Introduction
Gastroesophageal reflux (GER) and constipation are gastrointestinal (GI) disorders that may affect patients while in the NICU. The impact that GER and constipation have on patient outcomes during admission vary based on other patient conditions. However, both disorders may adversely affect a neonate’s enteral feeding tolerability. Properly addressing GER and constipation through nonpharmacologic or pharmacologic interventions is paramount for adequate enteral feeding in neonatal populations.
Gastroesophageal Reflux
Epidemiology
Regurgitation or GER is a normal process in neonates. Neonates have anatomical and physiological characteristics leading to GER such as decreased lower esophageal sphincter pressures, immature peristalsis, shorter esophageal length, and delayed gastric emptying to a lesser extent.1,2 In the first months of life, reflux is present with a peak incidence at approximately 4 months of age.3 GER typically resolves by 1 year of age.3–5 Gastroesophageal reflux disease (GERD), pathologic GER, is rare in neonatal populations.
Presentation
Neonates presenting with anemia, blood in stool, failure to thrive, food refusal, hematemesis, and swallowing difficulties should be evaluated for GER and GERD. Risk factors for GERD are prematurity and congenital abnormalities of the central nervous system, chest, GI tract, heart, lungs, or oropharynx.6 Acute signs and symptoms of GERD in neonates are back arching during or after feedings, crying and irritability, food refusal, and regurgitation or vomiting. Long-term signs and symptoms include poor weight gain and failure to thrive.7
Treatment
Nonpharmacologic
The goal of treatment is to relieve symptoms while preventing complications. In 2004, a survey was conducted of GERD treatment approaches in 77 NICUs. Body positioning (98%), feed thickening (98%), and placing the neonate on a slope (96%) were used most often as nonpharmacologic approaches.8 Body positioning improves GER symptoms. Approaches related to body positioning include head of bed elevation, left lateral position, prone position, and upright posture in seats.9,10 Prone and left lateral positioning increase the risk of sudden infant death syndrome,7 although left lateral position decreases GER compared to head of bed elevation.9 Thickening feeds have proven to reduce nonacid GER frequency and height in infants. However, no differences in acid GER were experienced. Thickening feeds may be an option to reduce symptomatic nonacid GER.11 Both intermittent and continuous enteral feeding strategies have been studied to determine the best approach to reduce GER symptoms. Because data are inconclusive, no specific feeding method is recommended at this time.12 Insufficient evidence suggests non-nutritive sucking as a treatment approach.13
Pharmacologic
In a survey of 77 NICUs conducted prior to the 2009 guideline publication,7 the pharmacologic treatment approaches consisted of H2-receptor antagonists (H2RAs) (100%), antacids (96%), and proton-pump inhibitors (PPIs) (65%).8 The two classes of medications most often used in practice for recurrent symptoms are acid-suppressant agents: PPIs and H2RAs. PPIs are superior to H2RAs in healing erosive esophagitis. Occasional symptoms may be treated with alginate, buffering agents such as calcium carbonate, or sucralfate. However, these agents are not recommended for long-term use.7
Most studies comparing lansoprazole, omeprazole isomers, or pantoprazole to placebo in neonates and infants have conflicting efficacy evidence but demonstrate select benefit.14–19 A meta-analysis and reviews concluded that even though PPIs are well tolerated in short-term use, they are not effective in reducing GERD symptoms in infants.20–23 A prospective study using both nonpharmacologic and pharmacologic approaches determined a PPI in combination with left lateral positioning was most effective in esophageal acid exposure and GER episode reductions.9 In infants, H2RAs were more effective than placebo in controlling GER symptoms. PPIs and H2RAs did not differ significantly in GER-related outcomes.24 H2RAs are recommended for acute symptom treatment. When used in very low birth weight infants, H2RAs have shown an increased risk of necrotizing enterocolitis (NEC) requiring astute evaluation of risk versus benefit of acute GER symptoms.25,26 Prokinetic agents such as bethanechol, erythromycin, and metoclopramide are not recommended for GERD treatment.7
Constipation
Epidemiology
Constipation in the first year of life is close to 2.9% overall. Approximate prevalence during the first 6 months of life for 0 to 2 months of age, 2 to 4 months of age, and 4 to 6 months of age are 1%, 6%, and 7%, respectively.27 Infrequent bowel movements do not solely represent or diagnose constipation in neonates. Constipation is often described by stool frequency and consistency as well as the ease of bowel movements.28 Stooling frequency varies based on neonatal diet. Human milk-fed patients
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