The Journal of Pediatrics
Volume 151, Issue 6 , Pages 560-561, December 2007

Gastroesophageal Reflux in Preterm Infants: Is Positioning the Answer?

Rainbow Babies and Children’s Hospital, Cleveland, Ohio

Article Outline

 

Determination of the optimal body position for preterm infants has generated considerable interest for many years. New technological advances in neonatal care have increased our understanding of the importance of body position to various aspects of physiological function in preterm infants. For example, nearly 30 years ago the advent of noninvasive blood gas monitoring demonstrated that prone positioning improved oxygenation and synchrony of respiratory muscle activation in preterm infants when compared with the supine position.1 This observation, together with a presumed decrease in gastroesophageal reflux in prone versus supine infants,2 caused the prone position to be favored in hospitalized preterm infants. This ended abruptly in 1994 when prone positioning was demonstrated as a significant risk factor for sudden infant death syndrome in the postneonatal period.3 However, maybe this is not the end of the story, at least for hospitalized preterm infants.

See related articles, p 585 and p 591

Monitoring of esophageal pH has traditionally been the technique of choice for evaluation of gastroesophageal reflux in infants. Obviously this method is of very limited usefulness postprandially when acidic stomach contents are buffered by milk. As a consequence, there has been very limited information on postprandial gastroesophageal reflux, even though this is the time at which cardiorespiratory events, such as apnea, bradycardia and desaturation, are most widely attributed to reflux. It is therefore refreshing to note 2 accompanying reports in this issue of The Journal, with novel alternative techniques in preterm infants to address the role of positioning on postprandial reflux in this population.4, 5

It is informative to compare and contrast these 2 reports. In both studies subjects were evaluated at a mean postconceptional (postmenstrual) age of approximately 35 to 36 weeks. Corvaglia et al4 studied symptomatic infants referred for diagnostic evaluation. This is the usual population of subjects being tested. In contrast, van Wijk et al5 studied healthy, symptom-free, preterm infants. This approach is key for ascertaining normative data, although obtaining institutional and parental approval to do these investigations on symptom-free infants is a challenge in most settings. Both studies characterized the effect of position on gastroesophageal reflux during 2 sequential postprandial periods, each of approximately 60 to 75 minutes’ duration. A common feature of both studies was impedance monitoring. Current state-of-the-art systems incorporate impedance in addition to pH monitoring to measure the frequency, duration, and height of a liquid (or air) bolus into the esophagus, regardless of bolus acidity.6 The van Wijk5 study also used manometry and isotope-labeled CO2 excretion to assess transient lower esophageal relaxations and gastric emptying, respectively.

Interpretations of the results generated by the 2 investigative groups are certainly interesting. Both studies clearly demonstrate, with the impedance technique, that postprandial gastroesophageal reflux is greater in the right (side down) versus left (side down) lateral position. Corvaglia additionally observed less reflux in the prone versus supine position, as might also be expected. When the first versus second postprandial periods were compared, acid reflux increased from the first to second hour as time after feeding increased, although acid reflux remained low in the prone position. This might lead one to conclude that the right lateral and supine positions should be avoided postprandially. Not so simple! Van Wijk et al5 noted that when infants were initially in the right lateral position after feeds, the greater liquid reflux was associated with greater gastric emptying. When the same subjects were then placed from right lateral to left lateral position during the second postprandial hour, liquid reflux was greatly reduced at a time when acidity of refluxate would be increasing. They speculate that the initially greater postprandial refluxate in the right lateral position may not be a problem because it is nonacidic, and the accompanying increase in gastric emptying might benefit the subsequent postprandial period when acidic refluxate constitutes a greater risk of morbidity. Of course it should be noted that transient lower esophageal relaxations are probably stronger correlates of reflux than delayed gastric emptying.5

So what are we to do, and does gastroesophageal reflux in preterm infants even matter? Many clinical problems have been attributed to reflux in preterm infants. These include the triad of apnea, bradycardia and desaturation, feeding disorders and growth failure, as well as a potential deterioration of bronchopulmonary dysplasia and airway hyperreactivity.7, 8, 9, 10 Although such morbidities associated with, or caused by, gastroesophageal reflux have been difficult to prove,11 the use of pharmacologic agents for treatment of gastroesophageal reflux disease in this population is widespread.12, 13, 14 Although definitive evidence of morbidities resulting from gastroesophageal reflux in premature infants remains elusive, optimal positioning of this fragile population is certainly preferable to potentially unnecessary medications.

Once again, use of creative physiological techniques has allowed us to address issues in neonatology that have important clinical implications. These 2 studies in preterm infants have documented that postprandial gastroesophageal reflux is enhanced in the right lateral and supine positions, as might be anticipated from anatomic configurations and clinical observations. The potential benefit of these positioning strategies in in-patient preterm infants will need to be balanced against the risk of undermining the “back to sleep” message as families prepare to take their infants home. Will these findings be pursued and form the basis for future changes in clinical practice? Only time will tell; however, optimal postprandial positioning to avoid reflux, as demonstrated by these authors, should be given strong consideration.

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References 

  1. Martin RJ, Herrell N, Rubin D, Fanaroff A. Effect of supine and prone positions on arterial oxygen tension in the preterm infant. Pediatrics. 1979;63:528–531
  2. Orenstein SR, Whittington PF. Positioning for prevention of infant gastroesophageal reflux. J Pediatr. 1983;103:534–537
  3. American Academy of PediatricsTask Force on Infant Sleeping Position and SIDS. Infant sleep position and sudden infant death syndrome [SIDS] in the United States: Joint commentary from the American Academy of Pediatrics and selected agencies of the federal government [commentary]. Pediatrics. 1994;93:820
  4. Corvaglia L, Rotatori R, Ferlini M, Aceti A, Ancora G, Faldella G. The effect of body positioning as gastroesophageal reflux in premature infants: evaluation by combined impedance and pH monitoring. J Pediatr. 2007;151:591–596
  5. van Wijk MP, Benninga MA, Dent J, Lontis R, Goodchild L, McCall LM, et al Effect of body position changes on postprandial gastroesophageal reflux and gastric emptying in the healthy premature neonate. J Pediatr. 2007;151:585–590
  6. Vandenplas Y, Salvatore S, Vieira MC, Hauser B. Will esophageal impedance replace pH monitoring?. Pediatrics. 2007;119:118–122
  7. Di Fiore JM, Arko M, Whitehouse M, Kimball A, Martin RJ. Apnea is not prolonged by acid gastroesophageal reflux in preterm infants. Pediatrics. 2005;116:1059–1063
  8. Peter CS, Sprodowski N, Bohnhorst B, Silny J, Poets CF. Gastroesophageal reflux and apnea of prematurity: no temporal relationship. Pediatrics. 2002;109:8–11
  9. Fuloria M, Hiatt D, Dillard RG, O’Shea TM. Gastroesophageal reflux in very low birth weight infants: association with chronic lung disease and outcomes through 1 year of age. J Perinatol. 2000;20:235–239
  10. Slocum C, Hibbs AM, Martin RJ, Orenstein SR. Infant apnea and gastroesophageal reflux: a critical review and framework for further investigation. Current Gastroenterol Reports. 2007;9:219–224
  11. Molloy EJ, Di Fiore JM, Martin RJ. Does gastroesophageal reflux cause apnea in preterm infants?. Biol Neonate. 2005;87:254–261
  12. Malcolm WF, Gantz M, Martin RJ, Goldstein RF, Goldberg RN, Cotten CM. Use of medications for gastroesophageal reflux in extremely low birth weight infants at discharge. Pediatrics (in press).
  13. Hibbs AM, Lorch SA. Metoclopramide for the treatment of gastroesophageal reflux disease in infants: a systematic review. Pediatrics. 2006;118:746–752
  14. Clark RH, Bloom BT, Spitzer AR, Gerstmann DR. Reported medication use in the neonatal intensive care unit: data from a large national data set. Pediatrics. 2006;117:1979–1987

PII: S0022-3476(07)00653-1

doi:10.1016/j.jpeds.2007.07.003

Refers to article:

  • Effect of Body Position Changes on Postprandial Gastroesophageal Reflux and Gastric Emptying in the Healthy Premature Neonate , 08 October 2007

    Michiel P. van Wijk, Marc A. Benninga, John Dent, Ros Lontis, Louise Goodchild, Lisa M. McCall, Ross Haslam, Geoffrey P. Davidson, Taher Omari
    The Journal of Pediatrics December 2007 (Vol. 151, Issue 6, Pages 585-590.e2)

  • The Effect of Body Positioning on Gastroesophageal Reflux in Premature Infants: Evaluation by Combined Impedance and pH Monitoring , 10 October 2007

    Luigi Corvaglia, Raffaella Rotatori, Marianna Ferlini, Arianna Aceti, Gina Ancora, Giacomo Faldella
    The Journal of Pediatrics December 2007 (Vol. 151, Issue 6, Pages 591-596.e1)

The Journal of Pediatrics
Volume 151, Issue 6 , Pages 560-561, December 2007

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