The team from leed have highlighted a very important area of neonatal practice that is still seeking clarification and enlightenment. Neonates do have a high incidence of reflux due to physiologic and iatrogenic causes. These have been clearly highlighted in this review. The choice and rationale for treating these babies clearly shows that more work still needs to done before we can be sure that the doctors and nurses are using appropriate measures to address the real problem and not just propagating a placebo effect and using medications that are not only unnecessary but potentially dangerous. The following questions may help to concentrate the thinking about this problem.

Do we know if reflux in neonates is the cause of apnoeas? If not why treat If we believe there is an association in the absence of aspiration, what is the mechanism? It is agreed that the stomach of milk fed neonate is unlikely to suffer from the effect of acid (buffering effect) what then is the rationale for prescribing gaviscon? Could it be acting as a thickening agent? In the absence of proven oesophageal irritation or inflammation why do we need to further reduce acid production by using H2 blocker or even worse a proton pump inhibitor in the face of significant side effects with this substance? Is there a place for using ph study with modified (acidified) feeds for testing to demonstrate acid reflux and how significant is the position of non acid reflux in this group of patients? Should positioning not be routinely adhered to as part of routine neonatal care since gastro oesophageal reflux is common in this age group? Surgical intervention in my experience is mainly offered for severe reflux especially in patients with neurological disease or do the authors have a different experience? Is contrast study underused in these patients? And could this be a better test in this uncertain field? I concede that reflux episde may be missed during this test but its presence can be noted in addition to any anatomical defect. Although I have raised a few questions, I appreciate the efforts of the authors who have tried to highlight the clear difficulties with the investigation and treatment of reflux in this age group. Neonatologists in the front line have to deal with problems using best evidence and in most cases extrapolate from management strategies of older children. It is how ever the time to look again at the evidence and adjust practice accordingly. I remember not long ago cisapride was the standard prokinetic agent used to treat gastroesophageal reflux in neonatal units even when the evidence was not there. Tertiary neonatal units had in their formularies this dangerous medicine which was dished out routinely and thanks to the responsible authorities for the withdrawal of this product from the UK, meaning that neonates have been spared the dangers of arrhythmias. I have an interest in paediatric gastroenterology and have practised in a DGH with sessions in gastroenterology at the Children's hospital. In my practice I have investigated neonates with symptoms suggestive of gastroesophageal reflux and also suggested and advised on treatment regimes. Having looked at the evidence, I still advice on ph studies with its flaws after initiation of treatment which had failed to resolve the observed symptoms. In addition, neonates with acute life threatening events in addition to Ph studies are subjected to contrast studies to make sure no anatomical defect exists. On the use of pharmacology agents, my emphasis is on the use of prokinetic agents and less of H2 blockers or proton pump inhibitors unless evidence of oesophagitis exists or the neonate is not enterally fed with milk while symptomatic. In my experience, surgical intervention for managing gastroesophageal reflux is only common with those neonates with neurological problem with severe reflux disease. The take home message for me after reading this article is that there is a presumption by some medical practitioners that gastroesophageal Reflux disease is associated with neonatal apnoes and bradcardias and also that no reliable form of investigation exists to confirm this and that pharmacological agents though lacking in evidence remain the mainstay of treatment. It also tells me that more research is needed to provide the necessary answers. I will be very willing to be a participant in any such study.

Reference:

Peter CS, Sprodowski N, Bohnhorst B,et al Gastroesophageal reflux and apnoea of prematurity: No temporal relationship. Pediatrics 2002;109:8-11

Birch JL; Newell SJ; Gastroesophageal reflux disease in preterm infants: Current management and diagnostic dilemmas ; Arch Dis Child fetal Neonatal Ed 2009;94:F379-F383 doi:10.1136/adc.2008.149112.

Dhillon AS, Ewer AK Diagnosis and management of gastroesophageal reflux in preterm infants in neonatal intensive care units. Acta Paediatrica 2004;93:88-93

Omari TI, Haslam RR, Lundborg P, et al Effect of omeprazole on acid gastroesophageal reflux and gastric acidity in preterm infants with pathological acid reflux. J Pedr Gastroenterol Nutr 2007;44:41-44.

Conflict of Interest:

None declared

The team from Leeds have highlighted a very important area of neonatal practice that is still seeking clarification and enlightenment.Neonates do have a high incidence of reflux due to physiologic and iatrogenic causes.These have been clearly highlighted in this review.The choice and rationale for treating these babies clearly shows that more work still needs to done before we can be sure that the doctors and nurses are using appropriate measures to address the real problem and not just propagating a placebo effect and using medications that are not only unnecessary but potentially dangerous. The following questions may help to concentrate the thinking about this problem. Do we know if reflux in neonates is the cause of apnoeas? If not why treat. If we believe there is an association in the absence of aspiration, what is the mechanism?. It is agreed that the stomach of milk fed neonate is unlikely to suffer from the effect of acid (buffering effect) what then is the rationale for prescribing gaviscon? Could it be acting as a thickening agent?. In the absence of proven oesophageal irritation or inflammation why do we need to further reduce acid production by using H2 blocker or even worse a proton pump inhibitor in the face of significant side effects with this substance?. Is there a place for using ph study with modified (acidified) feeds for testing to demonstrate acid reflux and how significant is the position of non acid reflux in this group of patients?. Should positioning not be routinely practised as part of routine neonatal care since gastro oesophageal reflux is common in this age group? Surgical intervention in my experience is mainly offered for severe reflux especially in patients with neurological disease or do the authors have a different experience? Is contrast study underused in these patients? And could this be a better test in this uncertain field?.

Although I have raised a few questions, I appreciate the effort of the authors who have tried to highlight the clear difficulties with the investigation and treatment of reflux in this age group. Neonatologists in the front line have to deal with problems using best evidence and in most cases extrapolate from management strategies of older children. It is however the time to look again at the evidence and adjust practice accordingly. I remember not long ago cisapride was the standard prokinetic agent used to treat gastroesophageal reflux in neonatal units even when the evidence was not there. Tertiary neonatal units had in their formularies this dangerous medicine which was dished out routinely and thanks to the responsible authorities for the withdrawal of this product from the UK for managing this problem,meaning that neonates have been spared the dangers of arrhythmias. I have an interest in paediatric gastroenterology and have practised in a DGH with sessions of gastro-enterology at the Childrens hospital. In my practice I have investigated neonates with symptoms suggestive of gastroesophageal reflux and also suggested and advised on treatment regimes.Having looked at the evidence,I still advice on ph studies with it's flaws after initiation of treatment which had failed to resolve the observed symptoms. In addition, neonates with acute life threatening events in addition to Ph studies are subjected to contrast studies to make sure no anatomical defect exists. On the use of pharmacology agents, my emphasis is on the use of prokinetic agents and less of H2 blockers or proton pump inhibitors unless evidence of oesophagitis exists or the neonate is not enterally fed with milk while symptomatic. In my experience, surgical intervention for managing gastroesophageal reflux is only common with those neonates with neurological problem with severe reflux disease. The take home message for me after reading this article is that there is a presumption by some medical practitioners that gastroesophageal Reflux disease is associated with neonatal apnoeas and bradcardias and also that no reliable form of investigation exists to confirm this and that pharmacological agents though lacking in evidence remain the mainstay of treatment. It also tells me that more research is needed to provide the necessary answers. I will be very willing to be a participant in any such study which is now over due.

References: Peter CS, Sprodowski N, Bohnhorst B, et al Gastroesophageal reflux and apnoea of prematurity: No temporal relationship.Pediatrics 2002;109;8 to 11.

Birch JL; Newell SJ; Gastroesophageal reflux disease in preterm infants: Current management and diagnostic dilemmas ; Arch Dis Child fetal Neonatal Ed 2009;94:F379-F383 doi:10.1136/adc.2008.149112

Dhillon AS, Ewer AK Diagnosis and management of gastroesophageal reflux in preterm infants in neonatal intensive care units. Acta Paediatrica 2004;93:88-93.

Omari TI, Haslam RR, Lundborg P, et al Effect of omeprazole on acid gastroesophageal reflux and gastric acidity in preterm infants with pathological acid reflux. J Pedr Gastroenterol Nutr 2007;44:41to44.

Conflict of Interest:

None declared