Reflux in Preemies

A very common condition in premature babies

Attempting to bottle feed a preemie.
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In This Article

Many premature babies are diagnosed, either during their NICU stay or after, with gastroesophageal reflux (GER)—otherwise known simply as reflux—which results in the contents of the stomach moving back up through the esophagus.

Physical immaturity plays a role in this, as does feeding. And while it can be difficult to watch your preemie become so unsettled by reflux symptoms, it can be comforting to know that most babies outgrow the condition as they mature.

Causes

Reflux occurs as a result of the transient relaxation of the lower esophageal sphincter (LES)—a circular ring of muscle located at the end of the esophagus that naturally opens to allow food to enter the stomach, but then tightens and closes to prevent stomach contents from going the other way.

Reflux happens when the LES does not close all the way (relaxes), allowing the contents of a baby's stomach to come up into the esophagus in small or large amounts that are sometimes visible as spit up or vomiting.

The transient relaxation of the LES is actually a normal phenomenon, but it may occur at a higher frequency in premature infants due to receiving relatively large volume liquid feedings while supine (lying on their back).

With the supine feeding position, instead of allowing gravity to pull milk into the stomach, some of the milk ends up sitting in the gastroesophageal junction (where the stomach joins the esophagus). Here, the milk is more accessible to reflux back into the esophagus when the LES relaxes.

Having a shorter and narrower esophagus, which displaces the LES, may also contribute to reflux in premature babies.

Symptoms and Complications

Many symptoms have been attributed to GER in premature infants, such as:

  • Significant irritability
  • Refusing to eat or only taking very small feedings
  • Choking, gagging, or coughing with feedings
  • Signs of discomfort when feeding like back arching or grimacing
  • Frequent and/or forceful vomiting

That said, studies have not shown a direct link between these nonspecific symptoms and GER. This means that if a baby is exhibiting any of the above symptoms, one cannot say that it's definitely occurring as a result of GER—there may be something else going on.

In addition to the above symptoms, GER may (perhaps not always directly) lead to various complications, including failure to thrive, esophagitis (inflammation of the esophagus), and lung aspiration.

Research shows that premature babies with GER have longer hospital stays compared to premature babies without GER. Some of the above complications may contribute to these longer hospitalizations.

Associated Health Conditions

In addition to the above symptoms and complications, GER is linked, albeit controversially, to two health conditions that are may occur in premature babies—apnea and chronic lung disease.

Apnea

Like GER, apnea (when a baby stops breathing) is a very common diagnosis in premature infants. Experts once thought that GER could trigger apnea and associated bradycardia (low heart rate) in premature infants. However, the scientific evidence supporting this link is scant.

In fact, studies have found no temporal connection between GER and apnea/bradycardia. For instance, researchers in one study performed 12-hour overnight studies in 71 preterm infants. They found that less than 3% of all cardiorespiratory events (defined as apnea greater than or equal to 10 seconds in duration, bradycardia less than 80 beats per minute, and oxygen desaturation less than or equal to 85%) were preceded by GER.

If your baby has both GER and/or apnea, be sure to speak to your doctor about how to best manage these separate conditions.

Chronic Lung Disease

There is some evidence to suggest that GER may be associated with underlying lung disease in premature babies—specifically, those with a lung condition called bronchopulmonary dysplasia or BPD. The thought is that stomach contents may be aspirated into the lungs and that this could contribute to the worsening of a baby's BPD.

The GER/BPD connection has not been fully teased out. More studies are needed to determine if there is a causal relationship.

When to See a Doctor

GER is very common in babies, especially premature babies, and often times resolves on its own. So if your baby is spitting up a lot but seems happy and is growing, then you can put your mind at ease—this is normal and will pass.

While they may be bothersome, frequent spit-ups in premature babies have not been found to cause problems with growth or nutritional deficiencies.

Still, if your baby is exhibiting more worrisome signs or symptoms, it's important to talk with your doctor. Specifically, get a medical opinion if your child:

  • Resists feeds
  • Chokes on spit-up
  • Has frequent or forceful vomiting
  • Shows discomfort when feeding (e.g., crying or arching her back)
  • Is not gaining weight

In these instances, GER may be the underlying problem or there may be something else going on.

Diagnosis

Most cases of GER in premature infants are diagnosed clinically, meaning the doctor will assess the baby for typical symptoms of GER and also rule out alternative reasons and diagnoses (for example, cow's milk protein allergy, constipation, infection, or neurological disorders).

In some cases, a doctor may recommend a trial of acid-suppressing medication for the baby in order to establish the diagnosis.

Less commonly, diagnostic tests—esophageal pH and multiple intraluminal impedance monitoring—are used to diagnose GER in preterm babies. These tests can be technically difficult to perform, and the results can be challenging to interpret.

Esophageal pH Probe

This test entails placing a thin tube called a catheter through a baby's nose into the lower part of the baby's esophagus. At the tip of the catheter is a sensor, which can measure the pH of the stomach contents. This information is recorded over a 24-hour period on a monitor that is connected to the catheter.

Multiple Intraluminal Impedance

Multiple intraluminal impedance (MI) also entails placing a catheter into the baby's esophagus. GER is detected by measured changes in the electrical resistance of a liquid bolus, as it moves between two electrodes located on the catheter. This information can help determine whether the bolus is moving antegrade (being swallowed and traveling towards the stomach) or retrograde (being refluxed back from the stomach).

Treatment

Keeping stomach contents down in the stomach, and not up in the esophagus, is the goal of treating GER. Many options to help with this exist.

While medication may be recommended, it is typically only suggested after trying other non-medication interventions first.

Positioning

After feeding, many pediatricians recommend keeping your baby in an upright position as much as possible. Keeping your infant in a prone and left-side-down position can also be effective, but only when your baby is awake and being supervised.

When it comes to sleeping, your baby needs to be on her back, regardless if she has GER or not. In addition, your baby should sleep on a flat and firm mattress, that contains no pillows, blankets, toys, or bumpers.

Furthermore, according to the American Academy of Pediatrics, devices used to elevate the head of a baby's crib (e.g., wedges) should not be used. They are not effective in reducing GER and are also dangerous, as they increase the risk of the baby rolling into a position that may cause breathing difficulty.

Milk and Formula

Sometimes, reflux may be related to a baby not tolerating certain proteins in their milk. Mothers who are breastfeeding their preemie with reflux may well be advised to eliminate some common problem foods such as dairy, eggs, soy, or certain meats, as these proteins can pass through breast milk. 

When preemies with reflux are fed formula, the same thing may be true—something in the formula may be triggering the poor digestion or irritating your baby. In these cases, your doctor may recommend an extensively-hydrolyzed formula, such as Similac Alimentum or Enfamil Nutramigen.

These formulas are technically for babies who cannot digest or are allergic to cow's milk protein, but they may help reduce symptoms in babies with GER as well.

Preemies may require specialized baby formulas, so you should not switch to a new one until you get the green light from your doctor.

Feeding Adjustments

Research suggests that giving smaller-volume feedings more frequently may be helpful.

Sometimes, parents are advised to use thickening agents such as rice cereal added to milk, with the reason being that thicker liquids have a harder time getting up and out of the stomach.

However, this practice is being used less often these days, due to the concern for an increased risk of necrotizing enterocolitis (NEC) in preterm infants. In fact, it is now recommended that thickeners, such as xanthan gum, not be used in preterm or former preterm infants in the first year of life. 

Reflux Medications

Research has found that acid-suppressing medications do not reduce symptoms of GER. They also increase a premature baby's risk for developing very serious complications, including NEC, sepsis, pneumonia, and urinary tract infections. Side effects may occur as a result of the medication inadvertently altering the "good" bacteria that live in a baby's gut.

As such, the questionable efficacy and safety of these acid-suppressing medications limit their use.

However, your baby's doctor may prescribe an acid-suppressing medication if non-medication therapies (e.g., smaller, more frequent feeds) are not helpful.

There are two main classes of medications that are used to treat GER in premature infants:

  • Histamine-2 receptor blockers: For example, Pepcid (famotidine)
  • Proton pump inhibitors (PPIs): For example, Prilosec (omeprazole) or Nexium (esomeprazole)

Both medications (through different mechanisms) work to decrease acid secretion in the stomach. That means reflux is still happening, but it's just not as damaging to the esophagus.

Reflux Surgery

Fundoplication, a surgical procedure in which the upper part of a baby's stomach is wrapped around the LES, is usually only recommended if a baby fails to respond to medication and their reflux is associated with serious (sometimes life-threatening) complications.

These complications may include:

Fundoplication can be performed in very small and young babies. In one study, the surgery was performed in infants as young as 2 weeks and as small as 2,000 grams.

It may help ease you to know that surgery on your little one is not something that doctors jump to by any means. It's really a last resort option, considering potential serious side effects such as:

  • Infection
  • Perforation (when a hole occurs in the intestines)
  • Tight wrap (when the end of the esophagus is wrapped too snuggly during the surgery, causing problems swallowing)
  • Dumping syndrome

A Word From Verywell

It is normal to feel frustrated and exhausted as the parent of a baby with reflux. While working with your pediatrician to address this problem, please be sure to take care of yourself.

Taking a break, whether it's for a nap or a walk outside in the fresh air, while a loved one or friend watches your baby, can do wonders for your soul and mental health.

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Article Sources
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