Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

Long-term maintenance treatment with omeprazole in children with healed erosive oesophagitis: a prospective study

BACKGROUND

Short-term studies show that PPIs heal erosive esophagitis in children. There are no prospective studies that examine long-term maintenance therapy of erosive esophagitis in children with and without underlying GERD-predisposing disorders.

AIM

To determine prospectively the dose of omeprazole needed to maintain remission of erosive oesophagitis and reflux symptoms in children.

METHODS

Patients aged 1-16 years with healed erosive reflux oesophagitis after omeprazole treatment (0.7-3.5 mg/kg/day) entered a 21-month maintenance phase where they initially received half the dose of omeprazole required to heal. Endoscopy was performed after 3, 12 and 21 months. The omeprazole dose was increased if erosive oesophagitis or reflux symptoms recurred.

RESULTS

A total of 46 patients entered the study and 32 completed it. Of these, 17 (53%) remained on the maintenance dose, 12 (38%) returned to their healing dose and 3 (9%) ended the study on a dose higher than their healing dose. Three-quarters of the completers (24/32) had no erosive oesophagitis relapse. Four patients (13%) had relapse of only erosive oesophagitis, 4 (13%) had relapse of erosive oesophagitis and symptoms, and 10 (31%) had only symptomatic relapse. Of the 46 patients, 48% had GERD-predisposing disorders (neurological impairment or oesophageal atresia). Overall, 62.5% (5/8) of patients who had an erosive oesophagitis relapse had a GERD-predisposing disorder versus 33.3% (8/24) of those who did not.

CONCLUSIONS

Remission of erosive oesophagitis is maintained with omeprazole treatment for at least 21 months in most children aged 1-16 years, and the drug is well tolerated. To maintain remission, some 60% of patients require more than half the dose required for healing. In children with GERD-predisposing conditions, GERD is often chronic and relapsing, and requires long-term management.

Lansoprazole for children with poorly controlled asthma: a randomized controlled trial

CONTEXT

Asymptomatic gastroesophageal reflux (GER) is prevalent in children with asthma. Untreated GER has been postulated to be a cause of inadequate asthma control in children despite inhaled corticosteroid treatment, but it is not known whether treatment with proton pump inhibitors improves asthma control.

OBJECTIVE

To determine whether lansoprazole is effective in reducing asthma symptoms in children without overt GER.

DESIGN, SETTING, AND PARTICIPANTS

The Study of Acid Reflux in Children With Asthma, a randomized, masked, placebo-controlled, parallel clinical trial that compared lansoprazole with placebo in children with poor asthma control who were receiving inhaled corticosteroid treatment. Three hundred six participants enrolled from April 2007 to September 2010 at 19 US academic clinical centers were followed up for 24 weeks. A subgroup had an esophageal pH study before randomization.

INTERVENTION

Participating children were randomly assigned to receive either lansoprazole, 15 mg/d if weighing less than 30 kg or 30 mg/d if weighing 30 kg or more (n = 149), or placebo (n = 157).

MAIN OUTCOME MEASURES

The primary outcome measure was change in Asthma Control Questionnaire (ACQ) score (range, 0-6; a 0.5-unit change is considered clinically meaningful). Secondary outcome measures included lung function measures, asthma-related quality of life, and episodes of poor asthma control.

RESULTS

The mean age was 11 years (SD, 3 years). The mean difference in change (lansoprazole minus placebo) in the ACQ score was 0.2 units (95% CI, 0.0-0.3 units). There were no statistically significant differences in the mean difference in change for the secondary outcomes of forced expiratory volume in the first second (0.0 L; 95% CI, -0.1 to 0.1 L), asthma-related quality of life (-0.1; 95% CI, -0.3 to 0.1), or rate of episodes of poor asthma control (relative risk, 1.2; 95% CI, 0.9-1.5). Among the 115 children with esophageal pH studies, the prevalence of GER was 43%. In the subgroup with a positive pH study, no treatment effect for lansoprazole vs placebo was observed for any asthma outcome. Children treated with lansoprazole reported more respiratory infections (relative risk, 1.3 [95% CI, 1.1-1.6]).

CONCLUSION

In this trial of children with poorly controlled asthma without symptoms of GER who were using inhaled corticosteroids, the addition of lansoprazole, compared with placebo, improved neither symptoms nor lung function but was associated with increased adverse events.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00442013.

Impact of antisecretory treatment on respiratory symptoms of gastroesophageal reflux disease in children

The effect of antisecretory treatment on extraesophageal symptoms of gastroesophageal reflux disease was evaluated. Seventy-eight children presenting with typical and extraesophageal symptoms of gastroesophageal reflux disease underwent a multichannel intraluminal impedance and pH monitoring (MII/pH). Children with a positive MII/pH were randomly treated with proton pump inhibitors (PPIs) or histamine H(2) -receptor antagonists (H(2) RAs) during 3 months. At the end of the treatment period, all patients were recalled. A second treatment period of 3 months was given to those patients who were not symptom-free after 3 months. Thirty-five of the forty-one (85.4%) children with a pathologic MII/pH presented with extraesophageal symptoms and were treated with PPIs (omeprazole; n:19) or H(2) RAs (ranitidine; n:16) for 12 weeks. After 3 months, 11/19 (57.9%) PPI-treated patients had a complete resolution of symptoms; 6/8 nonresponders were treated with PPI for another 3 months and became all symptom-free. The other two underwent a Nissen fundoplication. Only 5/16 (31.2 %) patients treated with H(2) RAs had a complete resolution of symptoms after 3 months; 1/11 was treated again with H(2) RAs during 3 months, and 10/11 were changed to PPIs. In 3/10, a partial resolution of symptoms was achieved, while in 7/10, a complete remission was obtained (P < 0.05). Antisecretory reflux treatment improves extraesophageal reflux symptoms. The efficacy of PPIs is superior to that of H(2) RAs in these children.

Proton pump inhibitor use in infants: FDA reviewer experience

The Food and Drug Administration has completed its review of 4 clinical trials evaluating the use of proton pump inhibitors (PPIs) in infants (ages 1 month to <12 months) for the treatment of gastroesophageal reflux disease (GERD). An Advisory Committee meeting was held in November 2010 to discuss the potential reasons why PPI use in these trials failed to show a benefit in infants with GERD, and directions for future study. The present review summarizes the findings from the clinical trials. Potential mechanisms for the failed clinical trials are discussed. The safety of long-term use is also discussed. As a result of our analysis and review, the authors agree with the Advisory Committee members that PPIs should not be administered to treat the symptoms of GERD in the otherwise healthy infant without the evidence of acid-induced disease.

Time to stop blaming gastroesophageal reflux

OBJECTIVES. Cough, pain, and desaturation episodes in infants are often ascribed to gastroesophageal reflux, and many are empirically treated with acid suppression medications. The authors hypothesize that most of these symptoms are not related to gastroesophageal reflux. METHODS. Retrospective review of 186 combined pH-multichannel intraluminal impedance studies performed in infants at Cincinnati Children's Hospital. RESULTS. Of 4159 symptoms reported 1504 (36%) were associated with reflux events (27% nonacid and 9% acid). When total number of symptoms and reflux events were taken into consideration, nonacid reflux events were as likely to be associated with a symptom as acid reflux events (P = .66). CONCLUSION. The extra-esophageal symptoms commonly attributed to gastroesophageal reflux in infants are most often not associated with a reflux event. Even though causality cannot be definitively proven, in the minority in whom a symptom association is observed, nonacid events are as likely as acid events to cause symptoms.

SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death that occur during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from focusing only on SIDS to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths, including SIDS. The recommendations described in this policy statement include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consideration of using a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in the accompanying "Technical Report--SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue of Pediatrics (www.pediatrics.org/cgi/content/full/128/5/e1341).

Impact of feeding strategies on the frequency and clearance of acid and nonacid gastroesophageal reflux events in dysphagic neonates

BACKGROUND

Feeding difficulties and gastroesophageal reflux (GER) are common problems in neonates. The authors hypothesize that GER could be influenced by feeding mechanics by evaluating the effects of feeding volumes, feeding durations, feeding flow rates, and caloric density on the chemical composition and clearance of GER in dysphagic neonates.

METHODS

Symptomatic dysphagic neonates (n = 35) underwent evaluation for suspected GER using pH-impedance methods.

RESULTS

The proportions of acid and nonacid GER were different during the first, second, and third postprandial hours (P < .0001). Prolonged feeding duration was significantly associated with decreased total, nonacid GER and BCT (P < .03). Significant positive correlations (P < .05) were detected between feeding flow rate vs frequency of total, nonacid GER and BCT. Significant positive correlation (P = .002) was noted between feeding volume and BCT. BCT decreased with each hourly interval (analysis of variance [ANOVA] P < .05); however, ACT increased with each hourly interval (ANOVA P = .05). Comparison between BCT and ACT at each postprandial hour is remarkable for longer ACT during the second and third hours after the initiation of feed (P ≤ .001). No significant correlation was noted between the milk types (breast milk or formula) or caloric density with regard to the GER characteristics. Oral-fed infants had more GER events than gavage-fed infants.

CONCLUSIONS

Prolonged feeding durations and slower flow rates are associated with decreased frequency of GER. Modification of feeding duration and flow rate can be a useful adjunct to ameliorate GER in dysphagic neonates.

Influence of percutaneous endoscopic gastrostomy on gastro-oesophageal reflux evaluated by multiple intraluminal impedance in children with neurological impairment

AIM

The aim of the study was to estimate the influence of percutaneous endoscopic gastrostomy (PEG) placement on gastro-oesophageal reflux (GOR) by using multiple intraluminal impedance (MII/pH) measurements in children with neurological impairments.

METHOD

Fifteen children with neurological impairments (cerebral palsy, n=10; cerebroidolipofuscinosis, n=2; Aicardi syndrome, n=1; and secondary encephalopathy, n=2) were investigated (interquartile range [IQR] 6y 4mo-14y 8mo; median age 10y 2mo; eight male, seven female). Individuals with nutritional disorders that could not be corrected by physiological means or with swallowing disorders that either caused chronic respiratory symptoms or prevented food intake were included in the study. The exclusion criteria included previous major abdominal surgery and a lack of consent for PEG. Participants underwent MII/pH for a 24-hour period and had an oesophagogastroduodenoscopy before PEG placement, which was repeated 6 to 8 months later.

RESULTS

At baseline, GOR was detected in 6 of the 15 participants, and the second MII/pH session revealed GOR in 2 of the 15 children. Differences between quantitative GOR indices obtained before and after PEG were not statistically significant, except for the proportion of the acidic/weakly acidic reflux events - among all participants in the first examination, 159 reflux episodes were acidic and 244 were weakly acidic, while in the follow-up recordings the proportion was inverted (244 acidic, 136 weakly acidic; χ(2) =47.0; p<0.001). Baseline endoscopy did not reveal any macroscopic changes in any of the examined individuals, but the follow-up examination revealed oesophagitis in two participants. The median body weight gain after 6 months as 22.0% (IQR 14.4-29.2%). All participants tolerated PEG feeding well, regardless of MII/pH results.

INTERPRETATION

Identification of GOR based on MII/pH in children with neurological impairments does not exclude a good clinical response to PEG feeding.

The crying baby: what approach?

PURPOSE OF REVIEW

Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management.

RECENT FINDINGS

New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended.

SUMMARY

The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.

Maternal psychopathology and psychomotor development of children with GERD

OBJECTIVES

The relation between gastroesophageal reflux disease (GERD) and maternal psychopathology as well as the role of impairments in mother-child interactions in the perpetuation of feeding problems in children with GERD was previously implicated but not confirmed. The present study aimed to study the relation between maternal psychopathology and feeding problems in children with GERD and the effects of GERD on the psychomotor development of children.

SUBJECTS AND METHODS

The case group included 39 children with GERD and their mothers and the comparison group included 39 healthy children and their mothers. The groups were matched for age, gestational age, socioeconomic status, and sex. Scales used for the psychiatric assessment of mothers were the Beck Anxiety Inventory, Hamilton Rating Scale for Depression, Eating Attitudes Test, and Experiences in Close Relationships-Revised. The children's developmental levels were assessed by the Brunet-Lezine Revised test.

RESULTS

Maternal Beck Anxiety Inventory, Hamilton Rating Scale for Depression, Eating Attitudes Test, and Experiences in Close Relationships-Revised scores were significantly higher in the case group. Forced feeding and maternal thoughts of the child's feeding as insufficient were associated with a high level of maternal attachment-related anxiety and avoidance. Children with GERD had significantly lower Brunet-Lezine-Revised scores.

CONCLUSIONS

Maternal psychopathology, especially insecure attachment, may play a role in the feeding problems in children with GERD. Children with GERD should be examined for maternal psychopathology and feeding problems so that maladaptive feeding behaviors can receive appropriate intervention before the development of negative reinforcement to feeding. The psychomotor development of children should be kept in mind.

The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review

BACKGROUND

Antireflux surgery (ARS) for gastroesophageal reflux disease (GERD) is one of the most frequently performed major operations in children. Many studies have described the results of ARS in children, however, with a wide difference in outcome. This study aims to systematically review the efficacy of pediatric ARS and its effects on gastroesophageal function, as measured by gastroesophageal function tests. This is the first systematic review comprising only prospective, longitudinal studies, minimizing the risk of bias.

METHODS

Three electronic databases (Medline, Embase, and the Cochrane Library) were searched for prospective studies reporting on ARS in children with GERD.

RESULTS

In total, 17 eligible studies were identified, reporting on a total of 1,280 children. The median success rate after ARS was 86% (57-100%). The success rate in neurologically impaired children was worse in one study, but similar in another study compared to normally developed children. Different surgical techniques (total versus partial fundoplication, or laparoscopic versus open approach) showed similar reflux recurrence rates. However, less postoperative dysphagia was observed after partial fundoplication and laparoscopic ARS was associated with less pain medication and a shorter hospital stay. Complications of ARS varied from minimal postoperative complications to severe dysphagia and gas bloating. The reflux index (RI), obtained by 24-h pH monitoring (n = 8) decreased after ARS. Manometry, as done in three studies, showed no increase in lower esophageal sphincter pressure after ARS. Gastric emptying (n = 3) was reported either unchanged or accelerated after ARS. No studies reported on barium swallow x-ray, endoscopy, or multichannel intraluminal impedance monitoring before and after ARS.

CONCLUSION

ARS in children shows a good overall success rate (median 86%) in terms of complete relief of symptoms. Efficacy of ARS in neurologically impaired children may be similar to normally developed children. The outcome of ARS does not seem to be influenced by different surgical techniques, although postoperative dysphagia may occur less after partial fundoplication. However, these conclusions are bound by the lack of high-quality prospective studies on pediatric ARS. Similar studies on the effects of pediatric ARS on gastroesophageal function are also very limited. We recommend consistent use of standardized assessment tests to clarify the effects of ARS on gastroesophageal function and to identify possible risk factors for failure of ARS in children.

Role of gastroesophageal reflux in children with unexplained chronic cough

OBJECTIVE

The relation between respiratory symptoms and gastroesophageal reflux (GER) is a matter of contention and debate, with limited data in children to substantiate or refute cause and effect. Moreover, there are few data on the relation between nonacid reflux and chronic cough in childhood. We aimed to describe the type and physical characteristics of reflux episodes in children with unexplained chronic cough.

PATIENTS AND METHODS

Forty-five children with chronic cough underwent 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH monitoring). Symptom association probability (SAP) characterized the reflux-cough association. Twenty children with erosive reflux disease (ERD) served as controls.

RESULTS

Twenty-four children had cough-related reflux (CRR), with 19 having no gastrointestinal symptoms. Twenty-one had cough-unrelated reflux (CUR). CRR and ERD had increased acid (AR), weakly acidic (WAc), and weakly alkaline (WAlk) reflux. Esophageal acid exposure time and acid clearance time were higher in ERD than in CRR and CUR. In the CRR group, of 158 cough episodes related to reflux episodes, 66% involved AR, 18% WAc, and 16% WAlk. Seventeen children had positive SAP, 7 for AR, 5 for both AR and WAc, 4 for both WAc and WAlk, and 1 for WAlk.

CONCLUSIONS

In children with unexplained chronic cough, asymptomatic acid and nonacid GER is a potential etiologic factor. The increased acid exposure time and delayed acid clearance characteristic of ERD are absent in cough-related GER. MII-pH monitoring increases the likelihood of demonstrating a temporal association between the cough and all types of reflux.

Inter- and intraobserver agreement in 24-hour combined multiple intraluminal impedance and pH measurement in children

OBJECTIVES

Assessment of intra- and interobserver agreement in multiple intraluminal impedance (MII) measurement between investigators from different institutions.

METHODS

Twenty-four 18- to 24-hour MII tracings were randomly chosen from 4 different institutions (6 per center). Software-aided automatic analysis was performed. Each result was validated by 2 independent investigators from the 4 different centers (4 investigator combinations). For intraobserver agreement, 6 measurements were analyzed twice by the same investigator. Agreement between investigators was calculated using the Cohen kappa coefficient.

RESULTS

Interobserver agreement: 13 measurements showed a perfect agreement (kappa > 0.8); 9 had a substantial (kappa 0.61-0.8), 1 a moderate (kappa coefficient 0.41 to 0.6), and 1 a fair agreement (kappa coefficient 0.11-0.4). Median kappa value was 0.83. Intraobserver agreement: 5 tracings showed perfect and 1 showed a substantial agreement. The median kappa value was 0.88.

CONCLUSIONS

Most measurements showed substantial to perfect intra- and interobserver agreement. Still, we found a few outliers presumably caused by poorer signal quality in some tracings rather than being observer dependent. An improvement of analysis results may be achieved by using a standard analysis protocol, a standardized method for judging tracing quality, better training options for method users, and more interaction between investigators from different institutions.

Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates

Gastroesophageal reflux disease (GERD) is a frequent consideration in intensive care unit neonates. We tested the hypothesis that symptoms in GERD are dependent on the spatiotemporal and physicochemical characteristics of reflux events by evaluating the symptom sensitivity index (SSI) and symptom index (SI) in relation to the refluxate characteristics. Thirty symptomatic neonates (30.7 ± 0.8 wk gestation) were evaluated using manometry and pH-impedance methods. During 704.3 h of recordings, 2063 gastroesophageal reflux (GER) were observed; 54% of the GER were associated with symptoms. Defined by physical characteristics, there were 51.3% liquid, 29.1% gas, and 19.6% mixed GER. Defined by chemical characteristics, there were 48.5% acid and 51.5% nonacid GER. Defined by most proximal extent, 79.2% were supra-UES (upper esophageal sphincter) and 20.8% were infra-UES. Higher SSI was noted with pH-only events (p < 0.0001 versus pH-impedance events). Higher SI was noted with movement symptoms (versus sensory, p = 0.04). In a subset analysis, the frequencies of GER events, acid clearance time, and SSI were all greater in chronic lung disease versus none (p < 0.001). In conclusion, clinical significance of symptoms as measured by SSI and SI and characterization of spatial-temporal-physical-chemical nature of GER events as defined by pH-impedance methods clarifies the definition of GERD.

Long-term outcomes in pediatric-onset esophageal eosinophilia

BACKGROUND

Pediatric eosinophilic esophagitis (EoE) is a newly recognized antigen-induced form of chronic esophagitis (CE).

OBJECTIVE

Characterization of long-term clinical outcomes in patients with pediatric EoE is needed.

METHODS

From histologic review of 3817 pediatric esophageal biopsy specimens from 1982-1999, we conducted a nested case-control study of patients with retrospectively identified histologic eosinophilic esophagitis (rEoE) and CE, as well as an age-matched control cohort. Participants were asked to complete validated health-related outcome questionnaires.

RESULTS

At an average of 15 years after initial endoscopy, both cohorts (42/198 patients with rEoE and 67/468 patients with CE, as well as 100 age-matched control subjects) completed questionnaires. Compared with control subjects, quality of life was significantly decreased among patients with rEoE (P < .001) and patients with CE (P < .001). Rates of dysphagia (patients with rEoE, 49%; patients with CE, 37%; control subjects, 6%) and food impaction (patients with rEoE, 40%; patients with CE, 14%; control subjects, 3%) were significantly increased in the rEoE cohort compared with those seen in control subjects (P < .001 and P < .001, respectively). Increased esophageal eosinophil counts (odds ratio [OR], 1.6; 95% CI, 1.1-2.5; P < .05) during childhood were predictive of dysphagia during early adulthood. Food allergy (OR, 2.7; 95% CI, 1.2-6.0; P < .01), allergic rhinitis (OR, 3.5; 95% CI, 1.8-6.8; P < .001), and asthma (OR, 2.1; 95% CI, 1.04-4.3; P = .04) were associated with dysphagia. Food impaction was more common among patients with reported food allergy than among those without (OR, 3.1; 95% CI, 1.2-7.8; P = .02).

CONCLUSIONS

Esophageal eosinophilia is associated with reduced quality of life and persistent symptoms 15 years after presentation. Increased esophageal eosinophil counts and the occurrence of food allergy and atopy in childhood increase the rate of dysphagia in young adulthood.

A multicenter, randomized, open-label, pharmacokinetics and safety study of pantoprazole tablets in children and adolescents aged 6 through 16 years with gastroesophageal reflux disease

Children with gastroesophageal reflux disease (GERD) may benefit from gastric acid suppression with proton pump inhibitors such as pantoprazole. Effective treatment with pantoprazole requires correct dosing and understanding of the drug's kinetic profile in children. The aim of these studies was to characterize the pharmacokinetic (PK) profile of single and multiple doses of pantoprazole delayed-release tablets in pediatric patients with GERD aged 6 to 11 years (study 1) and 12 to 16 years (study 2). Patients were randomly assigned to receive pantoprazole 20 or 40 mg once daily. Plasma pantoprazole concentrations were obtained at intervals through 12 hours after the single dose and at 2 and 4 hours after multiple doses for PK evaluation. PK parameters were derived by standard noncompartmental methods and examined as a function of both drug dose and patient age. Safety was also monitored. Pantoprazole PK was dose independent (when dose normalized) and similar to PK reported from adult studies. There was no evidence of accumulation with multiple dosing or reports of serious drug-associated adverse events. In children aged 6 to 16 years with GERD, currently available pantoprazole delayed-release tablets can be used to provide systemic exposure similar to that in adults.

Pharmacokinetics and tolerability of rabeprazole in children 1 to 11 years old with gastroesophageal reflux disease

BACKGROUND

The pharmacokinetics of rabeprazole after a single oral dose and once-daily administration for 5 consecutive days was characterized in children 1 to 11 years old with gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

The initial 8 patients received rabeprazole sodium (hereafter referred to as rabeprazole) 0.14 mg/kg (part 1); the next 20 patients were randomized to receive 0.5 or 1 mg/kg (part 2) to target concentrations in plasma expected to be safe and effective. Pharmacokinetic parameters of rabeprazole and the thioether metabolite were calculated using noncompartmental methods. Subjective evaluations of GERD severity, rabeprazole short-term effectiveness, palatability, and safety were also characterized.

RESULTS

Rabeprazole concentrations increased in a dose-dependent manner. Little or no accumulation was observed after repeated administration. The results suggest that formation of the thioether is an important metabolic pathway in young patients, which is consistent with adults. Plasma area under the concentration-time curve values of rabeprazole and the metabolite were poorly correlated with individual age and body weight. Furthermore, oral rabeprazole clearance values (not adjusted for weight) were similar to historical adult data. However, weight-adjusted values were higher for the pediatric patients, and approximately 2 to 3 times the milligram per kilogram dose of rabeprazole in these children was necessary to achieve comparable concentrations in adults. Subjective evaluations demonstrated an improvement of GERD symptoms in most patients after rabeprazole treatment.

CONCLUSIONS

Palatability of the formulation was reported to be good or excellent. Rabeprazole was well tolerated, with no notable differences in safety among the dose groups.

Gastroesophageal Reflux and Body Movement in Infants: Investigations with Combined Impedance-pH and Synchronized Video Recording

The aim of this paper was to investigate the temporal association of gastroesophageal reflux (GER) and body movement in infants. GER were registered by combined impedance-pH, documentation of body movement was done by video. Videorecording time (Vt) was divided into “resting time” and “movement time” and analyzed for occurrence of GER. Association was defined as movement 1 minute before/after the beginning of a GER. Statistical evaluation was by Fisher's exact test. In 15 infants, 341 GER were documented during Vt (86 hours). 336 GER (99%) were associated with movement, only 5 episodes (1%) occured during resting time. Movement was significantly associated with the occurrence of GER (P < .0001). There is a strong temporal association between GER and body movement in infants. However, a clear distinction between cause and effect could not be made with the chosen study design. Combined impedance-pH has proven to be the ideal technique for this approach.

Development and psychometric evaluation of 2 age-stratified versions of the Pediatric GERD Symptom and Quality of Life Questionnaire

OBJECTIVES

The Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) represents 2 related age-stratified tools developed to assess pediatric gastroesophageal reflux disease (GERD). These include the PGSQ-Cp (for children ages 2 to 8 years, parent/caregiver report) and the PGSQ-A (for adolescents ages 9-17 years). The objective of the present study was to develop and evaluate PGSQ measurement properties.

MATERIALS AND METHODS

The PGSQ items were generated based on information from focus groups, expert clinician review, and cognitive debriefing interviews. The symptoms of pediatric GERD and the effect of these symptoms were addressed. The tools were evaluated in a 3-week psychometric evaluation with participants from 11 clinical sites in the United States. The study included other measures such as the Pediatric Quality of Life questionnaire (PedsQL) and clinician-rated GERD severity. After item reduction, internal consistency, reproducibility, construct validity, known-group validity, and responsiveness were assessed.

RESULTS

The 231 participants included 75 parents of children ages 2 to 8 years and 75 children ages 9 to 17 years with GERD and 41 parents of children and 40 children ages 9 to 17 years without GERD. Exploratory factor analysis demonstrated 4 symptom subscales for the PGSQ-Cp and 3 symptom subscales for the PGSQ-A. Both had subscales for total impact and school impact. High to moderate internal consistency was observed, ranging from 0.76 to 0.96 for the PGSQ-Cp and from 0.67 to 0.94 for the PGSQ-A. The PGSQ significantly differentiated between patients with GERD and controls (P < 0.0001, PGSQ-Cp; P < 0.0022-0.0001, PGSQ-A) and demonstrated responsiveness.

CONCLUSIONS

These results support the reliability, validity, and responsiveness of both versions of the PGSQ. The instruments should be useful for clinical studies.

Obstructive hypopnea and gastroesophageal reflux as factors associated with residual obstructive sleep apnea syndrome

OBJECTIVE

The mechanism of persisting obstructive sleep apnea (OSA) after adenotonsillectomy is not fully explained. The purpose of this study was to evaluate factors associated with residual OSA. The primary outcome measures were metabolic tests and polysomnographic respiratory indices in children with residual disease compared with children who were diagnosed with OSA but were untreated. Secondary outcome measures were acid gastroesophageal reflux indices recorded parallel to the sleep study.

METHODS

In the one-year study consecutive series of patients with sleep disordered breathing hospitalized in a tertiary pediatric center were evaluated. Following the study protocol a sleep interview, physical examination, metabolic blood tests (serum leptin and the homeostasis model assessment index for insulin resistance, HOMA-IR) and an overnight polysomnography with pH-metry recording were performed. Children diagnosed with OSA were analyzed in two groups: I - residual OSA (after surgery), II - non-residual OSA (newly diagnosed). Logistic regression analysis was applied to obtain significant risk factors for prediction of OSA.

RESULTS

Fifty-seven children (mean age ± SE, 6.9 ± 0.5 years; 66.7% boys) met the inclusion criteria and were enrolled in the study as residual (n=19) or non-residual OSA (n=38). The groups differed significantly in mean oxygen saturation, SpO₂ (94.3% vs. 96.2%; p=0.018 respectively), in the Apnea Hypopnea Index, (20.6/h vs. 9.1/h; p<0.03), the number of respiratory arousals with desaturation (2.2/h vs. 0.8/h; p<0.03); mean intraluminal esophageal pH (5.36 vs. 5.86; p=0.007) and the Reflux Index (9.61% vs. 4.35%; p=0.003). The groups did not differ in total sleep time, tonsil size, BMI z-score and blood metabolic indices. Logistic regression analysis showed that residual OSA was significantly predicted by two polygraphic findings: the obstructive hypopnea index (OR 1.15; 95% CI 1.02-1.28; p=0.014) and by the Reflux Index (OR 1.01; 95% CI 1.00-1.34; p=0.042).

CONCLUSIONS

1. Obstructive hypopneas, rather than obstructive apneas, persist after adenotonsillar surgery resulting in residual OSA. 2. Children with residual OSA are at higher risk of acid gastroesophageal reflux and should be evaluated for gastroesophageal reflux disease.

Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review

INTRODUCTION

Use of proton-pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD) in children has increased enormously. However, effectiveness and safety of PPIs for pediatric GERD are under debate.

OBJECTIVES

We performed a systematic review to determine effectiveness and safety of PPIs in children with GERD.

METHODS

We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for randomized controlled trials and crossover studies investigating efficacy and safety of PPIs in children aged 0 to 18 years with GERD for reduction in GERD symptoms, gastric pH, histologic aberrations, and reported adverse events.

RESULTS

Twelve studies were included with data from children aged 0-17 years. For infants, PPIs were more effective in 1 study (compared with hydrolyzed formula), not effective in 2 studies, and equally effective in 2 studies (compared with placebo) for the reduction of GERD symptoms. For children and adolescents, PPIs were equally effective (compared with alginates, ranitidine, or a different PPI dosage). For gastric acidity, in infants and children PPIs were more effective (compared with placebo, alginates, or ranitidine) in 4 studies. For reducing histologic aberrations, PPIs showed no difference (compared with ranitidine or alginates) in 3 studies. Six studies reported no differences in treatment-related adverse events (compared with placebo or a different PPI dosage).

CONCLUSIONS

PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking.

Optimisation of the reflux-symptom association statistics for use in infants being investigated by 24-hour pH impedance

BACKGROUND AND AIM

pH-impedance monitoring is used to diagnose symptomatic gastroesophageal reflux (GER) based on symptom association probability (SAP). Current criteria for calculation of SAP are optimised for heartburn in adults. Infants, however, demonstrate a different symptom profile. The aim of the present study was to optimise criteria for calculation of SAP in infants with GER disease.

PATIENTS AND METHODS

Ten infants referred for investigation of symptomatic reflux were enrolled. GER episodes were recorded using a pH-impedance probe, which remained in place for 48 hours. During the test, cough, crying, and regurgitation were marked. Impedance recordings were analysed for the occurrence of bolus reflux episodes. SAP for behaviors following reflux episodes was separately calculated for day 1 and day 2 using automated reporting software, which enabled the time window used for SAP calculations to be modified from 15 to 600 seconds. Day-to-day agreement of SAP was assessed by calculating the 95% limits of agreement (mean difference ± 1.96 standard deviations of differences) and their confidence intervals.

RESULTS

The number of bolus GER episodes and symptom episodes reported did not differ from day to day. The best agreement in SAP between the 2 days was found using time intervals of 2 minutes for cough, 5 minutes for crying, and 15 seconds and/or 2 to 5 minutes for regurgitation.

CONCLUSIONS

We conclude that the standard 2-minute time interval is appropriate for the investigation of cough and regurgitation symptoms. The day-to-day agreement of SAP for crying was poor using standard criteria, and our results suggest increasing the reflux-symptom association time interval to 5 minutes.

Esophageal impedance monitoring for gastroesophageal reflux

Dual pH-multichannel intraluminal impedance (pH-MII) is a sensitive tool for evaluating overall gastroesophageal reflux disease, and particularly for permitting detection of nonacid reflux events. pH-MII technology is especially useful in the postprandial period or at other times when gastric contents are nonacidic.pH-MII was recently recognized by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as being superior to pH monitoring alone for evaluation of the temporal relation between symptoms and gastroesophageal reflux. In children, pH-MII is useful to correlate symptoms with reflux (particularly nonacid reflux), to quantify reflux during tube feedings and the postprandial period, and to assess efficacy of antireflux therapy. This clinical review is simply an evidence-based overview addressing the indications, limitations, and recommended protocol for the clinical use of pH-MII in children.

Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults

BACKGROUND

Gastroesophageal reflux disease (GORD) is said to be the causative factor in up to 41% of adults with chronic cough. Treatment for GORD includes conservative measures (diet manipulation), pharmaceutical therapy (motility or prokinetic agents, H(2)-antagonist and proton pump inhibitors (PPI)) and fundoplication.

OBJECTIVES

To evaluate the efficacy of GORD treatment on chronic cough in children and adults with GORD and prolonged cough that is not related to an underlying respiratory disease, i.e. non-specific chronic cough.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, review articles and reference lists of relevant articles. The date of last search was 8 April 2010.

SELECTION CRITERIA

All randomised controlled trials (RCTs) on GORD treatment for cough in children and adults without primary lung disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for further information.

MAIN RESULTS

We included 19 studies (six paediatric, 13 adults). None of the paediatric studies could be combined for meta-analysis. A single RCT in infants found that PPI (compared to placebo) was not efficacious for cough outcomes (favouring placebo OR 1.61; 95% CI 0.57 to 4.55) but those on PPI had significantly increased adverse events (OR 5.56; 95% CI 1.18 to 26.25) (number needed to treat for harm in four weeks was 11 (95% CI 3 to 232)). In adults, analysis of H(2) antagonist, motility agents and conservative treatment for GORD was not possible (lack of data) and there were no controlled studies of fundoplication. We analysed nine adult studies comparing PPI (two to three months) to placebo for various outcomes in the meta-analysis. Using intention-to-treat, pooled data from studies resulted in no significant difference between treatment and placebo in total resolution of cough (OR 0.46; 95% CI 0.19 to 1.15). Pooled data revealed no overall significant improvement in cough outcomes (end of trial or change in cough scores). We only found significant differences in sensitivity analyses. We found a significant improvement in change of cough scores at end of intervention (two to three months) in those receiving PPI (standardised mean difference -0.41; 95% CI -0.75 to -0.07) using generic inverse variance analysis on cross-over trials. Two studies reported improvement in cough after five days to two weeks of treatment.

AUTHORS' CONCLUSIONS

PPI is not efficacious for cough associated with GORD symptoms in very young children (including infants) and should not be used for cough outcomes. There is insufficient data in older children to draw any valid conclusions. In adults, there is insufficient evidence to conclude definitely that GORD treatment with PPI is universally beneficial for cough associated with GORD. Clinicians should be cognisant of the period (natural resolution with time) and placebo effect in studies that utilise cough as an outcome measure. Future paediatric and adult studies should be double-blind, randomised controlled and parallel-design, using treatments for at least two months, with validated subjective and objective cough outcomes and include ascertainment of time to respond as well as assessment of acid and/or non-acid reflux.

The unsettled baby: crying out for an integrated, multidisciplinary primary care approach

Unsettled behaviour in the first few months of life is a common clinical problem, with the associated risks of postnatal depression, premature cessation of breastfeeding, long-term psychological disturbance, and child abuse. Parents of new babies complain of difficulty accessing appropriate care and receiving conflicting advice. Although organic disturbance is implicated in only 5% of cases, gastro-oesophageal reflux disease, food allergies and lactose intolerance are often mistakenly diagnosed in unsettled babies. There is no evidence that acid-suppressive medications help in treating unsettled behaviour and, until the hypothesis that proton-pump inhibitors may predispose to food allergies has been properly investigated, treatment with acid-suppressive medications should be avoided in this population. Although unsettled behaviour in infants is commonly a transient neurodevelopmental phenomenon that peaks at 6 weeks of age, failure to diagnose other correctable problems, including breastfeeding difficulty and cows milk allergy, risks entrenching anxiety and disrupted mother-infant interactions in the long term. In the current climate of health system reform, the design and evaluation of an integrated, evidence-based, multidisciplinary primary care approach to management of unsettled babies and their mothers is a priority.

Lower esophageal sphincter relaxation reflex kinetics: effects of peristaltic reflexes and maturation in human premature neonates

We defined the sensory-motor characteristics of the lower esophageal sphincter relaxation (LESR) (stimulus threshold volume, response onset, and relaxation period, relaxation magnitude, nadir) during maturation in human neonates. We hypothesized that LESR kinetics differs during maturation and with peristaltic reflex type. Basal and adaptive esophageal motility testing was performed (N = 20 premature neonates) at 34.7 and 39.1 wk (time 1 and time 2). Effects of midesophageal provocation with graded stimuli (N = 1,267 stimuli, air and liquids) on LESR kinetics during esophagodeglutition response (EDR) and secondary peristalsis (SP) were analyzed by mixed models. Frequency of LESR with basal primary peristalsis were different during maturation (P = 0.03). During adaptive responses with maturation, 1) the frequencies of peristaltic reflexes and LESR were similar; 2) liquid stimuli resulted in a shorter LESR response latency and LESR nadir and greater LESR magnitude (all P < 0.05); 3) media differences were noted with LESR response latency (air vs. liquids, P < 0.02); and 4) infusion flow rate-LESR were different (P < 0.01 for air and liquids). Mechanistically, 1) frequency of LESR was greater during peristaltic reflexes at both times (vs. none, P < 0.0001); 2) LESR response latency, duration, and time to complete LESR were longer with EDR (all P < 0.05, vs. SP at time 2); and 3) graded stimulus volume LESR were different for air and liquids (P < 0.01). In conclusion, sensory-motor characteristics of LESR depend on the mechanosensitive properties of the stimulus (media, volume, flow), type of peristaltic reflex, and postnatal maturation. Maturation modulates an increased recruitment of inhibitory pathways that favor LESR.

Maintenance treatment with proton pump inhibitors for reflux esophagitis in pediatric patients: a systematic literature analysis

OBJECTIVES

Short-term treatment with a proton pump inhibitor (PPI) is effective for healing reflux esophagitis and improving reflux symptoms in pediatric patients. Our aim was to assess the efficacy and tolerability of maintenance PPI treatment after healing of reflux esophagitis in pediatric patients.

MATERIALS AND METHODS

Systematic searches of MEDLINE, Excerpta Medica database, and recent conference abstracts.

RESULTS

Five studies evaluated the efficacy of PPI maintenance therapy (6- to 90-month follow-up) in pediatric patients after healing of reflux esophagitis. Three found no relapse of reflux esophagitis or reflux symptoms during PPI maintenance therapy; however, a low relapse rate (1/14) was also found in the placebo group of the only prospective controlled study. Two of the 5 studies (both prospective) reported relapse of reflux esophagitis at half the original healing dose of omeprazole (7 of 51 patients relapsed after 3 months; 8 of 32 within 21 months), which resolved again in most patients when the healing dose or higher was given. Four studies evaluated relapse of reflux esophagitis and/or reflux symptoms after stopping PPI therapy. Reflux symptoms recurred in 18% to 76% of patients across all 4 studies. In the 4 studies that assessed the safety of PPI maintenance therapy, adverse events were infrequent and of low severity.

CONCLUSIONS

Pediatric patients with gastroesophageal reflux disease and certain chronic comorbidities appear to have the greatest need of maintenance PPI treatment after healing of reflux esophagitis. In patients requiring maintenance therapy, PPIs appear to be well tolerated and effective in maintaining remission of reflux esophagitis and reflux symptoms.

New treatments for infant colic

PURPOSE OF REVIEW

Infantile colic is a common problem within the first 3 months of life and causes considerable distress for parents and paediatricians. Despite 40 years of research, its pathogenesis is incompletely understood and treatment remains an open issue. This review will describe recent studies that have examined different kinds of interventions.

RECENT FINDINGS

Important advances in understanding the aetiopathogenesis of infantile colic have been recently proposed and opened new perspectives in its management.The composition of intestinal microbiota, specially an inadequate amount of lactobacilli and an increased concentration of coliforms, might influence the pathogenesis of infantile colic. The benefit of supplementation with Lactobacillus reuteri has been recently reported and experimental data showed the effect of probiotics may be related to the influence on gut motility and pain perception.

SUMMARY

Infantile colic is a clinical entity with a wide range of clinical presentations and outcome. Firstly, paediatricians have to exclude other underlying diseases with a medical examination and prevent feeding disorders. Then, considering the favourable clinical course of the disturbance, well tolerated strategies should be adopted. The findings highlighted in this review may promote the implementation of new researches and treatments to reduce abdominal pain related to infantile colic.

Management of gastroesophageal reflux disease and erosive esophagitis in pediatric patients: focus on delayed-release esomeprazole

OBJECTIVE

To review the literature on the treatment of gastroesophageal reflux disease (GERD) with emphasis on proton pump inhibitors (PPIs), particularly on delayed-release esomeprazole, and to identify properties and adverse effects of PPIs observed in the treatment of GERD in children and adolescents.

SOURCES

Electronic search of PubMed/Medline and Cochrane Collaboration databases, and of abstracts on DDW, NASPGHAN, and ESPGHAN. We focused on controlled and randomized studies published since 2000 and identified reviews that presented a consensual position, and directives published within the last 10 years.

MAIN RESULTS

PPIs are considered better antisecretory agents than H(2)-receptor antagonists. Although all PPIs are similar, they are not identical in their pharmacologic properties. For example, the acid-suppressive effect of esomeprazole, the S-isomer of omeprazole, persists for more than 16 hours after administration of the morning dose. Therefore, it can control acidity after night meals better than a single dose of omeprazole. Moreover, the onset of the suppressive effect of esomeprazole is faster. It achieves acid inhibition faster than other PPIs.

CONCLUSION

Currently, the mainstream treatment for GERD in children is a PPI. Although PPIs are safe drugs, effective in healing erosive esophagitis, and in relieving symptoms, studies with esomeprazole have shown that this drug has as powerful an ability to inhibit acid secretion as omeprazole. It also seems that some pharmacologic properties of esomeprazole are actually better for the treatment of GERD.

Clinical results from a randomized, double-blind, dose-ranging study of pantoprazole in children aged 1 through 5 years with symptomatic histologic or erosive esophagitis

In an 8-week, multicenter, randomized, double-blind study, we evaluated the efficacy and tolerability of pantoprazole (0.3mg/kg [low dose (LD)], 0.6 mg/kg [medium dose (MD)], and 1.2 mg/kg [high dose (HD)]) for delayed-release oral suspension (granules) in patients 1 to 5 years with documented symptoms of gastroesophageal reflux disease (GERD) and endoscopic evidence of reflux-related erosive esophagitis (EE) or histologic esophagitis (HE) consistent with GERD. Patients with HE were randomly assigned to LD, MD, or HD, and patients with EE, to MD or HD. A daily eDiary captured 5 individual GERD symptoms. A total of 60 patients (56 HE, 4 EE) were randomized. Mean weekly GERD symptom score (WGSS, sum of weekly mean frequency scores for 5 individual GERD symptoms) for the modified intention-to-treat HE population at the final week was improved with LD ( P < .001), MD (P = .063), and HD (P < 0.001) (paired t-tests). Patients with EE were healed at week 8. Adverse event incidences did not increase with dose.

Delayed-release oral suspension of omeprazole for the treatment of erosive esophagitis and gastroesophageal reflux disease in pediatric patients: a review

Omeprazole is a proton-pump inhibitor indicated for gastroesophageal reflux disease and erosive esophagitis treatment in children. The aim of this review was to evaluate the efficacy of delayed-release oral suspension of omeprazole in childhood esophagitis, in terms of symptom relief, reduction in reflux index and/or intragastric acidity, and endoscopic and/or histological healing. We systematically searched PubMed, Cochrane and EMBASE (1990 to 2009) and identified 59 potentially relevant articles, but only 12 articles were suitable to be included in our analysis. All the studies evaluated symptom relief and reported a median relief rate of 80.4% (range 35%–100%). Five studies reported a significant reduction of the esophageal reflux index within normal limits (<7%) in all children, and 4 studies a significant reduction of intra-gastric acidity. The endoscopic healing rate, reported by 9 studies, was 84% after 8-week treatment and 95% after 12-week treatment, the latter being significantly higher than the histological healing rate (49%). In conclusion, omeprazole given at a dose ranging from 0.3 to 3.5 mg/kg once daily (median 1 mg/kg once daily) for at least 12 weeks is highly effective in childhood esophagitis.

Gastroesophageal reflux symptoms in infants in a rural population: longitudinal data over the first six months

BACKGROUND

Increasing numbers of infants are receiving prescription medications for symptoms associated with gastroesophageal reflux. Our aim was to prospectively measure reported gastroesophageal reflux symptoms in healthy term infants for the first six months of life.

METHODS

In a prospective cohort study in the rural Upper Peninsula of Michigan, 128 consecutive maternal-infant pairs were followed for six months and administered the Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) at the one-month, two-month, four-month, and six-month well-child visits.

RESULTS

The I-GERQ-R scores decreased with age. Average scores were 11.74 (SE = 5.97) at one-month, 9.97(4.92) at two-months, 8.44(4.39) at four-months, and 6.97(4.05) at six months. Symptoms associated with colic were greatest at one month of age.

CONCLUSION

Symptoms of gastroesophageal reflux as measured by the I-GERQ-R decrease with age in the first six months of life in otherwise healthy infants; however the I-GERQ-R may have difficulty differentiating gastroesophageal reflux disease from colic in those under 3 months of age.

Effectiveness and Safety of Proton Pump Inhibitors in Infantile Gastroesophageal Reflux Disease

Objective:

To evaluate the efficacy and safety of proton pump inhibitors (PPIs) in the treatment of gastroesophageal reflux disease (GERD) in infants <1 year of age.

Data Sources:

A literature search was conducted through PubMed (up to December 2009), International Pharmaceutical Abstracts (1970–December 2009), and The Cochrane Library (up to December 2009) using combinations of the following key search terms: proton pump inhibitor, GERD, infant, children, pediatric, omeprazole, rabeprazole, lansoprazole, esomeprazole, and pantoprazole. Reference citations from identified articles were also reviewed.

Study Selection And Data Extraction:

All double-blind, placebc-controlled trials published in English that evaluated the safety and efficacy of PPIs in infants with GERD were included in this review. Trials involving children older than 12 months were not included.

Data Synthesis:

GERD is a source of pain and discomfort in adults; yet, in infants, symptoms that are thought to be indicative of painful stimuli have no clear cause-and-effect relationship with infant GERD. PPIs are beneficial in relieving symptoms of GERD in the adult population, but their usefulness in decreasing GERD-associated behaviors in infants is still questionable, despite a large increase in PPI prescribing for children <1 year of age. In all studies reviewed, infants treated with PPIs did not experience a significant decrease in behaviors perceived to be caused by GERD. The largest placebo-controlled trial to date found that rates of adverse events were increased in the PPI group compared with the placebo group, whereas the other trials reviewed reported no difference in adverse effects with the use of PPIs.

Conclusions:

Clinical trials reveal that PPI therapy is not an effective treatment for common infant GERD-associated symptoms. Evidence supporting safety of PPI use in infants is conflicting, and more large-scale, randomized, placebo-controlled trials are necessary to better establish the role of PPIs in infant GERD.