Seminars in perinatology最新文献

Introduction: The diagnosis, management and differentiating of gastroesophageal reflux (GER) and pathologic gastroesophageal reflux disease (GERD) in infants remains a clinical challenge. There is significant clinical and economic burden attributed to GERD in the NICU leading to longer length of stays, higher financial costs, and overuse of medications.

Current clinical practice: Current guidelines promote reduced reliance on acid suppression medication with shorter empiric trials (4 to 8 weeks) for the treatment of GERD, not attributing respiratory or laryngeal symptoms to GER due to a lack of diagnostic evidence, and a recommendation for trial of hydrolyzed formula before initiation of acid suppression. Few studies are demonstrating overall decrease use in all classes of medication for GERD, however, use of medications in infants remains high.

Diagnostic challenges and drivers of overuse: Diagnostic challenges remain in pediatrics including interchangeable use of GER and GERD amongst clinicians, non-specific symptoms attributed to GERD, and lack of gold-standard diagnostic testing. Multichannel intraluminal impedance-pH monitoring (pH/MII) probes allow for an objective assessment of reflux episodes, reflux content, acidity, distance of reflux column or bolus direction, and symptom correlation.

Conclusion: For any infant with a suspicion of GERD, priority should be made to take a thoughtful and complete history and physical exam, review of growth charts, and not only reviewing charted intake and output but observing feeding and episodes of reflux. A stepwise approach emphasizing non-pharmacological care, shared decision-making, and institutional-level stewardship remains essential to providing high-value care.

Cesarean delivery (CD), performed in nearly one in three U.S. births, is the most common surgical procedure. As utilization has increased, advances in surgical technique and perioperative management, guided by landmark trials, have refined the procedure and improved outcomes. Some of the most significant trials have focused on antibiotic prophylaxis, prevention of postpartum hemorrhage, and standardization of surgical techniques. For example, pre-incision prophylactic cefazolin has reduced the risk of postoperative infectious morbidity up to 60% compared to administration at the time of cord clamping. Additionally, the introduction of TXA to the treatment of obstetric hemorrhage has been shown to reduce maternal mortality related to hemorrhage. Future research should prioritize continuing reduction of maternal morbidity as CD still incurs increased risk of infectious and bleeding morbidity. Another important focus in the era of increased CD rates is research into the optimal closure of the hysterotomy. Identification of patients at risk of uterine rupture in future pregnancies can improve the safety of trial of labor after cesarean delivery (TOLAC); further investigation into how hysterotomy closure may contribute to the development of placenta accreta spectrum can significantly decrease maternal morbidity from an increasingly common and life-threatening placental disorder.

Gastroesophageal reflux disease (GERD) is common in neonates, and a wide variety of symptoms have been attributed to reflux in this age group, including regurgitation, fussiness, and respiratory symptoms. Though the natural history of GERD is one of resolution in most infants, treatment may be needed when symptoms are particularly bothersome or associated with concerning medical complications. An array of management options exists for neonatal GERD, including both medical and surgical treatments. The goal of this review is to present an overview of nonpharmacologic, pharmacologic, and surgical GERD treatments and to review the available evidence on these treatments with a focus on research completed in the neonatal population.

Bronchopulmonary dysplasia (BPD) is among the most common and serious complications of prematurity. The pathobiology of BPD and BPD associated pulmonary arterial hypertension (BPD-PH) is multifactorial and not yet fully defined. Gastroesophageal reflux (GER), a physiologic process that occurs in most preterm infants and is typically benign, has been proposed as a potential contributor to the development or worsening of BPD and BPD-PH. Infants who develop BPD compared to those who do not are more frequently diagnosed with symptomatic GER and undergo therapeutic interventions to treat GER. However, current evidence does not support a direct causal relationship between GER and the onset or progression of BPD or BPD-PH in preterm infants. While GER may contribute to respiratory morbidity in individual cases, population-level data do not implicate it as a major driver of BPD pathogenesis. Moreover, the limited available data from clinical trials and observational studies does not consistently demonstrate improved outcomes in patients with BPD who are treated for GER. This narrative review summarizes the current literature evaluating the relationship between GER, BPD, and BPD-PH.

Despite widespread use, electronic fetal monitoring (EFM) has not demonstrably reduced perinatal morbidity or mortality, and likely contributed to the rise in cesarean delivery. To improve its utility, a number of adjunctive approaches have been introduced over the past three decades, including fetal pulse oximetry, ST segment analysis (STAN), and maternal oxygen supplementation. Each intervention was supported by strong physiologic rationale, yet none achieved widespread clinical adoption due to inconsistent evidence of benefit and, in some cases, potential harm. This review critically evaluates landmark studies on EFM adjuncts, highlights the limitations that have impeded progress, and outlines emerging innovations, including artificial intelligence and multimodal surveillance. The persistent challenges in intrapartum fetal assessment underscore the need for high-quality evidence, rigorous implementation strategies, and a patient-centered reframing of EFM goals.

Both apnea and gastroesophageal reflux are nearly universal in premature infants delivered before 32 weeks gestational age. Apnea of prematurity is multifactorial, secondary to immaturity of several different aspects of respiratory control. Amongst these is the laryngeal chemoreflex, when stimulated in newborns results in central and obstructive apnea as opposed to a cough reflex in older infants, an observation leading to a hypothesis that reflux and apnea may be linked. The current evidence for a role of reflux as a causative factor for apnea of prematurity is poor despite multiple studies seeking to prove a relationship. The studies have been hampered by poor design, inadequate measurement techniques and differing endpoints as well as heterogeneous patient populations. Whether subsets of premature infants can be identified in whom GER plays a larger role in disorders of respiratory control will require careful identification of specific patient populations to be studied, accurate measurement of acidic and non-acidic reflux events, and strict definitions of cardiorespiratory endpoints.

Gastroesophageal reflux is physiologically normal in infants but can become gastroesophageal reflux disease when it leads to significant symptoms (persistent vomiting, weight loss, feeding difficulties). Gastroesophageal reflux disease is highly prevalent among infants and contributes to increased health care utilization. There are several physiologic and lifestyle factors that predispose infants to a higher degree of gastroesophageal reflux and disease related to it. Preterm infants and infants admitted to the neonatal intensive care unit, are a special population that have unique risk factors for gastroesophageal reflux disease and have a high prevalence of gastroesophageal reflux disease. To better understand gastroesophageal reflux in infants and neonates with medical complexity, this article will first review the physiology of typical swallowing and motility of the upper gastrointestinal tract in infants. Then, the pathophysiology of gastroesophageal reflux in infants will be reviewed. Finally, this article also addresses specific physiological differences in preterm infants that are important to aid in the understanding of management of gastroesophageal reflux disease in this specific population.