Diagnosing GERD in Neonates? Be Cautious

Approximately 10 percent of infants born preterm in the United States are diagnosed with gastroesophageal reflux disease (GERD). But it’s almost certain that not all of those babies actually have GERD, say neonatologists at Nationwide Children’s Hospital.

The probable over diagnosis leads to unnecessary treatment, which may have unintended consequences, according to Sudarshan Jadcherla, MD, director of the Neonatal and Infant Feeding Disorders Program and the Neonatal Aerodigestive Pulmonary Program at Nationwide Children’s.

During the last 20 years, Dr. Jadcherla and his teams have developed or standardized tests that measure reflux and aerodigestive reflexes in babies treated in neonatal intensive care units. These instrumental techniques have found that some babies who were presumed to have GERD did not have the disease.

“There is no consensus about how best to make the diagnosis of GERD in neonates,” says Dr. Jadcherla, who is also a professor of Pediatrics at The Ohio State University College of Medicine “Most neonatologists, gastroenterologists and ear, nose and throat specialists make the diagnosis subjectively based on airway and digestive symptoms – breathing disturbances, cough, spit up, irritability, arching and feeding difficulties. It’s true that GERD can cause those symptoms. Many other conditions can cause those symptoms as well, though.”

A diagnosis of GERD may lead a clinician to change feeding strategies for a baby, like cutting down volumes, increasing caloric density, adding thickeners or even changing the type of feeds altogether. All of those strategies have problems potentially associated with them, including the risk of not providing proper overall nutrition.

Perhaps most importantly to Dr. Jadcherla and his colleagues, a GERD diagnosis may result in the prescription of acid suppressive medications for a neonate. Since 2006, several published studies have associated histamine-2 receptor antagonists and proton pump inhibitors with infections, necrotizing enterocolitis, bone density changes, and malabsorption of nutrients, as well as increased risk of death in babies born preterm.

Dr. Jadcherla was the senior author of a study published in July in The Journal of Pediatrics showing that 23.8 percent of babies treated in 43 children’s hospital NICUs in the United States received these acid suppressive medications from January 2006 through March 2013.

The percentage has decreased in recent years as the negative associations have become better known. Still, a GERD diagnosis often leads to an acid suppressive therapy. Dr. Jadcherla notes that even if GERD is confirmed, stomach acid may not be the cause; stomach acid actually protects vulnerable neonates from some pathogenic organisms and is useful in other ways, so suppression can have negative effects.

Large-scale, well-controlled, long-term trials are needed to define true guidelines for diagnosing GERD, to learn how prevalent it is and to test multimodal therapies. For now, Dr. Jadcherla recommends 24-hour pH impedance and manometry studies, combined with observed symptoms, before making a diagnosis.

“Neonatologists should be cautious about diagnosing GERD without objective tests,” he says. “Even if diagnosis and a decision to treat are made, the treatment should be a defined, short course based on improvement of symptoms.”

References:

1. Slaughter J, Stenger M, Reagan P, Jadcherla S. Neonatal histamine-2 receptor antagonist and proton pump inhibitor treatment at United States Children’s Hospitals. The Journal of Pediatrics. 2016 July;174:63-70.
2. Jadcherla SR, Slaughter JL, Stenger MR, Klebanoff M, Kelleher K, Gardner W. Practice variance, prevalence, and economic burden of premature infants diagnosed with GERD. Hospital Pediatrics. 2013 Oct; 3(4): 335-341.