Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events

Abstract

Objectives To describe the pattern of gastro-esophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI> 7% in wake-state. Study design Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hr ARI (% duration that esophageal pH is <4) into ARI<3% (normal), ARI 3≥ to ≤7% (intermediate) and ARI>7% (abnormal). GER frequency, clearance mechanisms and symptoms were distinguished during wake-state and sleep-state. Results Total wake and sleep duration was similar (p≥ 0.2) in all ARI groups. Acidic events were frequent with increasing ARI in wake-state vs. sleep-state (p≤ 0.03). The Symptom Index increased with increasing ARI (p≤ 0.02) in both wake-state and sleep-state. Acid clearance time increased with increasing ARI in wake-state (p≤ 0.02). In ARI>7% vs. ARI≤7%, frequency of acidic GER events was higher (p≤0.02) in wake-state and sleep-state; proximal migration of acid (p=0.03) and acid clearance time were higher in wake-state (p=0.0005) only. Symptom index was higher in ARI>7% vs. ARI≤7% in wake-state (p<0.0001), comparable in normal vs. intermediate (p=0.4) and higher in abnormal vs. intermediate (p=0.0004) groups. Conclusions Severe esophageal acid exposure (ARI>7%) is associated with increased reflux-associated symptoms in wake-state. Sleep-state appears to be protective regardless of ARI, likely due to greater chemosensory thresholds. Attention to posture and movements during wake-state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.

Gastroesophageal Reflux Disease in Infants Who Presented Brief Resolved Unexplained Event (Brue)

“…MII-pH monitoring revealed acid or nonacid reflux in 2/3 of 53 HR-BRUE infants, non-acid reflux events were the most common findings (66%) (19) . A study performed in 25 infants presenting with BRUE who underwent concurrent MII-pH and video-polysomnography showed severe esophageal acid exposure (RI>7%) is associated with increased reflux-associated symptoms in wake state (20) .…”

Cardiorespiratory events in infants with gastroesophageal reflux symptoms: Is there any association?

“…The theory that GER events may play a causative role in CR events in infants is based on the existence of chemoreceptors in the upper airway able to elicit apnea to protect the airway, function influenced also by sleep/wake state, and on the existence of neuroreceptors responding to esophageal distension with vagal stimulation . Numerous studies have been published on the relationship between CR and GER events in infants, and on the nature of this relationship, but these studies have reported conflicting results .…”

Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Infant

“…Therefore, changes in sleep patterns and interventions in NICU infants may modify the symptoms and responses to reflux events. [13,14] In an attempt to determine the burden of GERD, we studied 33 academic freestanding children's hospital NICUs in the United States. Using the definition of GERD based on symptoms, we noted a 13-fold variation (2% to 26%) in the diagnosis of GERD and found that infants with a diagnosis of GERD stayed 1 month longer in the NICU.…”