Did you know non-pharmacologic management of GERD should be your first line of defense?

            Gastroesophageal Reflux (GER) commonly occurs in infant’s admitted to the neonatal intensive care unit. When reflux does occur, an infant can be asymptomatic or present with symptoms related to Gastroesophageal Reflux Disease (GERD). The clinical symptoms associated with GERD impact an infant’s comfort and physiological stability. However, the diagnosis and treatment of GERD varies considerably in practice and research recommendations are weak. This article aimed to provide guidelines to assist with treatment options and diagnosis of GERD due to the serious complications of anti-suppression medication.

            The first recommendation includes a thorough history, exam and screen for alternative underlying diseases responsible for GERD. Similar clinical presentations include apnea, bronchopulmonary dysplasia and upper airway irritation. Recent research does not support associations between GERD and these pathologies. Other diagnoses that are risk factors for GERD include craniofacial anomalies, GI anomalies and neurologic anomalies. The technology supported most by research for the diagnosis of GERD is combined pH-multi-channel intraluminal impedance (pH-MII.)

            Once an infant is diagnosed with GERD research supports beginning with non-pharmacological treatment including feeding modifications, positioning modifications and trial of elimination of cow’s milk protein. Suggested feeding modifications are frequent and smaller feedings, though these adjustments can compromise nutrition and should be closely monitored. Car seat placement is not supported by research as a recommended position as it places increased intraabdominal pressure. Prone or left lateral position is the most supported by research as this positioning reduces transient lower esophageal sphincter relaxation and reflux episodes. However, these positions are only recommended while the infant is monitored within the NICU setting and safe sleep should be modeled prior to discharge. Elimination of cow’s milk protein can be achieved by elimination of cow’s milk from maternal diet for 2-4 weeks or hydrolyzed formula for 1-2 weeks. Hydrolyzed formula is recommended for term infants and is not recommended for infants less than 34-36 weeks.

            Other treatment recommendations can be trialed if symptoms do not improve or severe symptoms are present. These recommendations include transpyloric feeding, fundoplication, thickening feeds and pharmacologic therapy. Thickening feeds is not recommended if the infant in less than 42 weeks PMA and acid-suppression therapy is contradicted for preterm infants. Research suggests to proceed with caution for all of these treatment options.

Gastroesophageal reflux is not new to the NICU, however, what we know about GER and how to treat it is ever changing. Maintaining ‘best practice’ can be very challenging when you work in a field where new research is consistently released and practice guidelines are always evolving. This is where Creative Therapy Consultants wants to support you and make this easier! You can always rest assured all of our trainings are current, evidenced based and reflect best practice. You will also feel supported with our consistent literature updates shared in our quarterly newsletter, social media accounts or trainings’ follow up emails. You focus on providing the best care possible for the babies and families you serve and we will take care of getting you the information you need to do this! 

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Sawyer, C., Sanghavi, R., Ortigoza, E. (2022). Neonatal gastroesophageal reflux. Early Human Development, 171, 105600. https://doi.org/10.1016/j.earlhumdev.2022.105600