Does gastroesophageal reflux cause apnea in preterm infants?

Gastroesophageal reflux (GER) and apnea are both common occurrences in premature infants but their relationship is controversial. We present the evidence for and against an association between GER and apnea and discuss the merits and limitations of the various methodologies employed in characterizing such a relationship. Overall, GER and apnea do not appear temporally related in preterm infants, despite strong physiologic evidence that stimulation of laryngeal afferents elicits central apnea and laryngeal adduction. In a subpopulation of infants with neurodevelopmental compromise, there may be an increased incidence of both apnea and GER, although the direct association between GER and apnea in this population is unclear. Therefore, we believe there is no evidence to support widespread use of anti-reflux medications in the treatment of apnea in preterm infants. Further studies are needed to clarify the existence of a small subpopulation of infants who may have GER-induced apnea, to identify potential triggering mechanisms, and to document benefit from newer pharmacological approaches.     

Gastroesophageal reflux disease in infants: how much is predictable with questionnaires, pH-metry, endoscopy and histology?

Symptoms of gastroesophageal reflux disease (GERD) are common in infants. It is often difficult to discriminate between physiological and pathologic gastroesophageal reflux, although this discrimination is essential to determine which infants to evaluate and treat. OBJECTIVES: To identify the prevalence of reflux symptoms in infants and to evaluate the predictive value of a questionnaire and the correlation between pH study, histology and clinical score. METHODS: Parents of 100 unselected infants visiting the well-baby clinic and 100 infants suspected of having gastroesophageal reflux disease were asked to fill in a 35-item questionnaire. A validated score, the Orenstein I-GERQ, was applied for selected questions. All infants suspected of having gastroesophageal reflux disease underwent prolonged esophageal pH monitoring and 44 or 100 underwent upper gastrointestinal tract endoscopy with esophageal biopsy. RESULTS: Parents of infants with suspected gastroesophageal reflux disease reported significantly more regurgitation (68% versus 45%, P < 0.05) and crying (51% versus 20%, P < 0.01) compared with the parents of healthy infants. A pathologic pH study (reflux index > 10%) was found in 21 of 100 (21%) infants and was significantly associated only with pneumonia, apnea with fussing (P = 0.013 for both), defecation less than once a day (P = 0.033) and constipation (P = 0.05). Esophagitis was present in 17 of 44 (39%) and no one question was found to be significantly predictive. 38% of infants with a pathologic pH study had a normal esophageal biopsy and 53% of infants with histologic esophagitis had a normal pH study. Discordance between pH study and biopsies occurred in 14 of 44 (32%) patients. The Orenstein I-GERQ cut-off score failed to identify eight of 31 (26%) infants with gastroesophageal reflux disease. Conversely, the score was positive in 17 of 22 (81%) infants with normal biopsy and pH study and in 14 of 47 (30%) infants with normal pH study. CONCLUSIONS: Clinical symptoms, histology and pH study show poor correlation in infants. Clinical symptoms such as regurgitation and crying are less frequent in unselected infants than in infants suspected of gastroesophageal reflux disease. However, questionnaires are poorly predictive for the severity of gastroesophageal reflux disease, as they do not correlate with esophageal acid exposure as measured by pH-metry and with esophagitis as evaluated by histology of esophageal biopsies.     

Gastroesophageal reflux—How to mend it?

Gastroesophageal reflux (GER) is a common condition affecting children. The clinical presentation varies widely from innocuous spitting up to life threatening apnea. Various diagnostic tests are available to document the etiology, presence or complications of GER. In most cases, conservative approach is sufficient. In complicated cases, pharmacotherapy is indicated while surgical therapy is reserved for resistant cases with complications.     

Palivizumab for preterm infants. Is it worth it?

Respiratory syncytial virus infection is an important cause of morbidity. Although palivizumab prophylaxis is widely used, it is uncertain whether the cost is justified. A systematic review was therefore performed of the safety, efficacy, and the likely cost effectiveness of prophylaxis for preterm infants in the United Kingdom using a standard search strategy. The only randomised controlled trial identified showed a reduction in hospital admission but no benefit on more serious outcomes. None of the United Kingdom cost studies showed economic benefit for palivizumab prophylaxis. New treatments are rarely cost effective, and, in the absence of a comprehensive economic assessment, continued use for high risk infants may appear justified.     

Probiotics for preterm infants?

Infants nursed in special care baby units develop an abnormal pattern of microbial colonisation, which may contribute to disease. Enteric feeding of live microbial supplements (probiotics) may provide benefit to such infants and help to prevent diseases such as neonatal necrotising enterocolitis.