NICU patients with gastroesophageal reflux disease

Specialties NICU

Published

I am a NICU nurse working on a research project. GERD is a common problem in the neonatal population. Acid suppressor medication use has increased dramatically despite evidence to prove that GERD is the problem behind specific clinical symptoms. Medication use is risky in neonates because of their age and instability.

As a fellow NICU nurse, what are your thoughts and/or assumptions about GERD in neonates?

How is it addressed and/or treated where you work?

How common is it in your population?

How do you explain it to families?

Up Vote Up Vote ×
Specializes in NICU, PICU, PCVICU and peds oncology.

I really hate how the pharmaceutical industry has led to labeling everything a disease. Gastroespohageal reflux is not necessarily a "disease". And most babies who spit up are not suffering from anything other than an immature digestive tract. But the minute spitting up is labeled a disease, parents demand pharmacologic treatment. In my practice I see far too many very young infants being given PPIs like omeprazole or lansoprazole for symptoms that are inconvenient but not dangerous. The only children who require treatment are those who aren't growing appropriately or who have proven aspiration. By treating them with drugs that were never tested on children but which are known to have serious side effects (neuropsychiatric disorders, osteoporosis, reduction of nutrient absorption - especially Fe, Mg, Ca and B12, alteration in metabolism of other drugs, increased risk of pneumonia and C. diff, increased incidence of spontaneous bacterial peritonitis and renal effects) we're creating a slew of new problems. When I first started my nursing career, I worked with prems, many of whom were on cisapride for GER. Cisapride was removed from the US market altogether around the time I left the neonatal work due to its association with torsades de pointes. Even domperidone isn't without concern: it penetrates the immature blood-brain barrier and it causes prolonged QT. Since infants are at very low risk for Barrett's esophagus or diabetic gastroparesis, the main reasons for treating adults with severe GER, I don't see a role for pharmacologic treatment for most babies.

It's interesting that you brought this subject up now. This article appeared in Medscape Pediatrics this week and tackles the issue quite well. http://www.medscape.com/viewarticle/827265_3 The authors give a very nice script for talking to parents about why it would be better to just do more laundry.

Up Vote Up Vote ×
Specializes in NICU, PICU, PACU.

So many of our kids have GERD! We are getting away from Reglan and only using Pepcid for the most part.

We are treating symptoms such as ALTE's with meds but other kids who are pukers, not showing signs of feeding aversions and are gaining weight get the HOB up or in the infant seat treatment, occasionally we use rice to thicken formula. We also try to get them to all PO feeds as soon as they can, to get rid of that tube which is always holding the sphincter open.

Our peds surgeons are also discouraging Nissans due to long term issues with this procedure. The kids who get this are only the kids who are at risk for aspiration.

We tell parents that many times kids will outgrow this as the sphincter between the stomach and esophagus matures and tightens up.

Up Vote Up Vote ×
Specializes in NICU.

Smaller NICU here..we don't treat for reflux too often. We went through a phase of using Reglan a lot (but then we went through a phase of NEC, so the Reglan stopped). Usually we just use reflux precautions (HOB elevated, positioning, ect.). Rarely, we will use rice to thicken formula.

Interestingly (at least to myself), I've been on a PPI for >10 years (and I'm a youngin'). I'm curious what the long term effects will be for myself. I have to have a bone density scan and an EGD in the next month.

Up Vote Up Vote ×
Specializes in NICU, ICU, PICU, Academia.
I really hate how the pharmaceutical industry has led to labeling everything a disease. Gastroespohageal reflux is not necessarily a "disease". And most babies who spit up are not suffering from anything other than an immature digestive tract. But the minute spitting up is labeled a disease, parents demand pharmacologic treatment. In my practice I see far too many very young infants being given PPIs like omeprazole or lansoprazole for symptoms that are inconvenient but not dangerous. The only children who require treatment are those who aren't growing appropriately or who have proven aspiration. By treating them with drugs that were never tested on children but which are known to have serious side effects (neuropsychiatric disorders, osteoporosis, reduction of nutrient absorption - especially Fe, Mg, Ca and B12, alteration in metabolism of other drugs, increased risk of pneumonia and C. diff, increased incidence of spontaneous bacterial peritonitis and renal effects) we're creating a slew of new problems. When I first started my nursing career, I worked with prems, many of whom were on cisapride for GER. Cisapride was removed from the US market altogether around the time I left the neonatal work due to its association with torsades de pointes. Even domperidone isn't without concern: it penetrates the immature blood-brain barrier and it causes prolonged QT. Since infants are at very low risk for Barrett's esophagus or diabetic gastroparesis, the main reasons for treating adults with severe GER, I don't see a role for pharmacologic treatment for most babies.

It's interesting that you brought this subject up now. This article appeared in Medscape Pediatrics this week and tackles the issue quite well. http://www.medscape.com/viewarticle/827265_3 The authors give a very nice script for talking to parents about why it would be better to just do more laundry.

This a HUNDRED BILLION times!!!!! ^^^^^^^

Up Vote Up Vote ×

Do any of your facilities actually test for GERD (24 hour pH impedance study) or do they just presume and treat?

Up Vote Up Vote ×
Specializes in NICU, PICU, PACU.

We haven't done that test in years. if it is severe enough they get a milk scan or UGI prior or a GT and Nissan procedure. Otherwise is is symptomatic treatment.

Up Vote Up Vote ×
Specializes in Neonatal ICU (Cardiothoracic).

For our babies who we believe are actually refluxing above what we'd expect for 1- a normal neonate and 2- floppy preterm LE sphincter, our SLP will do a video esophagram which can assess reflux. We have an incredibly hard time getting pH probes done, since a lot of those "refluxers" are on continuous feeds which alters results. Our stepdown attending uses a lot of lansoprazole, but we do our best to avoid any PPIs or H2 antagonists, since especially meds like Zantac are horrid on preemie bellies and immune systems. In most cases we will try thickening feeds, since meds don't stop the reflux, only maybe the pain from the reflux.

Up Vote Up Vote ×

Is that because of lack of resources/equipment or MD preference?

Up Vote Up Vote ×

At what corrected age do you add the rice to thicken?

Up Vote Up Vote ×
+ Add a Comment