Problem Solving: Reflux in the NICU


Regarding NICU preemies/infants, what are recommendations/guidelines utilized for concern with reflux (e.g., thickener, rice)? Are more behavioral and positioning strategies utilized first (e.g., HOB elevation, hold upright 30 min after feed) or is initiation of formula change/diagnostic imaging (MBSS) preferred? Also, if thickening, is there another approved way besides rice?


I am responding specifically to preterms in the NICU. Those discharged to home may have GI follow and/or pediatricians manage their care, which allows for more options and perhaps even more variation in practice. There are no agreed upon guidelines from NICU to NICU, often there is variability even among your group of neonatologists. Let me share what they and my GI friends have kindly taught me over the years along with what I have learned along the way.

They tell me that the lack of agreement is d/t the absence of compelling literature that clearly guides them, especially when it comes to use of medications for EERD/GERD. That said, a recent study brought to our team by our pharmacist concluded that PPIs can cause significant problems for preterms (increased risk of NEC, sepsis/bacteremia, PNA and GI infections; decreased absorption of nutrients such a calcium, iron, zinc, magnesium, B12 –and zinc is essential to function of their immune system). While use of medications has typically been infrequent and a last resort approach in the Level IV NICUs I have been a part of, evidence such as this has further decrease their use, understandably so. When risk benefit ratio is not clear, physicians will be cautious. There is risk with thickened feedings as well (such as adverse effect on GI emptying which can worsen reflux, constipation, increased risk for NEC, alterations in C02); if thickening for reflux, what is used and how much is quiet variable again r/t MD differences. Most often rice is utilized but it too can have attendant sequelae as mentioned previously, as well as potential allergenic responses and concerns for arsenic.

Instead reflux precautions are typically the first line of defense (elevating head of bed, L side down post feeding for the first hour, R side down for the second hour and beyond – when monitored; upright carry position on caregiver’s shoulder post feeding when held); avoid medium or fast flow nipples that might lead to air swallowing and exacerbate EERD/GERD, utilize co-regulated pacing to avoid air swallowing, frequent gentle burps, use of elevated elongated sidelying position for feeding (to minimize pressure gradients throughout the abdominal area that might inadvertently increase propensity for reflux).

Pump feedings that allow a slower delivery of feedings via NGT or OGT over time have been used but the literature is actually inconclusive as to its benefit, and there may be adverse effects especially on gall bladder function.

Concentrating formula so less volume is required to get the same calories is an option. However, this can backfire as the increased caloric density can actually create GI discomfort in preterms.

Change in formula to Gentle or Sensitive formulas (Enfamil Gentle Ease, Similac Sensitive, Good Start Gentle), low lactose formula (Similac Spit Up, Gerber Good Start), possibly Soy based formula (if tolerance to cow milk protein is in question), possibly Extensively Hydrolyzed formulas in which proteins are mostly broken down (Nutramigen, Alimentum, Pregestimil), or possibly Elemental formulas which contain 100% broken down proteins if suspected milk protein allergy (Neocate, Elecare). Such decisions may be made with GI or by neonatology alone.

Imaging typically starts with and UGI to look at structural integrity and if the structures are in proper rotation. An UGI is not a test for reflux; radiologists will tell you that if they do not capture reflux in the moment in radiology, that does not mean the infant does not reflux, but if they DO capture reflux on an UGI, it is such a brief and minimal volume procedure that reflux is likely a key issue for that infant. While other types of imaging are possible in a workup for GERD/EERD (Ph probe studies, reflux scans, MII), they are not typical in the NICU.

A swallow study would not be a test to assess for reflux though we may capture EER as an incidental finding during an instrumental assessment of swallowing physiology.

So, as you can see the neonatologists must weigh so many critical factors. Work with your team and their thinking, be present and learn their rationales, read the research they are discussing, contribute what you can, especially clinical interventions that are often first line. There is an evolving science and practice and being part of the team is ho we both learn and add value.

I hope this is helpful. See Dupont, C. (2017). Gastroesophageal Reflux (GER) in the Preterm Baby. In Gastroesophageal Reflux in Children (pp. 111-124). Springer. It is quite informative though there are multiple other articles. DOI

I hope this is helpful.


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