Continuous Feedings Are Not Associated With Lower Rates of Gastroesophageal Reflux When Compared With Bolus Feedings

Abstract

Gastroesophageal reflux disease is common in children with gastrostomy tubes. Clinicians often transition to continuous feedings in an attempt to reduce reflux burden, though there is limited data to support this practice. In this retrospective study, we analyzed 24-hour multichannel intraluminal impedance with pH studies in 18 children with gastrostomy tubes receiving exclusive enteral nutrition with a combination of daytime bolus and overnight continuous feedings. There were no significant differences in the rate of reflux (reflux events per hour) between no feeding, bolus feeding, and continuous feeding periods overall or stratified by prior fundoplications (P > 0.40). After adjusting for age, BMI, feeding rate, and feeding volume in multivariate analysis, there were no significant differences in the risk of reflux between different feeding periods. These results suggest that continuous feedings may not offer a significant advantage in reducing reflux burden.

Pathophysiology of Pediatric Gastroesophageal Reflux Disease

“…In preterm and low birth weight infants with concerns for GORD, there are no studies comparing intragastric bolus feeding with continuous feeding,120 despite the fact that this question is encountered often in clinical practice. In children with a gastrostomy in situ, continuous feeding does not reduce the number of reflux events when compared with bolus feeding, irrespective of the type of feed, that is, elemental/semi-elemental or milk based 121. In children with GORD, compared with a standard meal, meals of high volume promote an increase in the rate of TLOSRs leading to increased number of reflux events, while meals of high volume and osmolality also promote periods of low/absent LOS pressure leading not only to a higher number of reflux events but also to higher degrees of esophageal acid exposure time 122.…”

“…In children with a gastrostomy in situ, continuous feeding does not reduce the number of reflux events when compared with bolus feeding, irrespective of the type of feed, that is, elemental/semi-elemental or milk based. 121 In children with GORD, compared with a standard meal, meals of high volume promote an increase in the rate of TLOSRs leading to increased number of reflux events, while meals of high volume and osmolality also promote periods of low/absent LOS pressure leading not only to a higher number of reflux events but also to higher degrees of esophageal acid exposure time. 122 These effects are mediated by postantral distention and impaired gastric accommodation.…”

The Real Relevance of Nonacid Reflux in Pediatric Patients

“…But even in older children and adults, 40-60% of reflux is nonacidic 4,10–12 . In patients who are fed by enteral tube, in whom gastric feeding may occur at frequent or continuous intervals, up to 87% of refluxate is nonacidic 13 …”

“…4,[10][11][12] In patients who are fed by enteral tube, in whom gastric feeding may occur at frequent or continuous intervals, up to 87% of refluxate is nonacidic. 13 In addition, gastrointestinal molecules other than acid are found in refluxate and serve as potentially important contributors to the pathology associated with nonacid GER. Pepsin is a component of nonacid refluxate that has been proposed as a reflux biomarker and also as an etiologic contributor to both typical and atypical GERD symptoms.…”