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Objective To evaluate the pattern of acid and nonacid gastroesophageal reflux (GER) in different body positions in preterm
infants with reflux symptoms by a combined multichannel intraluminal impedance (MII)pH monitoring, which identifies both
acid and nonacid GER.
Study design Premature infants with frequent regurgitation and postprandial desaturation (n 22) underwent a 24-hour
recording of MII-pH. In a within-subjects design, reflux indexes were analyzed with the infants in 4 different positions: supine
(S), prone (P), on the right side (RS), and on the left side (LS).
Results All infants were analyzed for 20 hours. The mean number of recorded GER episodes was 109.7. The mean
esophageal exposure to acid and nonacid GER was lower in positions P (4.4% and 0.3%, respectively) and LS (7.5% and 0.7%,
respectively) than in positions RS (21.4% and 1.2%, respectively) and S (17.6% and 1.3%, respectively). The number of
postprandial nonacid GER episodes decreased but the number of acid GER episodes increased over time. The LS position
showed the lowest esophageal acid exposure (0.8%) in the early postprandial period, and the P position showed the lowest
esophageal acid exposure (5.1%) in the late postprandial period.
Conclusion Placing premature infants in the prone or left lateral position in the postprandial period is a simple intervention
to limit GER. (J Pediatr 2007;151:591-6)
astroesophageal reflux (GER) is common in premature infants. Because it may be linked to serious clinical consequences, it is cause for concern in neonatologists and parents and necessitates prolongation of hospitalization.1,2 As in
term infants,3 a conservative approach based on postural treatment has been suggested in preterm infants with GER.1
However, few studies have been performed to investigate the best body position for this approach to GER treatment in
premature infants, and results are not conclusive. Using pH monitoring, Ewer et al4 found that prone and left lateral positioning
was more effective in preventing GER. Omari et al,5 using combined manometry and multichannel intraluminal impedance
(MII) recording in preterm infants asymptomatic for GER, found that left lateral positioning was more advantageous than right
lateral positioning. These authors analyzed the mechanisms triggering GER and observed an increased number of transient lower
esophageal sphincter relaxations (TLESRs) in the right lateral position, despite a gastric
emptying rate twice that in the left lateral position. Despite these important findings, this
study was unable to differentiate acid and nonacid GER.5
The effect of positioning is predictable based on previous work, but it is important
See editorial, p 560 and
to describe this effect using the current state-of-the-art methods for GER measurement.
Consequently, the aim of our study was to evaluate the affect of body position on GER
related article, p 585
in symptomatic premature infants using combining intraluminal impedance and pH
monitoring.
From the Institute of Preventive Pediatrics
and Neonatology, St. Orsola Malpighi GenMII is based on the intraluminal electrical impedance changes occurring during
eral Hospital, University of Bologna, Bolothe passage of a bolus through the esophagus. It is measured by electrodes incorpogna, Italy (L.C., R.R., M.F., A.A., G.A., G.F.).
rated along a catheter. Impedance is decreased if the bolus is liquid and is increased
Submitted for publication Feb 1, 2007; last
revision received Apr 27, 2007; accepted
if it is air. The direction of the bolus is determined by evaluating changes in
Jun 6, 2007.
intraluminal impedance at various levels over time.6 MII can detect gas, mixed, and
BEI
GER
LES
LS
MACT
MII
P
RIpH
RS
S
TLESR
Prone
Reflux index
Right side
Supine
Transient lower esophageal sphincter
relaxation
591
METHODS
A total of 22 (16 male) symptomatic premature infants
with a median gestational age at birth of 31 weeks (range, 24
to 32 weeks) and a median birth weight of 1220 g (range, 630
to 2250 g) were enrolled in the study at a median age of 29
days (range, 12 to 83 days) and a median weight of 1747 g
(range, 1150 to 3215 g). The infants exhibited frequent regurgitation and postprandial desaturation; in addition, 7 infants had postprandial apnea, 4 had failure to thrive, 1 had
bradycardia, and 1 had both postprandial apnea and bradycardia. All were otherwise healthy at the time of examination.
None had malformation or major gastrointestinal problems or
was taking drugs influencing gastrointestinal motility or gastric acidity. Seven infants were fed extracted human milk
fortified with 3% FM85 (Nestl, Vevey, Switzerland), 3 were
fed a standard preterm formula, and the remaining 12 received both. All 22 infants tolerated at least 100 ml/kg per day
of milk.
The effect of postural intervention on GER was evaluated in a within-subjects design, taking for each subject
measurement of GER in different postural conditions. In a
within-subjects design, the same subjects are tested in each
condition; therefore, differences among subjects can be separated from error, increasing the power of significance tests. A
possible drawback of this method is the carry-over effecta
persistent effect in a subsequent treatment period from treatment in the previous period. In our study, this could be
represented by the effect on GER of each position on the
subsequent position. To limit this effect, we randomly assigned to each enrolled infant a different sequence of the
possible postural combinations.
Postural Intervention
In the 24-hour examination, 4 positionssupine (S),
prone (P), right side (RS), and left side (LS)were studied.
Each position was maintained for 6 hours, except for 2
periods of 30 minutes each for feeding. The order of different
positions was assigned randomly and was not known by the
data analysts. Each infant received 8 meals (1 every 3 hours)
through a feeding bottle or an orogastric tube, inserted and
removed at each meal. This approach allowed us to include 2
meals and 2 150-minute postprandial periods in each body
position.
GER Monitoring
Each patient underwent a 24-hour, continuous, simultaneous measurement of intraesophageal pH and multichannel electrical impedance. The system was calibrated before
each measurement using pH buffer solutions of pH 4.0 and
pH 7.0. A single-use combined MIIpH probe (Comfortec
592
Corvaglia et al
Left side
Right side
Supine
Prone
40.5 (20.5)
0-87
7.9 (4.8)
0-20
13.6 (8.8)
0-30
15.9 (9.7)
0-39
3.1 (2.6)
0-10
4.8 (5.2)
0-19
7.4 (5.9)
0-22
11.7 (9.1)
1-35
1.7 (2.1)
0-8
2.3 (2.6)
0-11
1.9 (2.1)
0-8
1.1 (1.4)
0-5
2.5 (2.9)
0-13
4.2 (4.4)
0-18
0.9 (1.2)
0-4
1.7 (1.9)
0-7
4.3 (3.5)
0-12
1.1 (2)
0-8
0.8 (1.4)
0-6
1.1 (1.2)
0-3
LS vs RS: .012
LS vs S: .002
P vs RS, S, LS: .001
NS
35.9 (22)
2-91
73.7 (44.3)
3-149
0.3 (0.2)
0-0.7
8.3 (5.8)
0-21
17.9 (15.7)
0-56
0.2 (0.3)
0-1
11.9 (8.9)
0-36
27.1 (18.1)
3-66
0.5 (0.5)
0-1.7
12.9 (9.1)
1-35
21.9 (15.3)
0-56
0.5 (0.5)
0-1.7
2.8 (2.6)
0-8
6.8 (5.3)
0-17
0.1 (0.1)
0-0.4
0.9 (0.5)
0-1.8
12.7 (10.5)
1.6-37.9
0.7 (0.6)
0-2.1
7.5 (8.2)
0-32.2
1.2 (0.9)
0-2.6
21.4 (19.4)
0.4-68.4
1.3 (1)
0.11-3.3
17.6 (16.1)
0-48.6
0.3 (0.3)
0-1
4.4 (5.8)
0-19.8
119.8 (116.1)
26.4-582.6
3.5 (1.2)
1.8-7.2
93.2 (143.9)
0-701.8
3.9 (1.7)
1.7-9
176.4 (245.6)
26.4-1216.9
3.4 (1.2)
1.5-7
162.7 (103)
17.1-282.9
3.8 (1.3)
1.7-7.3
94.9 (91.1)
0-257.1
3 (1.4)
0-7
NaMII-GER (n)
pH-acid-GER (n)
aMII-GER-BEI (%)
NaMII-GER-BEI (%)
RipH (%)
MACT (sec)
Mean MII-GER
height (cm)
NS
P vs S: .001
P vs RS: .019
LS vs S: .029
P vs RS, S, LS: .001
P vs S, RS: .001
P vs LS: .006
P vs RS: .001
P vs S: .006
RS vs LS: .015
P vs S, RS: .0001
LS vs S: .011
P vs RS: .001
P vs S: .002
LS vs RS: .004
LS vs S: .014
P vs S: .016
LS vs RS: .021
NS
Statistical Analysis
All statistical analyses were performed with SPSS 13.0
for Windows (SPSS Inc, Chicago IL). Normal distribution
was first evaluated by the Kolmogorov-Smirnov test. Reflux
variables in each position were analyzed using generalized
likelihood model repeated-measures design (1 within-subjects
factor) and Bonferroni post hoc pairwise comparison; differences between the first and second postprandial periods were
tested by paired-sample t tests. A P value .05 was considered statistically significant.
RESULTS
The Effect of Body Positioning on Gastroesophageal Reflux in Premature Infants: Evaluation by Combined Impedance
and pH Monitoring
593
DISCUSSION
Corvaglia et al
Figure 2. aMII-BEI and NaMII-BEI in different body positions (, median; ---, 95th percentile). (aMII-BEI: P vs RS P .001, P vs S P .006,
RS vs LS P .015; NaMII-BEI: P vs RS P .0001, P vs S P .0001, RS vs LS P .011.)
Table II. Variation of acid and nonacid GER during postprandial periods
RIpH
Left side
First period
Second period
Right side
First period
Second period
Supine
First period
Second period
Prone
First period
Second period
Total
First period
Second period
aMII-GER-BEI
NaMII-GER-BEI
.001
0 (0.1) 0-0.3
0.2 (0.5) 0-2
.03
.0001
.001
.01
.0001
.0001
.0001
.0001
NS
0 (0.1) 0-0.4
0.1 (0.2) 0-0.9
.04
.0001
.0001
.001
.0001
The Effect of Body Positioning on Gastroesophageal Reflux in Premature Infants: Evaluation by Combined Impedance
and pH Monitoring
595
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The Effect of Body Positioning on Gastroesophageal Reflux in Premature Infants: Evaluation by Combined Impedance
and pH Monitoring
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