Articulos

Gastroesophageal Reflux: A Critical Review of Its Role in Preterm Infants
Christian F. Poets, MD
ABSTRACT. There is widespread concern about gastroesophageal reflux (GER) in preterm infants. This article reviews the evidence for this concern. GER is common in infants, which is related to their large fluid intake
(corresponding to 14 L/day in an adult) and supine body
position, resulting inthe gastroesophageal junction’s being constantly “under water.” pH monitoring, the standard for reflux detection, is of limited use in preterm
infants whose gastric pH is >4 for 90% of the time. New
methods such as the multiple intraluminal impedance
technique and micromanometric catheters may be promising alternatives but require careful evaluation before
applying them to clinical practice. Acritical review of the
evidence for potential sequelae of GER in preterm infants shows that 1) apnea is unrelated to GER in most
infants, 2) failure to thrive practically does not occur with
GER, and 3) a relationship between GER and chronic
airway problems has not yet been confirmed in preterm
infants. Thus, there is currently insufficient evidence to
justify the apparently widespreadpractice of treating
GER in infants with symptoms such as recurrent apnea
or regurgitation or of prolonging their hospital stay, unless there is unequivocal evidence of complications, eg,
recurrent aspiration or cyanosis during vomiting. Objective criteria that help to identify those presumably few
infants who do require treatment for GER disease are
urgently needed. Pediatrics 2004;113:e128 –e132.URL:
http://www.pediatrics.org/cgi/content/full/113/2/ e 128;
lower esophageal sphincter, regurgitation, treatment indications.
ABBREVIATIONS. GER, gastroesophageal reflux; CMA, cow milk
protein allergy; TLESR, transient lower esophageal sphincter relaxation; GERD, gastroesophageal reflux disease; MII, multiple
intraluminal impedance; AOP, apnea of prematurity; NICU, neonatal intensive careunit.

G

astroesophageal reflux (GER) is common in
preterm infants, occurring on average 3 to 5
times per hour,1,2 but to what extent is it a
clinical problem? A recent survey of current practice
estimated that 19% of preterm infants admitted to US
teaching hospitals received cisapride.3 Thus, many
neonatologists seem to consider GER indeed a problem, but what is the evidence? Thisarticle revisits
the pathogenesis of GER in preterm infants and discusses methods for reflux detection, cow milk protein allergy (CMA) as a potential differential diagnoFrom the Department of Neonatology, University of Tuebingen, Tuebingen,
Germany.
Received for publication Aug 8, 2003; accepted Oct 6, 2003.
Reprint requests to (C.F.P.) Department of Neonatology, University of
Tuebingen,Calwerstrasse 7, D-72076 Tuebingen, Germany. E-mail: cfpoets@
med.uni-tuebingen.de
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Academy of Pediatrics.

e128

PEDIATRICS Vol. 113 No. 2 February 2004

sis, and clinical problems potentially resulting from
GER.
PATHOGENESIS OF GER IN INFANTS

Reflux may occur when the lower esophageal
sphincter relaxes. In an upright adult, gaswill exit
the stomach during these transient lower esophageal
sphincter relaxations (TLESRs), causing belching. In
a subject lying supine, however, the gastroesophageal junction is constantly under water, and liquid
instead of gas will enter the esophagus. The quantity
of the reflux depends on the fluid volume inside the
stomach. The volume of fluid given to an infant (180
mL/kg per day)would correspond to a daily intake
of 14 L/day in an adult. GER in an otherwise
healthy infant may simply serve as a pop-off valve to
cope with this high volume.4 Thus, GER may be a
completely normal phenomenon in infants, and its
frequent occurrence in this age group may be merely
a result of their age-specific body position and high
fluid intake. Whether GER will become clinically...