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Study Narrows Criteria for Treating NICU Babies for GERD

More than 10 percent of NICU babies are believed to have gastroesophageal reflux disease (GERD). Despite several risks associated with acid-suppressive medication in NICU babies, such as nosocomial infections, enterocolitis, osteopenia and malabsorption of nutrients, these tiny patients are often treated for the disease when any common symptom of the condition is present.

Symptoms can include feeding difficulties, gagging, coughing, arching the back or acting irritable, grimacing, vomiting, sneezing, flushing or grunting.

“NICU infants have many aerodigestive symptoms on a daily basis. There is a perception that these symptoms are due to acid GERD and therefore using acid-suppressive medications will ameliorate the symptoms. This is a myth and can be dangerous,” says Sudarshan Jadcherla, MD, director of the Neonatal and Infant Feeding Disorders Program at Nationwide Children’s and a member of the hospital’s Division of Neonatology. He’s also senior author of a study offering guidance, released in 2017 in Dysphagia. “Using acid-suppressive therapy without a definite diagnosis and symptom association probability not only diverts attention from what might be a different, undiagnosed problem, but creates the new problem of dealing with dosing, treatment duration decisions, side effects and sequelae.”

“There is a perception that these symptoms are due to acid GERD and therefore using acid-suppressive medications will ameliorate the symptoms. This is a myth and can be dangerous.”

– Sudarshan Jadcherla, MD

Dr. Jadcherla acknowledges the practical challenges to confirming acid GERD and symptom association probability. However, he says, “Accurate documentation of troublesome symptoms is required in a timely manner so that comparisons with the actual GER event characteristics can be made.”

To help overcome this clinical disconnect and determine which symptoms merit acid suppression therapy, Dr. Jadcherla and his colleagues performed 24-hour pH-impedance tests on 53 infants in the NICU at Nationwide Children’s. The team documented more than 2,000 acid reflux events (AREs) and determined whether the babies’ GERD symptoms correlated with the presence and location of acid in the esophagus.

Their findings suggest that treating apparent GERD with proton pump inhibitors may be appropriate when the baby’s acid reflux index (ARI) score is greater than 7, AREs reach the middle or proximal areas of the esophagus, and there is abnormal symptom correlation between the ARI and ARE based on pH-impedance testing.

“This approach will separate false positives from true positives, thus providing opportunities to test the effect of therapies for those with the probability of acid-GERD,” Dr. Jadcherla says.

He hopes that continued research will move neonatologists closer to an actionable, objective and more specific treatment criteria for GERD management in NICU babies.

Sivalingam M, Sitaram S, Hasenstab KA, Wei L, Woodley FW, Jadcherla SR. Effects of esophageal acidification on troublesome symptoms: An approach to characterize true acid GERD in dysphagic neonates. Dysphagia, 2017. 32(4):509-519.

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