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The main objectives of the present study were to assess the effectiveness of the current paradigm of acid suppression of esophageal reflux in infants, ²¹ and an attempt to improve feeding outcomes. With regards to the first objective, we used a primary outcome of dysphagia (OASIS-q score) and showed that there was no difference between the two arms of acid suppression (PPI and PPI+bundled strategies), based on our statistical power analysis. We did not have an a priori hypothesis regarding the secondary outcomes of feeding volume/duration and gestational age. We anticipated that symptomatic GER disease (the basis of the current standard paradigm) may initially respond to the administration of PPI over the shorter term. We showed that there was no difference in the odds of achieving a ‘normal’ feeding volume (under 20 mL/kg/day) with either the acid suppression approach; however, the postprandial time during hours 2 to 5 were also increased in the latter group, suggesting a possible concern with dysphagia. Lastly, another study by O’Brien et al., of the use of Apnoea Tent, found no advantage over modified positioning for prevention of GER in preterm infants ²² ; however, this study was in a very low risk group, with patients at a low-risk of GER. Hence, we surmised that risk of GER would improve in early infancy, with decreasing requirement of acid suppression.

Most studies about GERD in NICU patients have used a symptom-based approach, ^{23, 24, 25, 26} as opposed to pH-measurement-based approach, ^{27, 28, 29} to control for the presence of nonacidic reflux events. We did not have an a priori hypothesis about changes in reflux-related symptoms. Few studies have compared the effectiveness of a bundled-approach of acid suppression with the use of a pneumatic tube for positioning of infants in NICU patients. We observed a statistically significant and clinically relevant improvement in GERQ-R scores in our study, which is in agreement with other literature. However, we found no clinically relevant differences in rates of success/failure in our postprandial positioning group.

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