoing esophageal pH monitoring. Documented episodes of reflux were frequently associated with the following behaviors: discomfort as evidenced by crying or frowning, regurgitation, drooling, burping, yawning, stridor, stretching, and mouthing. Some behaviors were only found in some infants. These included hiccupping, sneezing, thumb-sucking, coughing or gagging.
Other behaviors that have been associated with reflux include gagging, coughing, and repeated swallowing between meals, red, teary eyes, and fussiness and irritability 30 to 60 minutes after a feeding. These symptoms can occur for other reasons, which should be ruled out.
Orenstein et al (1993) developed and validated a parental questionnaire that can be used clinically to assess the likelihood of GER. The entire questionnaire is provided in the August 1993 issue of Clinical Pediatrics.
This group used the questionnaire to compare 35 infants with gastroesophageal reflux disease as documented by pH probe or esophageal suction biopsy and 100 "normal" infants. See Orenstien et al (1996). Some infant behaviors as reported by parents were highly associated with positive diagnosis of GER. These were:
If infant behaviors, growth, and parental report seem to indicate that reflux in an infant is pathological, further investigation is warranted.
The pH probe is considered the "gold standard" for diagnosis of GER. A probe is inserted into an area just above the lower esophageal sphincter. The test is usually done over a 24-hour period and requires a hospital stay. Readings of pH are recorded over the testing period. Data may include total number of episodes with pH <4.0, total time with pH <4.0, number of episodes greater than 5 minutes, and the longest episodes. A reflux score is calculated and compared to normal values to make the diagnosis of reflux. Reflux that occurs immediately following a meal may be missed with the pH probe if the acidity of gastric contents is not below a pH of 4.
The infant is given a feeding that contains a radiopharmaceutical that will allow visualization of the position of labeled materials every 30 seconds. This method will pick up less acidic material that may reflux to the esophagus, and may also detect aspiration of gastric contents into the bronchial tree.
This intervention is a mainstay of non-invasive treatment for GER. Positive benefits are thought to be due to the effects of gravity as well as changes in lower esophageal sphincter (LES) pressure. Positioning changes are usually individualized. Frequently suggested changes include:
Infants who receive large volumes at one time seem to be at higher risk of GER. Smaller, more frequent feeds may be helpful.
While the addition of cereal to infant feedings to thicken them and reduce episodes of reflux has been a traditional approach to this problem, this approach to the treatment of GER is controversial.
Surgery is usually reserved for only the most difficult cases of well-documented GER that is accompanied by serious effects. There are several surgical procedures that may be used. The goal of surgery is to tighten the lower esophageal sphincter so that stomach contents cannot easily enter the esophagus. The immediate and long term results of GER surgery are variable.