Columbus, OH — December 2017
In the latest of their numerous innovative studies of the symptoms and experiences of NICU babies with trouble swallowing (dysphagia), physicians and researchers at Nationwide Children’s Hospital and The Ohio State University College of Medicine have identified and refined which symptoms suggest treatment-worthy gastroesophageal reflux disease (GERD). The team believes its body of work on the topic will make future GERD diagnosis and treatment in infants more appropriate.
More than 10 percent of NICU babies are believed to have 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 medically treated for GERD when any common symptom of the condition is present. In such young babies, these 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 perceived myth that these symptoms are due to acid GERD and therefore using acid-suppressive medications will ameliorate the symptoms. This myth is not true, and can be dangerous,” says Sudarshan Jadcherla, MD, director of the Neonatal and Infant Feeding Disorders Program at Nationwide Children’s, member of the hospital’s Division of Neonatology and senior author on the publication, released earlier this year 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 also creates the new problem of dealing with dosing, treatment duration decisions, side effects and sequelae.”
Dr. Jadcherla acknowledges the practical challenges to confirming acid GERD and symptom association probability, however. “Accurate documentation of troublesome symptoms is required in a timely manner so that comparisons with the actual GER event characteristics can be made,” he says.
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. More than 2000 acid reflux events (AREs) were documented, allowing the team to determine 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. “We still have to learn whether a placebo or acid-suppressive therapy can produce the same benefits, both in the short term and long term.”
Dr. Jadcherla hopes that this research and eventual randomized control trials evaluating GERD therapies using pH-impedance testing 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.