Mechanisms of gastroesophageal reflux in healthy premature infants

doi:10.1016/S0022-3476(98)70106-4

The Journal of Pediatrics

Volume 133, Issue 5, November 1998, Pages 650-654

https://doi.org/10.1016/S0022-3476(98)70106-4 Get rights and content

Abstract

Objectives: The aim of this study was to characterize the motor events responsible for gastroesophageal reflux (GER) and esophageal acid clearance in a cohort of healthy preterm infants. Study design: Esophageal motility was recorded for 2 to 3 hours after a feeding in 24 preterm infants, 31 to 38 weeks’ postmenstrual age, by using a sleeve-side hole micromanometric assembly incorporating a pH probe. Results: Sixty acid GER episodes were recorded by pH probe, and 133 non-acid GER episodes were recorded manometrically by the presence of esophageal common cavities. Of the 193 GER episodes, 159 (82%) were associated with transient lower esophageal sphincter relaxation (TLESR). TLESRs were significantly longer in duration than single swallows (15.1 seconds vs 5.6 seconds, P < .001) and had lower nadir pressures (0.8 mm Hg vs 2.3 mm Hg, P < .001). A total of 3216 esophageal body pressure waves were analyzed; 70% of swallow-induced pressure waves were peristaltic in sequence compared with 5% of swallow-unrelated pressure waves. During periods of esophageal acidification (pH below 4), peristaltic esophageal body pressure wave sequences cleared acid refluxate more effectively than nonperistaltic pressure wave sequences. Conclusions: In healthy preterm infants, TLESRs are the predominant mechanism underlying GER, and esophageal clearance mechanisms are well developed by at least 31 weeks’ postmenstrual age. (J Pediatr 1998;133:650-4)

Section snippets

Subjects

The study protocol was approved by the Ethics Research Committee of the Women’s and Children’s Hospital, and written informed parental consent was obtained before each study. Studies were performed in 24 (13 male and 11 female) healthy preterm infants with a mean postmenstrual age of 35 weeks (range, 31 to 38 weeks). All infants were well at the time of the study, were considered not to have reflux disease, had no evidence of neurologic dysfunction, and were not receiving prokinetic medication.

Mechanisms and Rate of GER

Sixty acid and 133 non-acid GER episodes were recorded. The mean nadir pH of acid GER episodes was 3.0 ± 0.3 (range, 1.1 to 5.7) with a mean pH fall of 1.7 ± 0.1 (range, 1.0 to 2.9). Five infants had no acid reflux episodes. Only 30 of the 60 acid GER episodes recorded were accompanied by manometric recordings of sufficient resolution to identify common cavities. In this subgroup of events, common cavities were observed on 27 (90%) occasions. For all other acid GER episodes, the possible

Discussion

This study shows that in healthy preterm infants, TLESRs are the most common pattern of LES function associated with postprandial reflux. In these infants esophageal body motor patterns were well developed, and esophageal peristalsis effectively facilitated esophageal clearance of refluxate.

We have previously shown that in premature infants TLESRs are the predominant mechanism of GER identified manometrically by common cavity phenomena (abrupt sustained pressurization of the esophageal body).²

Acknowledgements

We thank Dr Kazu Miki for his participation in this study and Dr Charles Malbert for the computerized data acquisition and analysis software used in this study.

References (18)

S. Orenstein
Gastroesophageal reflux
Curr Prob Pediatr
(1991)
T Omari et al.
Esophageal body and lower esophageal sphincter function in healthy premature infants
Gastroenterology
(1995)
S Werlin et al.
Mechanisms of gastroesophageal reflux in children
J Pediatr
(1980)
H Kawahara et al.
Evaluation of the mechanisms responsible for gastroesophageal reflux in children
Gastroenterology
(1997)
J. Dent
A new technique for continuous sphincter pressure measurement
Gastroenterology
(1976)
R Mittal et al.
Transient lower esophageal relaxation
Gastroenterology
(1995)
WE Berquist et al.
Effect of theophylline on gastroesophageal reflux in normal adults
J Allergy Clin Immunol
(1981)
T Omari et al.
Characterisation of lower oesophageal sphincter relaxation in healthy preterm infants
Gut
(1997)
S Newell et al.
Maturation of the lower oesophageal sphincter in the preterm baby
Gut
(1988)

There are more references available in the full text version of this article.

Cited by (120)

Neonatal Gastroesophageal Reflux
2023, Avery's Diseases of the Newborn
Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Neonate: Controversies, Current Understanding, and Future Directions
2020, Clinics in Perinatology
The enigma of gastroesophageal reflux disease among convalescing infants in the NICU: It is time to rethink
2020, International Journal of Pediatrics and Adolescent Medicine
Gastroesophageal reflux (GER) can be a normal physiological process, or can be bothersome, when aerodigestive consequences are associated; the latter is often interpreted as GER disease (GERD). However, the distinction between these two entities remains an enigma among infants surviving after neonatal intensive care (NICU) care. Symptoms related to GERD are heterogeneous, and are often managed with changes in diet, feeding methods, and acid suppressive therapy. However, none of these approaches have been well-tested in neonates; hence practice variation is very high world-wide. In this paper, we explain the variation in diagnosis, pathophysiology of the clinical presentation, and highlight approaches to diagnosis and management.
Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Infant: Who Needs to Be Treated and What Approach Is Beneficial?
2019, Pediatric Clinics of North America
Effects of Smoking Exposure in Infants on Gastroesophageal Reflux as a Function of the Sleep–Wakefulness State
2018, Journal of Pediatrics
To determine whether perinatal smoking exposure is associated with gastroesophageal reflux (GER)-related changes in sleep-wakefulness states in neonates.
Thirty-one neonates, referred for the investigation of suspected GER, were recruited and underwent multichannel impedance–pH monitoring and synchronized 8- to 12-hour polysomnography. The infants' exposure to tobacco smoke was estimated by means of a urine cotinine assay. The total number, frequency (h⁻¹), and mean duration (minutes) of GER-pH (reflux events detected by the pH electrode only) and GER-imp (reflux events with bolus movement detected by impedance) events were determined. Intergroup differences (smoking-exposed group vs nonexposed group) were probed with nonparametric, unpaired Mann–Whitney U tests. A χ² test was used to assess a possible intergroup difference in bolus retrograde migration during GER-imp events.
According to the urine cotinine assay, 21 of the 31 neonates had been exposed to cigarette smoke during the perinatal period. The number (and frequency) of GER-imp was significantly greater (P = .016) in the exposed group (29 [0-90]) than in the nonexposed group (12 [2-35]). Migration of the esophageal bolus from the distal segment to the most proximal segment was significantly more frequent (P = .016) in the exposed group (83% of GER) than in the nonexposed group (41%). The GER pattern associated with smoking exposure was particularly obvious during Rapid eye movement sleep.
The more frequent occurrence and greater proximal migration of GER-imp in the smoking-exposed group (especially during rapid eye movement sleep) may have clinical relevance. Smoking exposure is a preventable risk factor for limiting the occurrence of GER in neonates.
Maturation of Motor Function in the Preterm Infant and Gastroesophageal Reflux
2018, Gastroenterology and Nutrition: Neonatology Questions and Controversies
Upper gastroesophageal motility may be immature in neonates and preterm infants, predisposing them to gastroesophageal reflux (GER) events. Gastroesophageal reflux disease (GERD) occurs when GER causes complications and is difficult to diagnose and treat in infants because of multiple other potential causes of putative GERD symptoms, rapid maturational changes, and lack of gold standard tests or therapies. This chapter explores the development of gastroesophageal motility in term and preterm infants and discusses the challenges in diagnosing and treating GERD.

View all citing articles on Scopus

^☆: From the Gastroenterology Unit, Neonatal Medicine Unit, and Department of Biomedical Engineering, Women’s and Children’s Hospital, North Adelaide Australia; and Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, Australia.

^☆☆: Supported by the National Health and Medical Research Council of Australia, Women’s and Children’s Hospital Research Foundation, Queen Victoria Hospital Research Foundation, Channel 7 Children’s Research Foundation of South Australia.

^★: Reprint requests: Taher I. Omari, BSc, PhD, Gastroenterology Unit, Women’s and Children’s Hospital, North Adelaide, Australia, 5006.

^★★: 0022-3476/98/$5.00 + 0 9/21/94145

View full text

Mechanisms of gastroesophageal reflux in healthy premature infants☆,☆☆,★,★★

Abstract

Section snippets

Subjects

Mechanisms and Rate of GER

Discussion

Acknowledgements

Curr Prob Pediatr

Gastroenterology

J Pediatr

Gastroenterology

Gastroenterology

Gastroenterology

J Allergy Clin Immunol

Characterisation of lower oesophageal sphincter relaxation in healthy preterm infants

Gut

Maturation of the lower oesophageal sphincter in the preterm baby

Gut