The Refluxing Preemie- Is this a Problem?

Transcription

1 The Refluxing Preemie- Is this a Problem? Richard J. Martin, M.D. Drusinsky-Fanaroff Chair in Neonatology Rainbow Babies and Children s Hospital Professor of Pediatrics Case Western Reserve University Cleveland, Ohio

2 Disclosures for Richard J. Martin, M.D. I have no actual or potential conflict of interest in relation to this program/presentation. I have no FDA disclosures.

3 The Dilemmas Aspirate Spitting Desat Apnea Bradycardia Regurgitation

4 Reflux in Infants Magnitude of pharmacotherapy Basis for a relationship with apnea Diagnostic options and dilemmas Rationale for therapeutic approaches What about ALTE s? Overall recommendations

5 ELBW Infants Discharged on Anti-Reflux Medication 100 All ELBW Infants Discharged <42 weeks Discharged >42 weeks Percent Going Home on GER Medications WF Malcolm, Pediatrics 2008

6 Percent going home on GER medications Variation in Use of Antireflux Medication at Discharge Among Network Centers Discharged <42 weeks Discharged >42 weeks Individual Centers Malcolm W F et al. Pediatrics 2008

7 Proposed Overused Neonatal Therapies: Survey of US Neonatologists* *personal communication, DeWayne Pursley, M.D., 2012

8 Reflux in Infants Magnitude of pharmacotherapy Basis for a relationship with apnea Diagnostic options and dilemmas Rationale for therapeutic approaches What about ALTE s? Overall recommendations

9 Percent of Centers Most Common Clinical Criteria for GER Diagnosis (UK NICU Center Survey) Feeding Intolerance Apnea Bradycardia Desaturation Milk in Mouth or Oropharynx Respiratory Problems Dhillon, Acta Pædiatr 2004

10 Apnea and GER: Common Features May be physiologically linked Manifestations of developmental immaturity Exhibit natural resolution APNEA GER

11 Reflex Pathways Activated by Lung and Airway Afferents Brainstem - INSP NEURONS + Vagus heart + Vagus airways Phrenic

12 Protective Responses Activated by Lung and Airway Afferents glottic closure bronchospasm cough apnea bradycardia swallow lower esophageal sphincter relaxation

13 Anatomy of the Gastroesophageal Junction Epstein, NEJM 1997

14 Possible Causal Relationship Between Apnea in Preterm Infants GER APNEA

15 Respiratory Control and LES Pressure Hypoxia-induced apnea DIA EMG (AU) 25 PLES (mmhg) 0 30 s Kiatchoosakun, Pediatr Res 2002

16 mmhg LES Pressure Associated with Apnea Onset LES Pressure Apnea Time Relative to Apnea Onset (sec) Omari, J Pediatr 2009

17 Possible Causal Relationship Between Apnea in Preterm Infants GER APNEA

18 ph Gastroesophageal Reflux and Apnea RR 38/min sec Herbst, J Pediatr 1979

19 Number of Apnea (per 12h) Apnea and Gastro-Esophageal Reflux in the Preterm Infant Number of ph Based Reflux Episodes (per 12h) Barrington, J Perinatol 2002

20 Reflux in Infants Magnitude of pharmacotherapy Basis for a relationship with apnea Diagnostic options and dilemmas Rationale for therapeutic approaches What about ALTE s? Overall recommendations

21 Diagnostic Modalities Esophageal ph probe Multiple intraluminal impedance Combined ph and impedance Gastric emptying Ultrasonography Manometry

22 Reflux Index (%) 13 Reflux Index * Percentiles in Healthy Infants Age in Months *percent of time with ph < Vandenplas, Pediatrics 1991

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24 Gastroesophageal Reflux and Apnea of Prematurity GER (Impedance) Pharynx Esophagus Airflow Effort Peter CS, et al, Pediatr 2002

25 Median GER Events/hr Rates of Reflux Events Before and After Feeding Before Feed After Feed Acid Non-Acid Slocum, J Perinatol 2009

26 centimeters Median Height of Esophageal Reflux in Preterm Infants 10 8 Pre-Feed Post-Feed p= Slocum, J Perinatol 2009

27 Relationship between ph-mii Impedance Determined Reflux and PSG Determined Apnea in Preterm Infants Number of Apneas per Minute 0, 5 0, 4 * * * all p<0.05 * 0, 3 0, 2 0, 1 0 GER free period 1 min around GER 30 sec before GER 30 sec after GER Corvaglia L, et al. Arch Dis Child 2008

28 Non-acid (as opposed to acid)-ger is responsible for a variable amount of apnea detected after GER. 2011

29 Percent of Events Incidence of Cardiorespiratory Events 5 Preceded by GER % 3.4% 2.8% 2.9% All Apnea >10 sec Desaturation <85% Bradycardia <80bpm DiFiore, J Perinatol 2010

30 Reflux in Infants Magnitude of pharmacotherapy Basis for a relationship with apnea Diagnostic options and dilemmas Rationale for therapeutic approaches What about ALTE s? Overall recommendations

31 Rationale for GER Therapy Feeding intolerance-symptomatic GERD Apnea, bradycardia, desaturation episodes Growth failure? Risk of respiratory morbidity, e.g. wheezing disorders, worsening BPD

32 GER versus GERD!! Infants suspected of GERD have more frequent regurgitation, vomiting and crying than healthy control infants. However, clinical history and questionnaires cannot predict the severity of GERD. Therefore a highly sensitive and specific method to select infants for investigation and empiric pharmacotherapy still needs to be developed Salvatore S, J Pediatr Gastroenterol Nutr 2005

33 Percent Time ph<4 Physician Perceived Symptoms Do Not Identify Healthy Preterm Infants with Significant GER ± ± Control Physician Referral Hibbs AM, PAS 2010

34 % of Physicians reporting likelihood that Symptoms are caused by GERD, based on overall clinical impression * Irritability * Failure to Thrive * Feeding Intolerance * Apnea * Wheezing * Worsen. lung disease % reporting % reporting Very or Somewhat Unlikely Very or Somewhat Likely Neo. GI Pulm. % of Physicians reporting Effectiveness of therapies for GERD, based on overall clinical impression Golski C., Pediatrics 2009 * Positional changes

35 Our data indicate that otolaryngologists vary significantly in their ratings of the various laryngoscopic physical findings that could be associated with LRPD. We found relatively poor inter-rater reliability for all of the visually assessed variables. Laryngoscope 2002

36 Non-Pharmacologic Approaches Thickened feeds Positioning Nasojejunal feeds

37 Optimal Feed Thickener?

38 Thickened Feeds and Reflux: Frequency of Emesis Study Treatment N Control N Standardized Mean Difference 95% CI Moya Orenstein Wenzl Total (95%CI) Copyright 2007 The Cochrane Collaboration, John Wiley & Sons, Ltd

39 Effect of Increased Enteral Viscosity (Sodium Alginate) on Apnea and Reflux in Preterm Infants Control Treatment p-value Apnea Index 9.5 (0-35) 9.5 (0-44) NS Acid GER Index 3 (0-16) 1 (0-5) Non-acid GER Index 6 (1-21) 4.5 (0-22) NS Corvaglia, et al., Early Hum Dev, 2011

40 U.S. Department of Health & Human Services FDA U.S. Food and Drug Administration FDA Warns Not to Feed SimplyThick to Premature Infants UPDATE: June 5, 2011: Simply Thick Recalled, FDA Continues to Investigate Necrotizing Enterocolitis and SimplyThick

41 abc NEWS Arsenic in Rice: New Report Finds Worrisome Levels A major consumer magazine is warning Americans to limit how much rice they eat because of concerns over arsenic and the FDA is investigating the matter. Rice eaten once a day can drive arsenic levels in the human body up 44 percent. 2012

42 Positioning and Reflux: How do they do it?

43 Positioning and Reflux Postprandial GER is enhanced in the right lateral [right side down] and supine positions However, the right lateral position promotes gastric emptying Potential benefit of these positions for inpatients must be balanced against the back to sleep message for SIDS prevention

44 Positioning and Reflux Vandenplas, Arch Dis Child 2010

45 Major Candidates for Pharmacotherapy in Neonates Prokinetics metoclopramide, cisapride, erythromycin Acid suppression proton pump inhibitors histamine (H 2 receptor) antagonists

46 Efficacy of Oral Erythromycin for Treatment of Feeding Intolerance in Preterm Infants 0.00 Nuntnarumid P, Kiatchoosakun P, Tantiprapa W and Boonkasidecha S J Pediatr 2006;148: Placebo* *p value = < Erythromycin Time to Full Feeding

47 Gastroesophageal Reflux Medications for Apnea * * Before Treatment After Treatment p < Cisapride Metoclopramide Kimball and Carlton, J Pediatr 2001

48 Number of Bradycardia Episodes Cross-Over Trial of Treatment for Bradycardia Attributed to Gastroesophageal Reflux * p = Drug Metoclopromide or Ranitidine Placebo Wheatley, J Pediatr. 2009

49 Association of H2-Blocker Therapy and Higher Incidence of Necrotizing Enterocolitis in Very Low Birth Weight Infants Guillet, et al, Pediatrics, 2006 NICHD Neonatal Research Network

50 Efficacy and Safety of Proton Pump Inhibitor Therapy in Infants with GERD* Lansoprazole n=81 Placebo n=81 p value Efficacy rate 54% 54% NS All adverse events 62% 46% NS Severe adverse events 12% 2%.032 *term infants or preterms >44 wk PMA Orenstein, J Pediatr 2009

51 Ranitidine is Associated with Infections and Necrotizing Enterocolitis in Preterm Infants (24-32 weeks Gestational Age) No Treatment Treatment Odds Ratio Infection (%) ( ), p<0.001 NEC (%) ( ), p=0.003 Terrin G, Pediatrics 2012

52 Medications Commonly Used to Treat Gastroesophageal Reflux Disease in Infants in the United States Drug Class Robust Evidence for Effectiveness in Infants Safety Concerns Gastric Acid Suppression H 2 Receptor Antagonists No Yes Proton pump Inhibitors No Yes Prokinetics Metoclopramide No Yes Erythromycin No Yes Hibbs A, NeoReviews 2011

53 Reflux in Infants Magnitude of pharmacotherapy Basis for a relationship with apnea Diagnostic options and dilemmas Rationale for therapeutic approaches What about ALTE s? Overall recommendations

54 Case Scenario Former 37 weeks male now 42 weeks post menstrual age Found 1 hour after feeding; coughing and choking with formula in nose and mouth; face turned blue and reported apneic Mother picked him up, blew in his face, rubbed his back, gave rescue breaths and called Emergency Medical Service (EMS) When EMS arrived he appeared well Admitted for overnight, pneumogram (respiratory inductance plethysmography, pulse oximetry), and esophageal ph with impedance

55 Apparent Life-Threatening Event Admissions and GERD Doshi A, Pediatr Emer Care 2012

56 Disposition of ALTE Admissions at Rainbow ( ) n=100 GI Meds Other No Intervention Feeding Intervention Home Monitor

57 Potential Perpetuating Cycle of Apnea and GER Decreased LES Pressure Apnea GER/ Regurgitation Activation of Upper Airway Receptors

58 Reflux in Infants Magnitude of pharmacotherapy Basis for a relationship with apnea Diagnostic options and dilemmas Rationale for therapeutic approaches What about ALTE s? Overall recommendations

59 GER Pharmacotherapy: Recommendations Avoid therapeutic exuberance Seek evidence for benefit in the individual patient Discontinue therapy if symptoms not improved Short and long term safety of pharmacotherapy must be a high priority Therapy started in the NICU may be continued indefinitely

60 Acknowledgement Juliann DiFiore, BS Marina Arko, RN Anna Maria Hibbs, MD, MSCE