Is gastroesophageal reflux disease (GERD) a common cause of obstructive sleep apnea (OSA) in infants less than six months?

Gastroesophageal Reflux is Not a Common Cause of Obstructive Sleep Apnea in Infants Under Six Months

Gastroesophageal reflux (GER) is not a common cause of obstructive sleep apnea (OSA) in infants less than six months of age, although there is a temporal association between the two conditions in some cases. 1

Relationship Between GER and OSA in Infants

• While GER is extremely common in infants (occurring daily in 50% of all infants), it is generally a normal physiologic process that resolves spontaneously with maturation 1
• Studies show that when apnea and reflux are associated in infants, the predominant sequence is obstructive apnea preceding reflux (93.6% of episodes), not reflux causing apnea 2
• In 81% of apneic episodes in infants under 6 months, no relationship to GER was observed at all 2
• Acid reflux into the esophagus has been temporally associated with oxygen desaturation and obstructive apnea in some selected cases, but this does not establish GER as a common cause of OSA 1

Clinical Patterns When GER May Contribute to Respiratory Symptoms

Respiratory symptoms are more likely to be associated with GER when:

• Gross emesis occurs at the time of a Brief Resolved Unexplained Event (BRUE) 1
• Episodes occur while the infant is awake and supine (sometimes called "awake apnea") 1
• A pattern of obstructive apnea is observed while the infant is making respiratory efforts without effective air movement 1
• Reflux-related laryngospasm occurs, which may not be clinically apparent at initial evaluation 1

Evidence Against GER as a Common Cause of OSA

• In a study of infants with apparent life-threatening events, only 6.4% of apneic episodes followed reflux events, strongly suggesting that reflux is rarely the cause of apnea 2
• The American Academy of Pediatrics does not recommend acid suppression therapy for infants presenting with a lower-risk BRUE, indicating that GER is not considered a common underlying cause requiring treatment 1
• Infants with spitting up or throat-clearing coughs that are not troublesome do not meet diagnostic criteria for GERD (gastroesophageal reflux disease) 1

Common Comorbidities in Infants with OSA

• A comprehensive study of infants with OSA found that while GER was present in 68% of infants with OSA, other important comorbidities included 3:
  • Periodic limb movements in sleep (42%)
  • Craniofacial abnormalities (37%)
  • Neuromuscular abnormalities (34%)
  • Prematurity (29%)
  • Genetic syndromes (29%)
  • Laryngomalacia/tracheomalacia (27%)

Management Considerations

• For infants with both GER and respiratory symptoms, non-pharmacologic approaches are preferred 1:

  • Avoiding overfeeding
  • Frequent burping during feeding
  • Upright positioning in caregiver's arms after feeding
  • Avoidance of secondhand smoke
  • Holding infant on caregiver's shoulders for 10-20 minutes after feeding
  • Avoiding car seats or other semi-supine positions which can exacerbate reflux

• Acid suppression therapy is not recommended for infants with uncomplicated GER and may have harmful adverse effects including increased risk of pneumonia or gastroenteritis 1

• In specific cases where GERD is diagnosed (when reflux causes troublesome symptoms or complications), proton pump inhibitors may be indicated, but these represent a minority of cases 1

Clinical Pitfalls to Avoid

• Assuming that reflux is causing apnea without objective evidence - most studies show apnea precedes reflux, not the reverse 2
• Prescribing acid suppression therapy for infants with GER symptoms without clear evidence of benefit 1
• Failing to consider other more common causes of OSA in infants, such as craniofacial or neuromuscular abnormalities 3
• Not recognizing that a multidisciplinary approach is often needed for infants with OSA, as 86% require multispecialty evaluation 3