Gastroesophageal Reflux in Preterm Infants Clinical Practice Guidelines (2018)

American Academy of Pediatrics Committee on Fetus and Newborn

Reviewed and summarized by Medscape editors

August 09, 2018

The clinical practice guidelines on gastroesophageal reflux in preterm infants were released on June 18, 2018, by the AAP.[1,2]

GER is almost universal in preterm infants. It is a physiologic process secondary to frequent transient lower esophageal sphincter relaxation (TLESR), relatively large-volume liquid diet, and age-specific body positioning. As such, it is a normal developmental phenomenon that will resolve with maturation.

Pathologic GER occurs when reflux of acidic gastric contents causes injury to the lower esophageal mucosa. Although preterm infants do have some acidic GER episodes, most GER episodes in this population are only weakly acidic because of their lower gastric acidity and frequent milk feedings, making such esophageal injury unlikely to occur.

Signs commonly ascribed to GER in preterm infants include feeding intolerance or aversion, poor weight gain, frequent regurgitation, apnea, and desaturation and bradycardia and behavioral signs, including irritability and perceived postprandial discomfort. In the data, the temporal association of these perceived signs of GER with either acidic or nonacidic reflux episodes as measured by multichannel intraesophageal impedance (MII) and pH is not supported, and the signs will usually improve with time without treatment.

The most accurate method for detecting GER in preterm infants is MII, often combined with simultaneous pH sensoring. MII tracks the movement of fluids, solids, and air and can show whether a fluid bolus is moving antegrade (swallowing) or retrograde (reflux), and how high in the esophagus it is. Measuring lower-esophageal pH alone is a not a reliable method. Although contrast fluoroscopy images episodes of reflux, it cannot distinguish between clinically significant and insignificant GER.

Data regarding the possible association between worsening lung disease attributable to GER and microaspiration in mechanically ventilated preterm infants are sparse. Further studies to elucidate such an association and to assess the effect of GER treatment on the severity of lung disease are needed.

There is marked variability in the diagnosis and treatment of GER in preterm infants among NICUs, perhaps because the diagnosis is usually made by clinical assessment of signs and symptoms and/or a trial of nonpharmacologic or pharmacologic treatment rather than definitive tests.

Conservative measures to control reflux, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of GER in the preterm infant; for infants greater than 32 weeks’ postmenstrual age, safe sleep approaches, including supine positioning on a flat and firm surface and avoidance of commercial devices designed to maintain head elevation in the crib, should be paramount as a model for parents of infants approaching discharge from the hospital.

Preterm infants with clinically diagnosed GER are often treated with pharmacologic agents; however, a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in preterm infants.


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