Skip to main content

Gastro-Esophageal Reflux in Neonatology

  • Chapter
  • First Online:
Nutrition for the Preterm Neonate
  • 1868 Accesses

Abstract

Gastro-esophageal reflux (GER) is a near universal phenomenon in newborn infants. Regurgitation is so frequent that its complete absence may be considered as evidence of inadequate milk intake. GER occurs usually in association with transient relaxations of the lower esophageal sphincter, which may be triggered by entry of milk into the stomach, and is not associated with delayed gastric emptying. GER can be quantified using monitoring techniques which require prolonged presence of a foreign body in the esophagus. Either just pH (for possible complications related to acid exposure) monitoring or pH with multiple intraluminal impedance monitoring are available. Other investigations are rarely helpful. The definitions and diagnostic criteria of GER disease (GERD) are controversial and there is no consensus regarding which clinical signs may be caused by GER. In particular behavioural changes, feeding difficulties and significant apnea have not been clearly shown to be increased in infants with higher frequency of GER episodes, or to be temporally related to them. Prokinetic agents are ineffective. Anti-acid medications may effectively reduce gastric acid production, but have not been shown to improve clinical symptoms, and are associated with increased infectious risk, and may reduce the absorption of some micronutrients. In cases of acid related disease a therapeutic trial may be indicated if the benefits are thought to outweigh the risks. Reflux spontaneously improves over time in the preterm infant, but may be prolonged in those with surgical conditions such as esophageal atresia and diaphragmatic hernia.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Wenzl TG, Silny J, Schenke S, Peschgens T, Heimann G, Skopnik H (1999) Gastroesophageal reflux and respiratory phenomena in infants: status of the intraluminal impedance technique. J Pediatr Gastroenterol Nutr 28(4):423–428

    Article  PubMed  CAS  Google Scholar 

  2. Jeffery HE, Page M (1995) Developmental maturation of gastro-oesophageal reflux in preterm infants. Acta Pædiatrica 84(3):245–250

    Article  PubMed  CAS  Google Scholar 

  3. Kelly EJ, Newell SJ, Brownlee KG, Primrose JN, Dear PRF (1993) Gastric acid secretion in preterm infants. Early Hum Dev 35(3):215–220

    Article  PubMed  CAS  Google Scholar 

  4. Luthold SC, Rochat MK, Bahler P (2010) Disagreement between symptom-reflux association analysis parameters in pediatric gastroesophageal reflux disease investigation. World J Gastroentero: WJG 16(19):2401–2406

    Article  Google Scholar 

  5. Lopez-Alonso M, Moya MJ, Cabo JA et al (2006) Twenty-four-hour esophageal impedance-pH monitoring in healthy preterm neonates: rate and characteristics of acid, weakly acidic, and weakly alkaline gastroesophageal reflux. Pediatrics 118(2):e299–e308

    Article  Google Scholar 

  6. Omari TI, Davidson GP (2003) Multipoint measurement of intragastric pH in healthy preterm infants. Arch Dis Child Fetal Neonatal Ed 88(6):F517–F520

    Article  PubMed  CAS  Google Scholar 

  7. Loots CM, Van Wijk MP, Smits MJ, Wenzl TG, Benninga MA, Omari TI (2011) Measurement of mucosal conductivity by MII Is a potential marker of mucosal integrity restored in infants on acid-suppression therapy. J Pediatr Gastroenterol Nutr 53(1):120–123

    Article  PubMed  Google Scholar 

  8. Di Fiore JM, Arko M, Churbock K, Hibbs AM, Martin RJ (2009) Technical limitations in detection of gastroesophageal reflux in neonates. J Pediatr Gastroenterol Nutr 49(2):177–182

    Article  PubMed  Google Scholar 

  9. Savino A, Cecamore C, Matronola M et al (2012) US in the diagnosis of gastroesophageal reflux in children. Pediatr Radiol 42(5):515–524

    Article  PubMed  Google Scholar 

  10. Jadcherla SR, Hoffmann RG, Shaker R (2006) Effect of maturation of the magnitude of mechanosensitive and chemosensitive reflexes in the premature human esophagus. J Pediatr 149(1):77–82

    Article  PubMed  Google Scholar 

  11. Peter CS, Wiechers C, Bohnhorst B, Silny J, Poets CF (2002) Influence of nasogastric tubes on gastroesophageal reflux in preterm infants: a multiple intraluminal impedance study. J Pediatr 141(2):277–279

    Google Scholar 

  12. Omari TI, Miki K, Davidson G et al (1997) Characterisation of relaxation of the lower oesophageal sphincter in healthy premature infants. Gut 40(3):370–375

    PubMed  CAS  Google Scholar 

  13. Omari TI, Barnett CP, Benninga MA et al (2002) Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease. Gut 51(4):475–479

    Article  PubMed  CAS  Google Scholar 

  14. Omari TI, Barnett C, Snel A et al (1998) Mechanisms of gastroesophageal reflux in healthy premature infants. J Pediatr 133(5):650–654

    Article  PubMed  CAS  Google Scholar 

  15. Omari TI, Rommel N, Staunton E et al (2004) Paradoxical impact of body positioning on gastroesophageal reflux and gastric emptying in the premature neonate. J Pediatr 145(2):194–200

    Article  PubMed  Google Scholar 

  16. Ewer AK, Durbin GM, Morgan MEI, Booth IW (1996) Gastric emptying and gastro-oesophageal reflux in preterm infants. Arch Dis Child 75(2 Sp. Iss.):F117–F121

    Article  CAS  Google Scholar 

  17. Kawahara H, Okuyama H, Nose K et al (2010) Physiological and clinical characteristics of gastroesophageal reflux after congenital diaphragmatic hernia repair. J Pediatr Surg 45(12):2346–2350

    Article  PubMed  Google Scholar 

  18. Legrand C, Michaud L, Salleron J et al (2012) Long-term outcome of children with oesophageal atresia type III. Arch Dis Child 97(9):808–811

    Article  PubMed  Google Scholar 

  19. Maier S, Zahn K, Wessel LM, Schaible T, Brade J, Reinshagen K (2011) Preventive antireflux surgery in neonates with congenital diaphragmatic hernia: a single-blinded prospective study. J Pediatr Surg 46(8):1510–1515

    Article  PubMed  Google Scholar 

  20. Maki M, Ruuska T, Kuusela AL, Karikoski-Leo R, Ikonen RS (1993) High prevalence of asymptomatic esophageal and gastric lesions in preterm infants in intensive care. Crit Care Med 21(12):1863–1867

    Article  PubMed  CAS  Google Scholar 

  21. Snel A, Barnett CP, Cresp TL et al (2000) Behavior and gastroesophageal reflux in the premature neonate. J Pediatr Gastroenterol Nutr 30:18–21

    Article  PubMed  CAS  Google Scholar 

  22. Moore DJ, Tao BS-K, Lines DR, Hirte C, Heddle ML, Davidson GP (2003) Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr 143(2):219–223

    Article  PubMed  CAS  Google Scholar 

  23. Farhath S, He Z, Nakhla T et al (2008) Pepsin, a marker of gastric contents, is increased in tracheal aspirates from preterm infants who develop bronchopulmonary dysplasia. Pediatrics 121(2):e253–e259

    Article  PubMed  Google Scholar 

  24. Akinola E, Rosenkrantz TS, Pappagallo M, McKay K, Hussain N (2004) Gastroesophageal reflux in infants < 32 weeks gestational age at birth: lack of relationship to chronic lung disease. Am J Perinatol 21(2):57–62

    Article  PubMed  Google Scholar 

  25. Mousa H, Woodley FW, Metheney M, Hayes J (2005) Testing the association between gastroesophageal reflux and apnea in infants. J Pediatr Gastroenterol Nutr 41(2):169–177

    Article  PubMed  Google Scholar 

  26. Barrington KJ, Tan K, Rich W (2002) Apnea at discharge and gastro-esophageal reflux in the preterm infant. J Perinatol 22(1):8–11

    Article  PubMed  Google Scholar 

  27. Poets CF, Brockmann PE (2011) Myth: gastroesophageal reflux is a pathological entity in the preterm infant. Semin Fetal Neonatal Med 16(5):259–263

    Article  PubMed  Google Scholar 

  28. de Ajuriaguerra M, Radvanyi-Bouvet MF, Huon C, Moriette G (1991) Gastroesophageal reflux and apnea in prematurely born infants during wakefulness and sleep. Am J Dis Child (1960) 145(10):1132–1136

    Google Scholar 

  29. Wenzl TG, Schenke S, Peschgens T, Silny J, Heimann G, Skopnik H (2001) Association of apnea and nonacid gastroesophageal reflux in infants: Investigations with the intraluminal impedance technique. Pediatr Pulmonol 31(2):144–149

    Article  PubMed  CAS  Google Scholar 

  30. Poets CF (2004) Gastroesophageal reflux: a critical review of its role in preterm infants. Pediatrics 113(2):e128–e132

    Article  PubMed  Google Scholar 

  31. Newell SJ, Booth IW, Morgan ME, Durbin GM, McNeish AS (1989) Gastro-oesophageal reflux in preterm infants. Arch Dis Child 64(6):780–786

    Article  PubMed  CAS  Google Scholar 

  32. Di Fiore JM, Arko M, Whitehouse M, Kimball A, Martin RJ (2005) Apnea is not prolonged by acid gastroesophageal reflux in preterm infants. Pediatrics 116(5):1059–1063

    Article  PubMed  Google Scholar 

  33. Corvaglia L, Zama D, Gualdi S, Ferlini M, Aceti A, Faldella G (2009) Gastro-oesophageal reflux increases the number of apnoeas in very preterm infants. Arch Dis Child Fetal Neonatal Ed 94(3):F188–F192

    Article  PubMed  CAS  Google Scholar 

  34. Peter CS, Sprodowski N, Bohnhorst B, Silny J, Poets CF (2002) Gastroesophageal reflux and apnea of prematurity: no temporal relationship. Pediatrics 109(1):8–11

    Article  Google Scholar 

  35. Di Fiore J, Arko M, Herynk B, Martin R, Hibbs AM (2010) Characterization of cardiorespiratory events following gastroesophageal reflux in preterm infants. J Perinatol 30(10):683–687

    Article  PubMed  CAS  Google Scholar 

  36. Perkett EA, Vaughan RL (1982) Evidence for a laryngeal chemoreflex in some human preterm infants. Acta Paediatr Scand 71:969

    Article  PubMed  CAS  Google Scholar 

  37. Kovar I, Selstam U, Catterton WZ, Stahlman MT, Sundell HW (1979) Laryngeal chemoreflex in newborn lambs: respiratory and swallowing response to salts, acids, and sugars. Pediatr Res 13(10):1144–1149

    Article  Google Scholar 

  38. Page M, Jeffery HE (1998) Airway protection in sleeping infants in response to pharyngeal fluid stimulation in the supine position. Pediatr Res 44(5):691–698

    Article  PubMed  CAS  Google Scholar 

  39. Page M, Jeffery HE, Marks V, Post EJ, Wood AK (1995) Mechanisms of airway protection after pharyngeal fluid infusion in healthy sleeping piglets. J Appl Physiol 78(5):1942–1949

    PubMed  CAS  Google Scholar 

  40. Magistà AM, Indrio F, Baldassarre M et al (2007) Multichannel intraluminal impedance to detect relationship between gastroesophageal reflux and apnoea of prematurity. Digest Liver Dis 39(3):216–221

    Article  Google Scholar 

  41. Salvatore S, Hauser B, Vandemaele K, Novario R, Vandenplas Y (2005) Gastroesophageal reflux disease in infants: how much is predictable with questionnaires, pH-metry, endoscopy and histology? [Article]. J Pediatr Gastroenterol Nutr 40(2):210–215

    Article  PubMed  Google Scholar 

  42. Jadcherla SR, Peng J, Chan CY et al (2011) Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res 70(2):192–198

    Article  PubMed  Google Scholar 

  43. van Wijk MP, Benninga MA, Dent J et al (2007) Effect of body position changes on postprandial gastroesophageal reflux and gastric emptying in the healthy premature neonate. J Pediatr 151(6):585–590.e2

    Article  PubMed  Google Scholar 

  44. Horvath A, Dziechciarz P, Szajewska H (2008) The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics 122(6):e1268–e1277

    Article  PubMed  Google Scholar 

  45. Corvaglia L, Ferlini M, Rotatori R et al (2006) Starch thickening of human milk is ineffective in reducing the gastroesophageal reflux in preterm infants: a crossover study using intraluminal impedance. J Pediatr 148(2):265–268

    Article  PubMed  Google Scholar 

  46. Beal J, Silverman B, Bellant J, Young TE, Klontz K (2012) Late onset necrotizing enterocolitis in infants following use of a Xanthan gum-containing thickening agent. J Pediatr 161(2):354–356

    Google Scholar 

  47. Woods CW, Oliver T, Lewis K, Yang Q (2012) Development of necrotizing enterocolitis in premature infants receiving thickened feeds using SimplyThick[reg]. J Perinatol 32(2):150–152

    Article  PubMed  CAS  Google Scholar 

  48. Jadcherla SR, Chan CY, Moore R, Malkar M, Timan CJ, Valentine CJ (2012) Impact of feeding strategies on the frequency and clearance of acid and nonacid gastroesophageal reflux events in dysphagic neonates. J Parenter Enteral Nutr 36(4):449–455

    Article  CAS  Google Scholar 

  49. Terrin G, Passariello A, De Curtis M et al (2012) Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns. Pediatrics 129(1):e40–e45

    Article  PubMed  Google Scholar 

  50. Graham PLr, Begg MD, Larson E, Della-Latta P, Allen A, Saiman L (2006) Risk factors for late onset gram-negative sepsis in low birth weight infants hospitalized in the neonatal intensive care unit. Pediatr Infect Dis J 25(2):113–117

    Article  PubMed  Google Scholar 

  51. Writing Committee for the American Lung Association Asthma Clinical Research C, Holbrook JT, Wise RA et al (2012) Lansoprazole for children with poorly controlled asthma: a randomized controlled trial. JAMA: J Am Med Assoc 307(4):373–381

    Article  Google Scholar 

  52. Orenstein SR, Shalaby TM, Devandry SN et al (2003) Famotidine for infant gastro-oesophageal reflux: a multi-centre, randomized, placebo-controlled, withdrawal trial. Aliment Pharm Therap 17(9):1097–1107

    Article  CAS  Google Scholar 

  53. Yang YX (2012) Chronic proton pump inihibitor therapy and calcium metabolism. Curr Gastroenterol Rep 14(6):473–479

    Article  PubMed  Google Scholar 

  54. Ito T, Jensen RT (2010) Association of long-term proton pump inhibitor therapy with bone fractures and effects on absorption of calcium, vitamin B12, iron, and magnesium. Curr Gastroenterol Rep 12(6):448–457

    Article  PubMed  Google Scholar 

  55. Orenstein SR, Hassall E, Furmaga-Jablonska W, Atkinson S, Raanan M (2009) Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr 154(4):514–520.e4

    Article  PubMed  CAS  Google Scholar 

  56. Tham SY, Rogers IM, Samuel KF, Singh A, Ong KK (2012) Does oral lansoprazole really reduce gastric acidity in VLBW premature neonates? Med J Malaysia 67(3):284–288

    PubMed  Google Scholar 

  57. Omari TI, Haslam RR, Lundborg P, Davidson GP (2007) Effect of omeprazole on acid gastroesophageal reflux and gastric acidity in preterm infants with pathological acid reflux. J Pediatric Gastroenterol Nutr 44(1):41–44

    Article  CAS  Google Scholar 

  58. Corvaglia L, Aceti A, Mariani E, De Giorgi M, Capretti MG, Faldella G (2011) The efficacy of sodium alginate (Gaviscon) for the treatment of gastro-oesophageal reflux in preterm infants. Aliment Pharm Therap 33(4):466–470

    Article  CAS  Google Scholar 

  59. Corvaglia L, Spizzichino M, Zama D et al (2011) Sodium alginate (Gaviscon®) does not reduce apnoeas related to gastro-oesophageal reflux in preterm infants. Early Hum Dev 87(12):775–778

    Article  PubMed  CAS  Google Scholar 

  60. Hibbs AM, Lorch SA (2006) Metoclopramide for the treatment of gastroesophageal reflux disease in infants: a systematic review. Pediatrics 118(2):746–752

    Article  PubMed  Google Scholar 

  61. Machida HM, Forbes DA, Gall DG, Scott RB (1988) Metoclopramide in gastroesophageal reflux of infancy. J Pediatr 112(3):483–487

    Article  PubMed  CAS  Google Scholar 

  62. Wheatley E, Kennedy KA (2009) Cross-over trial of treatment for bradycardia attributed to gastroesophageal reflux in preterm infants. J Pediatr 155(4):516–521.e1

    Article  PubMed  Google Scholar 

  63. Vandenplas Y, Salvatore S, Hauser B (2005) The diagnosis and management of gastro-oesophageal reflux in infants. Early Hum Dev 81(12):1011–1024

    Article  PubMed  Google Scholar 

  64. Maclennan S, Augood C, Cash-Gibson L, Logan S, Gilbert RE (2010) Cisapride treatment for gastro-oesophageal reflux in children. Cochrane Database Syst Rev (4):CD002300

    Google Scholar 

  65. McClure RJ, Kristensen JH, Grauaug A (1999) Randomised controlled trial of cisapride in preterm infants. Arch Dis Child Fetal Neonatal Ed 80(3):F174–F177

    Article  PubMed  CAS  Google Scholar 

  66. Cresi F, Marinaccio C, Russo MC, Miniero R, Silvestro L (2008) Short-term effect of domperidone on gastroesophageal reflux in newborns assessed by combined intraluminal impedance and pH monitoring. J Perinatol 28(11):766–770

    Article  PubMed  CAS  Google Scholar 

  67. Vieira MC, Miyague NI, Van Steen K, Salvatore S, Vandenplas Y (2012) Effects of domperidone on QTc interval in infants. Acta Paediatrica 101(5):494–496

    Article  Google Scholar 

  68. Ng E, Shah VS (2008) Erythromycin for the prevention and treatment of feeding intolerance in preterm infants Cochrane Database Syst Rev (3):CD001815

    Google Scholar 

  69. Pacilli M, Chowdhury MM, Pierro A (2005) The surgical treatment of gastro-esophageal reflux in neonates and infants. Semin Pediatr Surg 14(1):34–41

    Article  PubMed  Google Scholar 

  70. Hassall E (2005) Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child 90(10):1047–1052

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Keith J. Barrington MB ChB .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2013 Springer Science+Business Media Dordrecht

About this chapter

Cite this chapter

Barrington, K. (2013). Gastro-Esophageal Reflux in Neonatology. In: Patole, S. (eds) Nutrition for the Preterm Neonate. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-6812-3_7

Download citation

Publish with us

Policies and ethics