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Andrew B. Kairalla MD, Editor
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Positioning for GE Reflux
Paradoxical impact of body positioning on gastroesophageal reflux and gastric emptying in the premature neonate. Omari TI, Rommel N, Staunton E, et al. J Pediatr (August 2004) 145: 194-200.
Objectives. To
combine manometry and impedance to characterize the mechanisms of
gastroesophageal reflux (GER) and to explore their relation to the rate of
gastric emptying (GE) and body position.
Study design. Ten healthy preterm infants (35 to 37 weeks' postmenstrual
age) were studied with the use of a micromanometric/impedance assembly. Episodes
of GER were identified by impedance, and the mechanism(s) of GER triggering and
GER clearance were characterized. GE was determined with a C13Na-octanoate
breath test.
Results.
Gastroesophageal reflux episodes (n=89) were recorded, consisting of 74% liquid,
14% gas, and 12% mixed. Transient lower esophageal sphincter relaxation (TLESR)
was the predominant mechanism of reflux, triggering 83% of GER. Of 92 TLESRs
recorded, 27% were not associated with reflux. Infants studied in the right
lateral position had significantly (P < .01) more GER, a higher
proportion of liquid GER (P < .05), and faster GE (P < .005) when
compared with infants studied in the left lateral position.
Conclusions. In healthy preterm infants, GER is
predominantly liquid in nature. Right-side positioning is associated with
increased triggering of TLESR and GER despite accelerating GE.
Comments. Put this one in the category of
“everything you learned in your training is wrong”! We now appreciate that
premature babies actually have more GER when placed on their right side,
despite the fact that their gastric emptying is increased in that position. I
wish the authors had included measurements taken in the prone and supine
positions as well. Frankly, I’m now totally confused on how best to position
premature infants to avoid GER and facilitate gastric emptying. ABK.
Sept 14, 2004
This study from Adelaide Australia should serve as a catalyst for many of us to reconsider critically our clinical approach to gastroesophageal reflux (GER) in infants. GER, transient lower esophageal sphincter relaxations (TLESRs), and gastric emptying rates were determined by a combination of esophageal manometry, multichannel intraluminal impedance measurements, and C13Na-octanoate breath testing in 10 infants on gavage feedings who were not on xanthines. Half of the infants were studied in the left side down position with the other half assessed right side down. The two notable findings were: (1) most GER episodes (83%) were triggered by TLESRs, and most TLESRs (73%) resulted in GER; (2) infants positioned left side down had significantly fewer TLESRs (22 vs. 69) and fewer episodes of GER (18 vs. 71) despite having prolonged gastric emptying compared to infants positioned right side down. One possible explanation hinges on the observation that distention of the gastric cardia is the most potent stimulant of TLESR. The geometry of positioning is such that the postprandial liquid level lies below the GE junction with left side down, whereas this level lies above the GEJ when the right side is down. Hence, more facile venting of gas with the left side down might cause less distention of the cardia. This study would have been more convincing if each infant had been studied in both positions (frankly, I am not sure why this was not done, but someone should do it). The use of reglan for GER, which appears to be creeping back into practice after the demise of cisapride, should be reconsidered because there is no evidence to support that this agent attenuates GER even as its prokinetic properties reduce residuals. Finally, we should all revisit the use of Avery chairs in our more mature patients in light of old data that supports prone rather than supine positioning for minimization of symptomatic GER.
Mark Hudak MD
President, FSN
mark.hudak@jax.ufl.edu
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