Managing GERD in Preterm Infants

by Cristina Sifuentes MS, RD, CSP, LD  Gastroesophageal reflux disease (GERD) is a common issue for preterm infants. For pediatric dietitians working in the NICU, it can be challenging to manage. The guidelines provided by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition define gastroesophageal reflux (GER) as the physiologic passage of gastric contents into the esophagus and gastroesophageal reflux disease (GERD) as reflux associated with troublesome symptoms or complications (1). GER is considered a normal process that occurs in otherwise healthy infants throughout the day (2). When the reflux is recurrent and results in excessive crying, apnea or bradycardia, regurgitation and irritability, then its considered GERD. Although important to note that these symptoms can also occur without GERD in healthy infants. Feeding changes in addition to positioning changes can help reduce the symptoms of GERD. In formula fed infants, a simple start is reducing the total volume of feeds while increasing the frequency and monitoring symptoms. Using continuous feeds is not ideal because formula sticks to the tubing reducing total intake (5).  If symptoms persist, consider a formula change. The use of pre-thickened formulas or adding dry rice cereal to a formula is a commonly used, albeit controversial, solution to reflux in the NICU. Thickening feedings seems to reduce the number of observed emesis events but not the number of reflux events (1). There is also concern for overfeeding when adding rice cereal to a formula, adding 1 tablespoon of rice cereal to 1 ounce of a 20 kcal/oz infant formula makes a 34 kcal/oz formula. Because of this, using commercially pre-thickened formulas is preferred. These formulas have starch that thickens at gastric pH level while not exceeding the RDA for energy. However, since the nutrient profile of these formulas are intended for term infants, the RDN should weigh the risk and benefits of using these in preemies. Commercial starch based powdered thickeners have not been well researched in the preemie population, but are appealing for use in formulas that are not available in anti-reflux formulations. One advantage is that less thickener is required per ounce compared to rice cereal, reducing the macronutrient shift. With close medical supervision, the use of powder starch thickeners can help alleviate symptoms of GERD temporarily, but due its limited study not recommended post-discharge. An important note on thickeners, in 2011 the FDA released a warning against the use of SimplyThick in preterm infants because of its association with necrotizing enterocolitis (4). In 2012, the warning was extended to term infants. Thickening breast milk is not feasible because of the enzymes present that breakdown starches, so positioning and pacing are tools to combat GERD in these infants. Placing the infant in the left-side-down or prone position after a feeding is associated with reduced episodes of reflux as opposed to the supine position (3). The prone position should only be used when the infant is monitored and not recommended post-discharge for risk of sudden infant death syndrome (SIDS). If the mother is directly breastfeeding and the infant is experiencing GERD, talk with the mom about the infant’s positioning during a feed; the infant’s head, shoulders and hips should be in alignment and the baby should not be reaching awkwardly for the nipple. Ask if the infant feeds without taking a pause. If the infant is gulping during a feed, ask the mother to lean the infant forward to allow the milk to flow away from the nipple to pause for a few seconds and then return. Some studies suggest that decreasing or eliminating allergens in the mother’s diet can alleviate symptoms of GERD.  Mothers can be instructed on how to follow an exclusion diet restricting cows milk and eggs for a 2-4 week trial and then determine if symptoms are reduced. The symptoms of GERD and cow milk protein allergy are very similar and switching to an extensively hydrolyzed or elemental formula may reduce reflux episodes. When compared to formulas with intact proteins they have significantly faster gastric emptying time. One study found that the gastrointestinal transit time of extensively hydrolyzed formula was twice as fast as intact protein formula (7). It is believed that the decreased transit time promotes gastrointestinal hormone secretion, resulting in less GERD (6). GERD is a common issue for preterm infants and will continue to perplex clinicians, as each infant is unique and will respond to treatments differently. References

1. Rosen, R., Vandenplas, Y., Singendonk, M., Cabana, M., DiLorenzo, C., Gottrand, F., Gupta, S., Langendam, M., Staiano, A., Thapar, N., Tipnis, N., & Tabbers, M. (2018). Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of pediatric gastroenterology and nutrition, 66(3), 516–554. https://doi.org/10.1097/MPG.0000000000001889
2. Lightdale, J. R., Gremse, D. A., & Section on Gastroenterology, Hepatology, and Nutrition (2013). Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics, 131(5), e1684–e1695. https://doi.org/10.1542/peds.2013-0421
3. Eichenwald, E. C., & COMMITTEE ON FETUS AND NEWBORN (2018). Diagnosis and Management of Gastroesophageal Reflux in Preterm Infants. Pediatrics, 142(1), e20181061. https://doi.org/10.1542/peds.2018-1061
4. United States Food and Drug Administration. (2011, May 20). FDA: Do not feed SimplyThick to premature infants [press release]. Retrieved from https://wayback.archive-it.org/7993/20170112130913/http:/www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm256253.htm
5. Dutta, S., Singh, B., Chessell, L., Wilson, J., Janes, M., McDonald, K., Shahid, S.,     Gardner, V. A., Hjartarson, A., Purcha, M., Watson, J., de Boer, C., Gaal, B., &          Fusch, C. (2015). Guidelines for feeding very low birth weight infants. Nutrients, 7(1), 423–442. https://doi.org/10.3390/nu7010423
6. Yin, L. P., Qian, L. J., Zhu, H., Chen, Y., Li, H., Han, J. N., & Qiao, L. X. (2015). Application effect of         extensively hydrolyzed milk protein formula and follow-up in preterm children with a gestational         age of less than 34 weeks: study protocol for a randomized controlled trial. Trials, 16, 498.   https://doi.org/10.1186/s13063-015-1030-5
7. Mihatsch, W. A., Högel, J., & Pohlandt, F. (2001). Hydrolysed protein accelerates the gastrointestinal transport of formula in preterm infants. Acta paediatrica (Oslo, Norway : 1992), 90(2), 196–198. https://doi.org/10.1080/080352501300049442

 About the Author:

Cristina is a Texas based board certified pediatric dietitian working in the neonatal intensive care unit. She is new to freelance writing and looks forward to writing about her passion for pediatric nutrition.