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 pulmonary function in esophageal atresia-A case-control study

BACKGROUND

Esophageal atresia (EA) is a congenital anomaly associated with substantial pulmonary morbidity throughout childhood.

AIM

The aim of this study was to evaluate pulmonary complications among 59 five to 15-year-old children and adolescents with surgically corrected congenital EA.

METHODS

Participants underwent a structured interview, spirometry, body plethysmography, mannitol challenge test, skin prick test, as well as measurements of the diffusion capacity, airway resistance, fraction of exhaled NO, and specific immunoglobulin E in serum. A control group consisted of 25 children being evaluated for gastroesophageal reflux disease.

RESULTS

Among the EA patients 33 (55.9%) had respiratory symptoms, 31 (53.4%) had a history of at least three pneumonias, and 32 (54.2%) reported more frequent cough episodes than peers. The Forced Vital Capacity (FVC) was 84.9% ± 13.2% of predicted, forced expiratory volume 1 sec (FEV1) was 78.2% ± 12.4% of predicted, and forced expiratory fraction 25-75% (FEF25-75%) was 71.5 ± 17.8% of predicted in EA patients, lower than disease controls (P < 0.0001 for all). In addition, the total lung capacity (TLC) was lower in patients with EA than in the controls (P < 0.0001). Fifteen patients (28.8%) with EA had obstructive ventilatory impairment, compared to nine patients (17.3%) with restrictive ventilatory impairment, while one had a combination.

CONCLUSIONS

The present study demonstrated significantly decreased pulmonary characteristics in EA patients. Restrictive ventilatory impairment occurring in EA is probably due to poor lung growth after thoracotomy. No single factor predicted ventilatory impairment in children and adolescents with EA. Pediatr Pulmonol. 2017;52:98-106. © 2016 Wiley Periodicals, Inc.

Parents reported reduced symptoms and improved satisfaction after fundoplication and their perceptions were an important outcome measure

AIM

Fundoplication is required for children with chronic recurrent gastro-oesophageal reflux disease (GERD). The aim of this study was to report parental perceptions of symptoms and overall satisfaction with the long-term course following fundoplication with special reference to patients with GERD risk factors.

METHODS

We studied 34 patients, with a median age of 6.5 ± 4.9 years, who received fundoplication between 2001 and 2005. Clinical information and surgical complications were recorded. Parents were interviewed to evaluate post-operative symptoms, mode of nutrition and satisfaction.

RESULTS

The median follow-up time was 7.3 years. Comorbidities were neurological impairment in 15 patients, other gastrointestinal disorders in seven patients and isolated GERD in 12 patients. The parents reported that fundoplication effectively treated initial reflux symptoms in 60% and improved symptoms in 37%. Vomiting and reflux-associated pain were treated most effectively. Pulmonary symptoms often remained unchanged in neurologically impaired children. Redo fundoplication was necessary in seven patients. Only two parents regretted consenting to surgery.

CONCLUSION

A high percentage of parents reported improved gastrointestinal reflux-related symptoms and a high level of satisfaction following fundoplication. Parental perceptions of GERD symptoms should be an important outcome measure when assessing the efficacy of antireflux surgery in children in routine clinical follow-up.

Gastric Function in Children with Oesophageal Atresia and Tracheoesophageal Fistula

Oesophageal atresia and tracheoesophageal fistula (OA-TOF) are a multifaceted condition which affects patients throughout their lives. Even though it is one of the most common gastrointestinal malformations, most of the current studies focus on gastro-oesophageal reflux disease, anastomotic strictures, and feeding difficulties. However, there is increasing evidence that a proportion of patients with OA-TOF also have abnormal gastric function. This review aims to provide a comprehensive understanding of studies of gastric function in patients with OA-TOF. The etiology of this abnormality has been hypothesized to be congenital and/or acquired. Several modalities are currently available for the investigation of gastric function, each of them trying to answer specific clinical questions. This review summarizes the studies that have looked at gastric function in the OA-TOF cohort with gastric emptying studies (gastric emptying scintigraphy and ¹³C octanoic breath test), gastric manometry, electrogastrography, and oral glucose tolerance test. However, these modalities are limited due to poor age-specific normative values and heterogeneous methodologies used. The evaluation of symptoms in this cohort is crucial, modalities for abnormal gastric function are also described. With appropriate investigations and symptoms questionnaires, treatment strategies can be implemented to correct abnormal gastric function and thereby improve the outcomes and quality of life of patients with OA-TOF. This review highlights the need for large international multicentre collaborative studies and high-quality prospective randomized controlled trials to improve our understanding of gastric function in this cohort.

Re-evaluation of locust bean gum (E 410) as a food additive

Following a request from European Commission, the EFSA Panel on Food Additives and Nutrient Sources added to Food (ANS) provides a scientific opinion re-evaluating the safety of locust bean gum (E 410) as a food additive. Locust bean gum (E 410) is an authorised food additive in the EU. Locust bean gum (E 410) as specified in the Commission Regulation (EU) No 231/2012 is derived from the ground endosperm of the seeds of the strains of carob tree, Ceratonia siliqua (L.) Taub. (Family Leguminosae). An acceptable daily intake (ADI) 'not specified' was allocated by the Joint Food and Agriculture Organization/World Health Organization Expert Committee on Food Additives (JECFA) in 1981. Although not evaluated by the Scientific Committee for Food (SCF), it was accepted by the SCF in 1991 for use in weaning food, and in 1994, in infant formulae for special medical purposes. Locust bean gum is practically undigested, not absorbed intact, but significantly fermented by enteric bacteria in humans. No adverse effects were reported in 90-day toxicity and carcinogenicity studies in rodents at the highest doses tested and there was no concern with respect to the genotoxicity and to reproductive and developmental toxicity of locust bean gum (E 410). The Panel concluded that there is no need for a numerical ADI for locust bean gum (E 410), and that there is no safety concern for the general population at the refined exposure assessment for its reported uses as a food additive. However, infants and young children consuming foods for special medical purposes may show a higher susceptibility to gastrointestinal effects of locust bean gum due to their underlying medical condition. The Panel concluded that the available data do not allow an adequate assessment of the safety of locust bean gum (E 410) in these foods for infants and young children.

Impedance Testing in Esophageal Atresia Patients

Esophageal atresia patients are predisposed to gastroesophageal reflux as a result of the altered esophageal anatomy and motility. These patients experience significant morbidity from gastroesophageal reflux. As a result, an effective way to diagnose and monitor for reflux is crucial. pH-metry is able to quantify acid burden, ensure that acid suppression is adequate during long-term follow-up, and correlate acid reflux to symptoms. pH with impedance is additionally able to detect non-acid reflux as well as volume clearance, both of which also correlate with patient symptoms. It is also able to correlate extra-gastrointestinal symptoms to reflux, which may help guide treatment. If complications associated with uncontrolled reflux are identified, aggressive reflux management is necessary, oftentimes requiring surgical intervention.

Dose-Finding Study of Omeprazole on Gastric pH in Neonates with Gastro-Esophageal Acid Reflux Using a Bayesian Sequential Approach

Objective

Proton pump inhibitors are frequently administered on clinical symptoms in neonates but benefit remains controversial. Clinical trials validating omeprazole dosage in neonates are limited. The objective of this trial was to determine the minimum effective dose (MED) of omeprazole to treat pathological acid reflux in neonates using reflux index as surrogate marker.

Design

Double blind dose-finding trial with continual reassessment method of individual dose administration using a Bayesian approach, aiming to select drug dose as close as possible to the predefined target level of efficacy (with a credibility interval of 95%).

Setting

Neonatal Intensive Care unit of the Robert Debré University Hospital in Paris, France.

Patients

Neonates with a postmenstrual age ≥ 35 weeks and a pathologic 24-hour intra-esophageal pH monitoring defined by a reflux index ≥ 5% over 24 hours were considered for participation. Recruitment was stratified to 3 groups according to gestational age at birth.

Intervention

Five preselected doses of oral omeprazole from 1 to 3 mg/kg/day.

Main outcome measures

Primary outcome, measured at 35 weeks postmenstrual age or more, was a reflux index <5% during the 24-h pH monitoring registered 72±24 hours after omeprazole initiation.

Results

Fifty-four neonates with a reflux index ranging from 5.06 to 27.7% were included. Median age was 37.5 days and median postmenstrual age was 36 weeks. In neonates born at less than 32 weeks of GA (n = 30), the MED was 2.5mg/kg/day with an estimated mean posterior probability of success of 97.7% (95% credibility interval: 90.3–99.7%). The MED was 1mg/kg/day for neonates born at more than 32 GA (n = 24).

Conclusions

Omeprazole is extensively prescribed on clinical symptoms but efficacy is not demonstrated while safety concerns do exist. When treatment is required, the daily dose needs to be validated in preterm and term neonates. Optimal doses of omeprazole to increase gastric pH and decrease reflux index below 5% over 24 hours, determined using an adaptive Bayesian design differ among neonates. Both gestational and postnatal ages account for these differences but their differential impact on omeprazole doses remains to be determined.

Use of Low-Value Pediatric Services Among the Commercially Insured

BACKGROUND

Claims-based measures of "low-value" pediatric services could facilitate the implementation of interventions to reduce the provision of potentially harmful services to children. However, few such measures have been developed.

METHODS

We developed claims-based measures of 20 services that typically do not improve child health according to evidence-based guidelines (eg, cough and cold medicines). Using these measures and claims from 4.4 million commercially insured US children in the 2014 Truven MarketScan Commercial Claims and Encounters database, we calculated the proportion of children who received at least 1 low-value pediatric service during the year, as well as total and out-of-pocket spending on these services. We report estimates based on "narrow" measures designed to only capture instances of service use that were low-value. To assess the sensitivity of results to measure specification, we also reported estimates based on "broad measures" designed to capture most instances of service use that were low-value.

RESULTS

According to the narrow measures, 9.6% of children in our sample received at least 1 of the 20 low-value services during the year, resulting in $27.0 million in spending, of which $9.2 million was paid out-of-pocket (33.9%). According to the broad measures, 14.0% of children in our sample received at least 1 of the 20 low-value services during the year.

CONCLUSIONS

According to a novel set of claims-based measures, at least 1 in 10 children in our sample received low-value pediatric services during 2014. Estimates of low-value pediatric service use may vary substantially with measure specification.

Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events

OBJECTIVES

To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state.

STUDY DESIGN

Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state.

RESULTS

Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups.

CONCLUSIONS

Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.

Concomitant Fundoplication With Gastrostomy: A Two-State Comparison Showing Continued Use of Reflux Medications

OBJECTIVES

We sought to determine whether practice differences for fundoplication exist between 2 geographically distinct states, and to determine the reflux medication use pattern associated with concomitant fundoplication.

METHODS

A retrospective observational cohort study of children in Colorado (CO) and North Carolina (NC) insured by Medicaid from 2006 to 2008. Children who received a surgical gastrostomy during the study period were included, and our primary outcome measure was the performance of a concomitant gastric fundoplication. Thirty-day prescription fills for reflux medications were examined before and after gastrostomy procedure.

RESULTS

We examined 969 surgical gastrostomy admission in both states over the 3-year study period (CO, n = 341 and NC, n = 628). Patients in each state had similar age (median age, 6 months, P = 0.97). Use of pH probe (CO: 15%, NC: 11%) and diagnosis of reflux (CO: 84%, NC: 72%) differed in each state. Concomitant fundoplication was performed in 60% of patients in CO and 43% in NC (P < 0.01). Age less than 6 months was associated with an increased adjusted odds of fundoplication in CO (OR 9.77, CI, 3.91, 24.43), but less so in NC (OR 2.73, CI, 1.48, 5.04). Among patients undergoing gastrostomy, the proportion of patients on reflux medication 4 to 6 months post-discharge did not differ between those receiving fundoplication and those that did not in either state.

CONCLUSIONS

Rates of concomitant fundoplication varied in the 2 states despite patients having similar demographic and clinical characteristics. Antireflux surgery was not associated with a reduction in reflux medications in either state.

Use of Gastroesophageal Reflux Medications in Premature Infants After NICU Discharge

OBJECTIVES

To describe the epidemiology and management of gastroesophageal reflux (GER) medications started in the first year of life for premature infants.

METHODS

Retrospective review of a cohort of infants ≤35 weeks' gestation presenting for care by 168 days of age to a 30-site network between 2005 and 2009 (n = 2217) and followed to 3 years of age. Medication frequency, types, and duration of use were assessed. Logistic regression identified factors associated with treatment.

RESULTS

Thirty-seven percent (812) were prescribed GER medications with 77% begun after NICU discharge. Ninety percent (727) received histamine-2 receptor antagonists, 33% (269) proton pump inhibitors, 22% (182) prokinetics; 40% (325) received >1 medication. Outpatient medication was initiated at 95 ± 69 days of life for total of 294 ± 249 days (interquartile ratio: 117-359). Feeding issues (adjusted odds ratio [aOR] 2.05, 95% confidence interval [CI]: 1.24-3.39) were associated with outpatient initiation. Forty-three percent (322) of infants started before 6 months were still on at 1 year of age associated with gestational age <32 weeks (aOR 1.76, 95% CI: 1.16-2.67), chronic lung disease (aOR 2.59, 95% CI: 1.29-5.22), and reactive airways disease (aOR 1.67, 95% CI: 1.05-2.65).

CONCLUSIONS

Of the 37% of the cohort on GER medications, 77% were started after NICU discharge with prolonged use of medications. Feeding difficulties were associated with starting medication and markers of chronic lung disease with continuation of treatment. With uncertain evidence of efficacy, use of these medications in a high-risk population should be carefully evaluated.

Comparison of multichannel intraluminal impedance-pH monitoring and reflux scintigraphy in pediatric patients with suspected gastroesophageal reflux

AIM

To evaluate the agreement of multichannel intraluminal impedance-pH monitoring (MII-pHM) and gastroesophageal reflux scintigraphy (GES) for the diagnosis of gastroesophageal reflux disease.

METHODS

Seventy-five consecutive patients with suspected gastroesophageal reflux disease (GERD) underwent 24-h combined MII-pHM recording and one hour radionuclide scintigraphy during the course of the MII-pHM study. Catheters with 6 impedance channels and 1 pH sensor were placed transnasally. Impedance and pH data analysis were performed automatically and manually. For impedance monitoring, reflux was defined as a retrograde 50% drop in impedance, starting distally and propagating retrogradely to at least the next two more proximal measuring channels. Reflux index (RI, percentage of the entire record that esophageal pH is < 4.0) greater than 4.2% for pHM and number of refluxes more than 50 for 24 h for MII were accepted as positive test results. At scintigraphy, 240 frames of 15 seconds duration were acquired in the supine position. Gastroesophageal reflux was defined as at least one reflux episode in the esophagus. After scintigraphic evaluation, impedance-pH recordings and scintigraphic images were evaluated together and agreement between tests were evaluated with Cohen's kappa.

RESULTS

Sufficient data was obtained from 60 (80%) patients (34 male, 56.7%) with a mean age of 8.7 ± 3.7 years (range: 2.5-17.3 years; median: 8.5 years). Chronic cough, nausea, regurgitation and vomiting were the most frequent symptoms. The mean time for recording of MII-pHM was 22.8 ± 2.4 h (range: 16-30 h; median: 22.7 h). At least one test was positive in 57 (95%) patients. According to diagnostic criteria, GERD was diagnosed in 34 (57.7%), 44 (73.3%), 47 (78.3%) and 51 (85%) patients by means of pHM, MII, GES and MII-pHM, respectively. The observed percentage agreements/κ values for GES and pHM, GES and MII, GES and MII-pHM, and MII and pHM are 48.3%/-0.118; 61.7%/-0.042; 73.3%/0.116 and 60%/0.147, respectively. There was no or slight agreement between GES and pHM alone, MII alone or MII-pHM. pH monitoring alone missed 17 patients compared to combined MII-pHM. The addition of MII to pH monitoring increased the diagnosis rate by 50%.

CONCLUSION

No or slight agreement was found among pH monitoring, MII monitoring, MII-pH monitoring and GES for the diagnosis of gastroesophageal reflux disease.

Laparoscopic antireflux surgery increases health-related quality of life in children with GERD

INTRODUCTION

Improving health-related quality of life (HRQoL) is increasingly recognized as an essential part of patient care outcome. Little is known about the effect of laparoscopic antireflux surgery (LARS) on the HRQoL in the pediatric patients. The aims of this study were to evaluate the effect of LARS on HRQoL in children with gastroesophageal reflux disease (GERD) and to identify predictors that influence HRQoL outcome after LARS.

METHODS

Between 2011 and 2013, 25 patients with therapy-resistant GERD [median age 6 (2-18) years] were included prospectively. Caregivers and children with normal neurodevelopment (>4 years) were asked to fill out the validated PedsQL 4.0 Generic Core Scales before and 3-4 months after LARS.

RESULTS

The PedsQL was completed by all caregivers (n = 25) and 12 children. HRQoL total score improved significantly after LARS, both from a parental (p = 0.009) and child's perspective (p = 0.018). The psychosocial health summary and physical health summary scores also improved significantly after LARS. HRQoL before and after LARS was significantly lower in children with impaired neurodevelopment (p < 0.001). However, neurodevelopment did not influence the effect of LARS on HRQoL. The only significant predictor for improvement in HRQoL after LARS was age at the time of operation (p = 0.001).

CONCLUSIONS

HRQoL significantly improves after LARS. Although children with impaired neurodevelopment had lower overall HRQoL, neurodevelopment by itself does not predict inferior improvement in HRQoL after LARS. Older children have a more favorable HRQoL outcome after LARS compared to younger children. This may suggest caution when considering LARS in younger GERD patients.

Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe?

Gastroesophageal reflux is a common phenomenon in infants, but the differentiation between gastroesophageal reflux and gastroesophageal reflux disease can be difficult. Symptoms are non-specific and there is increasing evidence that the majority of symptoms may not be acid-related. Despite this, gastric acid inhibitors such as proton pump inhibitors are widely and increasingly used, often without objective evidence or investigations to guide treatment. Several studies have shown that these medications are ineffective at treating symptoms associated with reflux in the absence of endoscopically proven oesophagitis. With a lack of evidence for efficacy, attention is now being turned to the potential risks of gastric acid suppression. Previously assumed safety of these medications is being challenged with evidence of potential side effects including GI and respiratory infections, bacterial overgrowth, adverse bone health, food allergy and drug interactions.

ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula

BACKGROUND

Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA.

METHODS

Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

Helicobacter pylori infection and gastroesophageal reflux in children

Some studies suggest that Helicobacter pylori (H. pylori) infection would be a protective factor for the gastroesophageal reflux. The aim of this study was to explore this fact. A group of 72 children, admitted in a pediatric gastroenterology regional center in Northeast Romania, diagnosed with gastroesophageal reflux by 24-hour continuous esophageal pH monitoring (results were interpreted using the Boix-Ochoa score), underwent upper endoscopy with gastric biopsy to detect the presence of H. pylori by the rapid urease testing and for bacteriological and histologic examination. 19 children (26.39%) had H. pylori infection, while 53 (73.61%) did not. The grade of esophagitis was classified according to the Los Angeles classification system. Out of 47 children with esophagitis A, 16 (34.04%) had H. pylori infection, while out of the 25 children with esophagitis B, only 3 (12%) had H. pylori infection, with statistic significance (χ² = 54.69, P << 0.05, 95% confidence interval [CI]). Regarding the value of the Boix-Ochoa score, it appears that the presence of the H. pylori determines lower pH-metry scores (F = 8.13, P = 0.0015, 95% CI). The presence of the H. pylori was not an important factor in the gastroesophageal reflux. On the other hand its relationship with esophagitis appears to be inverse ratio. The fact that the H. pylori presence is statistically greater in the grade A esophagitis could confirm the hypothesis that the bacteria would slow down the development of the esophagitis.

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment

Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.

Combined Multichannel Intraluminal Impedance and pH Measurement in Detecting Gastroesophageal Reflux Disease in Children

OBJECTIVE

The aim of the study was to evaluate and compare multichannel intraluminal impedance-pH (MII-pH) monitoring with standard investigations including pH testing for detecting gastroesophageal reflux disease (GERD) in children.

METHODS

A retrospective review of all MII-pH studies performed between July 2007 and March 2013 at Sydney Children's Hospital. Results from MII-pH testing, esophagogastroduodenoscopy (EGD), barium meal and pepsin assay, symptoms, underlying comorbidities, age, and medication usage were evaluated.

RESULTS

An additional 47.18% of children had GERD detected by MII-pH testing, which would have been missed by pH testing alone. Based on symptomatology, 50.49% of children with respiratory symptoms as a result of GERD and 47.54% of those with gastrointestinal symptoms would have been missed by pH testing alone. GERD was detected in an additional 39.47% of children with neurological impairment, 44.44% for those with cystic fibrosis, and 52.17% for those with esophageal atresia-tracheoesophageal fistula by MII-pH. In patients with persistent symptoms on anti-reflux medication, GERD would have been missed by pH testing alone in 50.40%. GERD was detected in an additional 62.79% of infants and 42.76% of older children by MII-pH compared with pH testing alone. With reference to MII-pH, the sensitivity of other standard investigations, pH testing (32.35%), barium meal (25.00%), EGD (45.26%), and pepsin assay (48.89%) was significantly lower in the detection of GERD in children. Of all abnormal MII-pH results, 51.1% were abnormal because of symptom association alone.

CONCLUSIONS

Combined MII-pH testing is superior to standard investigations such as 24-hour pH testing, barium meal, EGD, and pepsin assay in detecting GERD in children, particular because of its ability to associate symptoms with acid and non-acid reflux events.

Reflux monitoring in children

Recently, multichannel intraluminal impedance (MII) monitoring was added to the repertoire of tests to evaluate the (patho)physiology of gastroesophageal reflux (GER) in children. Its advantage above the sole monitoring of the esophageal pH lies in the ability of the detection of both acid and nonacid GER and to discern between liquid and gas GER. Currently, combined 24 h pH-MII monitoring is recommended for evaluation of gastro-esophageal reflux disease (GERD) and its relation to symptoms in infants and children, despite the lack of reference values in these age groups. There is new evidence in the current issue of this Journal supporting the role of pH-MII monitoring for the evaluation of children presenting with gastrointestinal symptoms suggestive of GERD and the prediction of the presence of reflux esophagitis. However, several issues should be taken into account when performing pH-MII clinically.

The role of combined 24-h multichannel intraluminal impedance-pH monitoring in the evaluation of children with gastrointestinal symptoms suggesting gastro-esophageal reflux disease

BACKGROUND

The aim of this study was to determine the role of multichannel intraluminal impedance-pH (pH-MII) monitoring in the diagnosis of gastro-esophageal reflux disease (GERD) in children who presented with gastrointestinal (GI) symptoms in comparison with the results of pH-metry alone and endoscopy.

METHODS

All children who underwent pH-MII monitoring due to GI symptoms, suggestive of GERD, from October 2013 to October 2015 in Children's Hospital Zagreb, were retrospectively enrolled in the study. The cohort was divided into three groups according to age - group 1: children <1 year of age; group 2: 1-9 years of age; and group 3: ≥9 years of age.

KEY RESULTS

One hundred thirty-three patients met our inclusion criteria (73 female/60 male; mean age 9.2 years [0.19-18.0]). Gastro-esophageal reflux disease was determined in 44 of 133 patients (33.1%) by pH-MII and only in 21 of 133 patients (15.8%) by pH-metry alone. Endoscopy was performed in 77 (57.9%) children and esophagitis was found in 32/77 (41.6%). The finding of esophagitis significantly correlated with the number of total reflux episodes (coef. 0.42, p < 0.001), acidic (coef. 0.26, p = 0.02), weakly acidic (coef. 0.3, p = 0.008) and non-acidic (coef. 0.26, p = 0.02) reflux episodes detected by pH-MII; but, no correlation was found to reflux episodes detected by pH-metry alone (coef. 0.21, p = 0.07).

CONCLUSIONS & INFERENCES

Compared with pH-metry alone, pH-MII performed significantly better in the detection of GERD in all age groups. On the basis of our data, pH-MII had a strong correlation with endoscopically confirmed esophagitis.

Salivary Pepsin Lacks Sensitivity as a Diagnostic Tool to Evaluate Extraesophageal Reflux Disease

OBJECTIVES

To determine the sensitivity of salivary pepsin compared with multichannel intraluminal impedance with pH testing (pH-MII), endoscopy, and gastroesophageal reflux disease (GERD) questionnaires.

STUDY DESIGN

We prospectively recruited 50 children from Boston Children's Hospital who were undergoing pH-MII to evaluate for GERD. The patients completed 24-hour pH-MII testing, completed symptom and quality of life questionnaires, and provided a saliva specimen that was analyzed using the PepTest lateral flow test. A subset of patients also underwent bronchoscopy and esophagogastroduodenoscopy. Receiver operating characteristic curve analyses were performed to determine the sensitivity of salivary pepsin compared with each reference standard.

RESULTS

Twenty-one of the 50 patients (42%) were salivary pepsin-positive, with a median salivary pepsin concentration of 10 ng/mL (IQR, 10-55 ng/mL). There was no significant difference in the distributions of acid, nonacid, total reflux episodes, full column reflux, or any other reflux variable in patients who were pepsin-positive compared with those who were pepsin-negative (P > .50). There was no significant correlation between the number of reflux episodes and pepsin concentration (P > .10). There was no positive relationship between salivary pepsin positivity, any extraesophageal symptoms or quality of life scores, or inflammation on bronchoscopy or esophagogastroduodenoscopy (P > .30).

CONCLUSION

Salivary pepsin measurement has a low sensitivity for predicting pathological gastroesophageal reflux in children.

Apparent life-threatening event in infancy

An apparent life-threatening event (ALTE) is defined as the combination of clinical presentations such as apnea, marked change in skin and muscle tone, gagging, or choking. It is a frightening event, and it predominantly occurs during infancy at a mean age of 1–3 months. The causes of ALTE are categorized into problems that are: gastrointestinal (50%), neurological (30%), respiratory (20%), cardiovascular (5%), metabolic and endocrine (2%–5%), or others such as child abuse. Up to 50% of ALTEs are idiopathic, where the cause cannot be diagnosed. Infants with an ALTE are often asymptomatic at hospital and there is no standard workup protocol for ALTE. Therefore, a detailed initial history and physical examination are important to determine the extent of the medical evaluation and treatment. Regardless of the cause of an ALTE, all infants with an ALTE should require hospitalization and continuous cardiorespiratory monitoring and evaluation for at least 24 hours. The natural course of ALTEs has seemed benign, and the outcome is generally associated with the affected infants' underlying disease. In conclusion, systemic diagnostic evaluation and adequate treatment increases the survival and quality of life for most affected infants.

Does Helicobacter pylori play a role in the pathogenesis of non-cystic fibrosis bronchiectasis?

BACKGROUND

The aim of this study was to investigate whether Helicobacter pylori plays a role in the pathogenesis and severity of non-cystic fibrosis bronchiectasis, and its relationship with gastroesophageal reflux (GER).

METHODS

Forty-one patients and 16 controls between 5 and 18 years of age were enrolled. H. pylori was investigated on polymerase chain reaction and culture in gastric juice (GJ) and bronchoalveolar lavage fluid (BALF). Urea breath test (UBT) was also used for defining H. pylori infection. GER was detected on 24 h pH monitoring or scintigraphy. Computed tomography (CT) scoring was used to quantify the severity and extent of bronchiectasis.

RESULTS

Nine patients (22%) in the bronchiectasis group (BG) and three patients (18.8%) in the control group (CG) had H. pylori-positive BALF. Sixteen BG patients (39%) and seven CG patients (43.8%) had H. pylori-positive GJ. UBT was positive in 11 BG patients (26.8%) and in three CG patients (18.8%). H. pylori positivity in BALF, GJ and UBT was not significantly different between the two groups (P > 0.05). Six patients with GER and five patients without GER in BG had H. pylori-positive BALF and GJ (P = 0.827). No association was found between BALF H. pylori positivity and forced expiratory volume in 1 s (FEV1 ) in BG. CT score was significantly higher in BG patients with H. pylori-positive compared with H. pylori-negative BALF (P < 0.05).

CONCLUSIONS

Helicobacter pylori is not associated with the pathogenesis of bronchiectasis but it may be responsible for the severity of the disease.

Diagnosis and Management of Drooling in Children With Progressive Dystonia: A Case Series of Patients With MEGDEL Syndrome

Drooling is a common problem in children with progressive dystonia. The authors noted a 58% incidence of drooling in 22/38 children with MEGDEL, a rare neurodegenerative cause of dystonia and report on the clinical course of four patients. Drooling of varying severity and subsequent respiratory problems were treated at the authors' multidisciplinary saliva-control outpatient clinic. One patient improved on antireflux medication, the second after medication with drooling as side effect was changed. Two other patients underwent salivary gland surgery, one of whom significantly improved; the other died shortly after surgery. The heterogeneity of the cases presented shows the need for stepwise and personalized treatment. The authors recommend the following: (1) optimize the treatment of the underlying neurological condition and replace medication that stimulates saliva secretion; (2) treat constipation, scoliosis, and gastroesophageal reflux if there is still a risk of chronic aspiration of saliva; (3) perform more intense/invasive treatment (botulinum toxin, salivary gland surgery).

Middle East Consensus Statement on the Diagnosis and Management of Functional Gastrointestinal Disorders in <12 Months Old Infants

This paper covers algorithms for the management of regurgitation, constipation and infantile colic in infants. Anti-regurgitation formula may be considered in infants with troublesome regurgitation, while diagnostic investigations or drug therapy are not indicated in the absence of warning signs. Although probiotics have shown some positive evidence for the management of functional gastrointestinal disorders (FGIDs), the evidence is not strong enough to make a recommendation. A partially hydrolyzed infant formula with prebiotics and β-palmitate may be considered as a dietary intervention for functional constipation in formula fed infants. Lactulose has been shown to be effective and safe in infants younger than 6 months that are constipated. Macrogol (polyethylene glycol, PEG) is not approved for use in infants less than 6 months of age. However, PEG is preferred over lactulose in infants >6 months of age. Limited data suggests that infant formula with a partial hydrolysate, galacto-oligosaccharides/fructo-oligosaccharides, added β-palmitate may be of benefit in reducing infantile colic in formula fed infants in cases where cow's milk protein allergy (CMPA) is not suspected. Evidence suggests that the use of extensively hydrolyzed infant formula for a formula-fed baby and a cow's milk free diet for a breastfeeding mother may be beneficial to decrease infantile colic if CMPA is suspected. None of the FGIDs is a reason to stop breastfeeding.

Costs associated with functional gastrointestinal disorders and related signs and symptoms in infants: a systematic review protocol

INTRODUCTION

Functional gastrointestinal disorders (FGIDs) and FGID-related signs and symptoms have a fundamental impact on the psychosocial, physical and mental well-being of infants and their parents alike. Recent reviews and studies have indicated that FGIDs and related signs and symptoms may also have a substantial impact on the budgets of third-party payers and/or parents. The objective of this systematic review is to investigate these costs.

METHODS AND ANALYSIS

The population of interest is healthy term infants (under 12 months of age) with colic, regurgitation and/or functional constipation. Outcomes of interest will include the frequency and volume of reported treatments, the cost to third-party payers and/or parents for prescribed or over the counter treatments, visits to health professionals and changes in infant formula purchases, and the loss of income through time taken off work and out of pocket costs. Relevant studies will be identified by searching databases from 2005 onwards (including MEDLINE, EMBASE, PsycINFO, NEXIS, DARE, Health Technology Assessment database, National Health Service Economic Evaluation Database and others), conferences from the previous 3 years and scanning reference lists of eligible studies. Study selection, data extraction and quality assessment will be conducted by two independent reviewers and disagreements resolved in discussion with a third reviewer. Quality assessment will involve study design-specific checklists. Relevant studies will be summarised narratively and presented in tables. An overview of treatments and costs will be provided, with any geographical or other differences highlighted. An assessment of how the totals for cost differ across countries and elements that contribute to the differences will be generated.

ETHICS AND DISSEMINATION

This is a systematic review of published studies that will be submitted for publication to a peer-reviewed journal. Ethical committee approval is not required.

TRIAL REGISTRATION NUMBER

CRD42016033119.

Gastroesophageal Reflux Burden, Even in Children That Aspirate, Does Not Increase Pediatric Hospitalization

OBJECTIVES

Gastroesophageal reflux is common but remains a controversial disease to diagnose and treat and little is known about the role of reflux testing in predicting clinical outcomes, particularly in children at risk for extraesophageal reflux complications. The aim of this study was to determine if rates of hospitalization were affected by reflux burden even after adjusting for aspiration risk.

METHODS

We prospectively recruited, between 2009 and 2014, a cohort of pediatric patients with suspected extraesophageal reflux disease who were referred for reflux testing and underwent both multichannel intraluminal impedance with pH (pH-MII) and modified barium swallow studies. A subset of patients also underwent bronchoalveolar lavage with pepsin analysis. We determined their rates of hospitalization for a minimum of 1 year following pH-MII testing.

RESULTS

We prospectively enrolled 116 pediatric patients who presented for care at Boston Children's Hospital and underwent both pH-MII and modified barium swallow studies. There was no statistically significant relationship between reflux burden measured by pH-MII or bronchoalveolar pepsin and total number of admissions or number of admission nights even after adjusting for aspiration status (P > 0.2). There were no statistically significant relationships between reflux burden by any method and the number or nights of urgent pulmonary admissions before or after adjusting for aspiration risk (P > 0.08).

CONCLUSIONS

Even in aspirating children, reflux burden did not increase the risk of hospitalization. Based on these results, routine reflux testing cannot be recommended even in aspirating children, because the results do not impact clinically significant outcomes.

Dietary habits and gastroesophageal reflux disease in preschool children

Purpose

To identify the relationship between dietary habits and childhood gastroesophageal reflux disease (GERD) in preschool children.

Methods

We performed a questionnaire study to analyze the relationship between dietary habits and GERD in 85 preschool children with GERD and 117 healthy children of the same age.

Results

Irregular and picky eating were more p–revalent in the GERD group than in the control group (odds ratio [OR], 4.14; 95% confidence interval [CI], 1.37–12.54 and OR, 4.96; 95% CI, 1.88–13.14, respectively). The snack preferences and the late night eating habits were significantly more prevalent in the GERD group than in the control group (OR, 3.83; 95% CI, 1.23–11.87 and OR, 9.51; 95% CI, 2.55–35.49, respectively). A preference for liquid foods was significantly more prevalent in the GERD group (OR, 9.51; 95% CI, 2.548–35.485). The dinner-to-bedtime interval was significantly shorter in the GERD group than in the control group (157.06±48.47 vs. 174.62±55.10, P=0.020). In addition, the time between dinner and bedtime was shorter than 3 hours in 47 children (55.3%) of the GERD group and 44 (37.6%) of the control group. This difference was statistical significance (P=0.015).

Conclusion

Dietary habits such as picky and irregular eating, snack preference, a preference of liquid foods, late night eating, and a shorter dinner-to-bedtime interval had a significant correlation with GERD. Further large-scale studies are necessary to confirm our results.

Prevalence of overlap syndromes and symptoms in pediatric functional dyspepsia

Background

The purpose was to evaluate the overlap frequency of irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and overactive bladder syndrome (OBS), as well as other gastrointestinal and systemic symptoms, in functional dyspepsia (FD). Additionally, we sought to determine whether adult Rome III FD subtypes were uniquely related to overlap syndromes or symptoms.

Methods

The study was a retrospective review of 100 consecutive pediatric patients, age 8–17 years, diagnosed with FD. All had completed a standardized medical history including gastrointestinal and systemic symptoms as well as specific symptoms related to GERD and OBS. The frequency of overlap with IBS, GERD, and OBS were determined for the whole group and for those fulfilling adult FD subtype criteria. Individual symptoms were also compared by FD subtype.

Results

Overlap IBS was present in 33 % of the FD patients. At least one GERD symptom was present in 74 % of patients with 41 % reporting heartburn. At least one OBS symptom was present in 44 % of patients with 29 % reporting urinary urgency. Other than pain, the most common reported gastrointestinal symptom was nausea (86 %). Systemic symptoms were common. Overlap syndromes/symptoms did not vary by FD subtype. Postprandial distress syndrome was associated with pain with eating, weight loss, and waking at night to have a stool.

Conclusions

FD is a heterogeneous condition in children and adolescents with significant variability in the presence of gastrointestinal and non-gastrointestinal symptoms and overlap syndromes. Varying symptom profiles need to be accounted for and analyzed in studies involving subjects with FD.

Clinical Utility of Bronchoalveolar Lavage Pepsin in Diagnosis of Gastroesophageal Reflux among Wheezy Infants

Background. There is no gold standard test for diagnosis of gastroesophageal reflux disease (GERD) associated infantile wheezing. Objectives. To evaluate the value of bronchoalveolar lavage (BAL) pepsin assay in diagnosis of GERD in wheezy infants. Methods. Fifty-two wheezy infants were evaluated for GERD using esophageal combined impedance-pH (MII-pH) monitoring, esophagogastroduodenoscopy with esophageal biopsies, and BAL pepsin. Tracheobronchial aspirates from 10 healthy infants planned for surgery without history of respiratory problems were examined for pepsin. Results. Wheezy infants with silent reflux and wheezy infants with typical GERD symptoms but normal MII-pH had significantly higher BAL pepsin compared to healthy control (45.3 ± 8.6 and 42.8 ± 8 versus 29 ± 2.6, P < 0.0001 and P = 0.011, resp.). BAL pepsin had sensitivity (61.7%, 72 %, and 70%) and specificity (55.5%, 52.9%, and 53%) to diagnose GERD associated infantile wheeze compared to abnormal MII-pH, reflux esophagitis, and lipid laden macrophage index, respectively. Conclusion. A stepwise approach for assessment of GERD in wheezy infants is advised. In those with silent reflux, a trial of antireflux therapy is warranted with no need for further pepsin assay. But when combined MII-pH is negative despite the presence of typical GERD symptoms, pepsin assay will be needed to rule out GERD related aspiration.

Pharmacological interventions on early functional gastrointestinal disorders

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are chronic or recurrent gastrointestinal symptoms without structural or biochemical abnormalities. FGIDs are multifactorial conditions with different pathophysiologic mechanisms including altered motility, visceral hyperalgesia, brain-gut disturbance, genetic, environmental and psychological factors. Although in most cases gastrointestinal symptoms are transient and with spontaneous resolution in infancy multiple dietary changes and pharmacological therapy are often started despite a lack of evidence-based data. Our aim was to update and critically review the current literature to assess the effects and the clinical appropriateness of drug treatment in early (occurring in infants and toddlers) FGIDs.

METHODS

We systematically searched the Medline and GIMBE (Italian Group on Medicine Based on Evidence) databases, according to the methodology of the Critically Appraised Topics (CATs). We included reviews, clinical studies, and evidence-based guidelines reporting on pharmacological treatments. Systematic reviews and randomized controlled trials (RCTs) concerning pharmacologic therapies in children with early FGIDs were included, and data were extracted on participants, interventions, and outcomes.

RESULTS

We found no evidence-based guidelines or systematic reviews about the utility of pharmacological therapy in functional regurgitation, infant colic and functional diarrhea. In case of regurgitation associated with marked distress, some evidences support a short trial with alginate when other non pharmacological approach failed (stepped-care approach). In constipated infants younger than 6 months of age Lactulose is recommended, whilst in older ages Polyethylene glycol (PEG) represents the first-line therapy both for fecal disimpaction and maintenance therapy of constipation. Conversely, no evidence supports the use of laxatives for dyschezia. Furthermore, we found no RCTs regarding the pharmacological treatment of cyclic vomiting syndrome, but retrospective studies showed a high percentage of clinical response using cyproheptadine, propanolol and pizotifen.

CONCLUSION

There is some evidence that a pharmacological intervention is necessary for rectal disimpaction in childhood constipation and that PEG is the first line therapy. In contrast, for the other early FGIDs there is a lack of well-designed high-quality RCTs and no evidence on the use of pharmacological therapy was found.

Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study

INTRODUCTION

Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS.

METHODS

Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a ¹³C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS.

RESULTS

After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001).

CONCLUSIONS

In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.

Neonatal Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Treatment at United States Children's Hospitals

OBJECTIVE

To determine treatment frequency and duration of histamine-2 receptor antagonist (H2RA)/proton pump inhibitor (PPI) use among infants hospitalized within US children's hospital neonatal intensive care units and evaluate diagnoses/demographic factors associated with use.

STUDY DESIGN

We retrospectively analyzed a cohort of neonatal intensive care unit infants admitted to 43 US children's hospitals within the Pediatric Health Information System database between January 2006 and March 2013 to determine H2RA/PPI treatment frequency, timing/duration of treatment, factors associated with use, percent of infants remaining on treatment at discharge, and interhospital prescribing variation. We used a modified Poisson regression to calculate the adjusted probability of infants ever receiving H2RAs/PPIs in relation to diagnosis, gestation, and sex.

RESULTS

Of the 122 002 infants evaluated, 23.8% (n = 28 989) ever received an H2RA or PPI; 19.0% received H2RAs (n = 23 187), and 10.5% (n = 12 823) received PPIs. Extremely preterm infants and term infants were the most likely to receive H2RA and PPI treatment. Infants with gastroesophageal reflux disease (relative risk [RR] = 3.13) and congenital heart disease (RR = 2.41) had the highest H2RA/PPI treatment probabilities followed by those with an ear, nose, and throat diagnosis (RR = 2.34; P < .05). The majority of treated infants remained treated at discharge.

CONCLUSIONS

Despite limited evidence and increasing safety concerns, H2RAs/PPIs are frequently prescribed to extremely preterm neonates and those with congenital anomalies and continued through discharge. Our findings support the need for innovative studies to examine the comparative effectiveness and safety of H2RA/PPIs vs no treatment in these high-risk neonatal populations.

Beyond pancreatic insufficiency and liver disease in cystic fibrosis

Cystic fibrosis is a life shortening hereditary disease, primarily leading to progressive pulmonary infection and exocrine pancreatic dysfunction. Several gastrointestinal complications other than malabsorption can arise during the disease course and with the progressively increasing life span of patients with CF; new and more rare complications are being recognized. We review the literature on gastrointestinal manifestations in CF, excluding the liver and pancreas.

CONCLUSION

We describe the clinical presentation and treatment of more common conditions like gastroesophageal reflux, small intestinal bacterial overgrowth, intussusception, meconium ileus, distal intestinal obstruction syndrome, and constipation, and we also discuss what is known on celiac disease, appendicitis, fibrosing colonopathy, inflammation and inflammatory bowel disease and gastrointestinal cancer.

WHAT IS KNOWN

• Gastrointestinal complications arise early in the course of the disease and have a severe impact on the quality of life of the patients. What is New: • This review is a concise summary of the current literature on gastrointestinal complications of cystic fibrosis. • We focused on clinical presentation and diagnostic investigations and provide a comprehensive resume of the current treatment options.

COMBINED 24-HOURS ESOPHAGEAL PH MONITORING AND MULTICHANNEL INTRALUMINAL IMPEDANCE FOR COMPARISON OF GASTROESOPHAGEAL REFLUX IN CHILDREN WITH TYPICAL VERSUS ATYPICAL SYMPTOMS OF GASTROESOPHAGEAL REFLUX DISEASE

BACKGROUND

- Gastroesophageal reflux disease is the most common esophageal disorder in pediatrics.

OBJECTIVE

- The aim of this study was to compare reflux parameters of typical and atypical symptoms of gastroesophageal reflux disease using 24-hour esophageal pH monitoring and multichannel intraluminal impedance in pediatric population.

METHODS

- In this prospective study, 43 patients aged less than 18 year with suspected gastroesophageal reflux disease were enrolled. The patients were divided into two groups based on the main presenting symptoms (typical versus atypical). Twenty four-hour pH monitoring and multichannel intraluminal impedance were performed in all the patients for comparing these two group regarding association of symptoms and reflux. Number of refluxes, pH related reflux, total reflux time, reflux more than 5 minutes, longest time of the reflux, lowest pH at reflux, reflux index were recorded and compared. Data comparison was done using SPSS.

RESULTS

- The mean age of the patients was 5.7±3.4 years and 65.1% were male. Out of 43 patients 24 cases had typical symptoms and 19 had atypical symptoms. The mean reflux events detected by multichannel intraluminal impedance was more than mean reflux events detected by pH monitoring (308.4±115.8 vs 69.7±66.6) with P value of 0.037, which is statistically significant. The mean symptom index and symptom association probability were 35.01% ± 20.78% and 86.42% ± 25.79%, respectively in multichannel intraluminal impedance versus 12.73% ± 12.48% and 45.16% ± 42.29% in pH monitoring (P value <0.001). Number of acid reflux was 46.26±47.16 and 30.9±22.09 for atypical and typical symptoms respectively. The mean symptom index was 18.12% ± 13.101% and 8.30% ± 10.301% in atypical and typical symptoms respectively (P=0.034). Bolus clearance was longer in atypical symptoms compared typical symptoms(P<0.05).

CONCLUSION

- Symptom index was significantly higher in atypical symptoms compared to typical symptoms. Higher number of acid reflux was found in children with atypical symptoms of reflux. Longer duration of bolus clearance was found in group with atypical symptoms of reflux.

Domperidone-Associated QT Interval Prolongation in Non-oncologic Pediatric Patients: A Review of the Literature

BACKGROUND

Domperidone is a prokinetic agent used to treat pediatric gastroesophageal reflux disease. Health Canada has issued warnings about an increased risk of domperidone-associated ventricular arrhythmias and sudden cardiac death. However, the supporting data referred only to adult patients; therefore, extrapolating the safety risks to pediatric patients is difficult.

OBJECTIVE

To summarize and evaluate the evidence for domperidone-associated QT interval prolongation, ventricular arrhythmias, and sudden cardiac death to determine the safety of this drug for pediatric patients.

DATA SOURCES

Two databases (MEDLINE [1946 to August 2015] and Embase [1980 to August 2015]) were searched with the following Medical Subject Headings and keywords: "domperidone", "arrhythmias, cardiac", "death, sudden, cardiac", "electrocardiography", "heart diseases", "long QT syndrome", "tachycardia, ventricular", "torsades de pointes", and "ventricular fibrillation". The search was limited to studies conducted in humans under 18 years of age and published in English.

STUDY SELECTION AND DATA EXTRACTION

Original research included in this review reported on the cardiac-related safety of domperidone in nononcologic patients under 18 years of age.

DATA SYNTHESIS

Of the 5 studies meeting the inclusion criteria (n = 137 patients), one reported a statistically significant change in the corrected QT (QTc) interval, but the clinical significance was unclear. Most of the studies reported rare occurrences of pathological QTc intervals in a limited number of patients. However, confounding factors (e.g., abnormal electrolyte level or concurrent medications) were not consistently considered. Potential bias might have been alleviated by blinding of electrocardiogram (ECG) assessors; however, this was not consistently implemented. The designs of the included studies did not allow assessment of causality. The results should be interpreted with caution.

CONCLUSIONS

Although the available evidence is limited, pathological QTc intervals were noted among a small number of infants, which supports the possibility of domperidone-associated risk of prolonged QTc interval. Because of the potential severity of QT interval prolongation, individual assessment and routine ECG monitoring should be implemented for patients receiving domperidone.

Efficacy and Tolerance of a New Anti-Regurgitation Formula

PURPOSE

Regurgitation is a common physiological phenomenon in infants. The aim of the present study was to evaluate the efficacy of a new anti-regurgitation (AR) formula (Novalac), thickened with an innovative complex including fibres, on the daily number of regurgitations and to assess its impact on stool consistency and frequency.

METHODS

Infants younger than five months, presenting at least 5 regurgitations per day were recruited in this trial. The efficacy of the new formula on regurgitation (daily number and Vandenplas score), stool frequency and consistency were assessed at day 14 and 90. Growth data were recorded at each study visit.

RESULTS

Ninety babies (mean age 9.6±5.8 weeks) were included in the full analysis data set. The mean number of regurgitation episodes at inclusion was 7.3±3.4. In all infants, regurgitations improved after 2 weeks. The daily number of regurgitations decreased significantly (-6.3±3.3, p<0.001) including in those previously fed a thickened formula (-6.2±3.0, p<0.001). There was no significant change in stool consistency at day 14. After 3 months, 97.5% of infants had formed or soft stools. Growth was appropriate with a slight increase of weight-for-age z-score (from -0.5±1.0 to -0.1±0.9) and no change of weight-for length z-score (-0.1±1.1 to -0.1±-1.1).

CONCLUSION

The new AR formula thickened with an innovative complex is very effective in reducing the daily number of regurgitations without having a negative impact on stools consistency.

Correlation between the different pH-metry scores in gastroesophageal reflux disease in children

The 24-hour esophageal pH-metry is the most widely used method to diagnose the gastroesophageal reflux disease (GERD). The study compares the different scores obtained during the 24-hour esophageal pH-metry. A retrospective study over 5 years including 234 children (1 month and 18 years old) admitted in a pediatric gastroenterology regional center in Northeast Romania, with suspicion of GERD. They underwent 24- hour esophageal pH-metry, and the scores obtained (Boix-Ochoa, DeMeester, Johnson-DeMeester) were compared. Out of the 234 children, 172 (73.50%) had positive Boix-Ochoa score and 62 (26.50%) had normal Boix-Ochoa score (<11.99). Based on the DeMeester score, 149 children (63.68%) were positive and 85 (36.32%) were negative. The correlation of the Demeester score with the Boix-Ochoa score was very high (r = 0.978, P <  < 0.01, 95% confidence interval). Considering the Johnson-DeMeester score, 120 cases (51.28%) had GERD and 114 (48.72%) did not. The correlation of the Johnson-DeMeester score with the Boix-Ochoa score was still high (r = 0.94, P <  < 0.01, 95% 95% confidence interval). As considered until now, the Boix-Ochoa score is the most accurate score to be used in pediatrics for the diagnosis of GERD. The use of the different scores-Boix-Ochoa, DeMeester, Johnson-DeMeester-showed a high sensitivity and specificity of the pH-metry measurements applied to the study lot, but the last score has a higher risk of false-negative results.

Current status of surgical management of gastroesophageal reflux in children

PURPOSE OF REVIEW

Surgical therapy for gastroesophageal reflux disease (GERD) is controversial with considerable debate ranging from the indications for antireflux surgery to surgical technique. This article will attempt to clarify these issues with the most up-to-date information available on the prevalence, pathophysiology, diagnosis, and surgical treatment of GERD in children. Although laparoscopic Nissen fundoplication (LNF) has become the most popular operation performed for pathologic reflux, its superiority over both open surgery and other types of fundoplication is not well established.

RECENT FINDINGS

Large retrospective studies suggest LNF has a lower complication rate than open surgery. However, three prospective randomized controlled trials have been published recently which cast doubt on the superiority of LNF and suggest that LNF may have a higher failure rate compared to open fundoplication. Antireflux surgery has higher morbidity and failure rates in infants and in children with neurologic impairment.

SUMMARY

Based on the best available evidence, LNF may be less morbid, but have a higher rate of failure than open surgery. Pediatric surgeons should be mindful of the risks and benefits of both approaches to best counsel their patients. Larger prospective randomized controlled trials are needed to determine the best treatments for pediatric GERD.

High Prevalence of Response to Proton-pump Inhibitor Treatment in Children With Esophageal Eosinophilia

OBJECTIVES

Proton-pump inhibitor-responsive esophageal eosinophilia is a newly recognized entity with an unclear prevalence in children, as only retrospective data are available. The aim of this study was to determine the prevalence and clinical features of proton-pump inhibitor-responsive esophageal eosinophilia in children.

METHODS

This prospective study enrolled patients with esophageal symptoms and esophageal eosinophilic counts as 15 or more than 15 eos/hpf (eosinophils per high-power field). Children received treatment with esomeprazole 1 mg · kg per dose twice daily for 8 weeks and the endoscopy was repeated. Complete response to proton-pump inhibitor (PPI) was defined as 5 or less than 5 eos/hpf, and a partial response as >5 and <15 eos/hpf in post-treatment biopsies.

RESULTS

Fifty-one children (74.5% boys) were included. Histological response was observed in 35 children (68.6%): 24 children (47%) had a complete response and 11 children (21.6%) had a partial response. Only 16 children (31.4%) were diagnosed with eosinophilic esophagitis (EoE). There were no differences in history of atopy, allergy tests, pH study results, and endoscopic scores. Clinical symptoms were similar, with the exception of food impaction, which was more frequent in children with EoE (56.2% vs 20%, P = 0.01). The mean pretreatment peak eosinophil count was higher in patients with EoE (74.8 ± 36.2 vs 46.3 ± 30.7, P = 0.007). Eleven of the 14 patients (78.6%) on a lower PPI treatment maintenance dose remained in clinicopathologic remission at 1-year follow-up.

CONCLUSIONS

A significant proportion of children with esophageal eosinophilia responded to high dose PPI treatment. Clinical, endoscopic, and pH study results were similar, with exception of patients with EoE, who were more likely to experience food impaction and have higher esophageal eosinophil counts.

Morphological and Functional Assessment of Oesophageal Mucosa Integrity in Children With Cystic Fibrosis

OBJECTIVES

The aim of the study was to investigate morphological and functional characteristics of oesophageal epithelial barrier in children with cystic fibrosis (CF) with or without gastro-oesophageal reflux disease (GORD) in comparison to healthy controls.

METHODS

Oesophagogastroduodenoscopy with oesophageal biopsies and combined oesophageal multichannel intraluminal impedance-pH monitoring was performed in 17 children with CF (CFtot) with (CFgord) or without GORD (CFnorm). Histological combined severity score was calculated and widths of spaces between epithelial cells were measured. Basal impedance value was used to assess functional integrity of epithelial barrier. Results of each investigation were compared with a group of children without oesophageal disease.

RESULTS

CFtot, but also CFnorm, had more severe pathohistological changes included in the compound severity score than controls (0.75 ± 0.32 and 0.75 ± 0.20 vs 0.27 ± 0.25; P < 0.001 and P = 0.001, respectively). They also had more dilated intercellular spaces (2.6 μm ± 0.6 and 2.7 μm ± 0.5 vs 1.9 μm ± 0.2; P = 0.001 and P < 0.001, respectively). Baseline impedance values between proximal and distal pairs of electrodes were significantly lower in CFtot (2876 Ω ± 484, 2590 Ω ± 1013) and also in CFnorm (2922 Ω ± 363, 2844 Ω ± 457) than in controls (3703 Ω ± 859, 3753 Ω ± 1070) (P = 0.012 and P = 0.002; and P = 0.027 and P = 0.005, respectively). The treatment of CFgord with proton pump inhibitor increased, but did not normalise the baseline impedance values (2860 Ω ± 560 to 3355 Ω ± 750 and 2178 Ω ± 1564 to 3057 Ω ± 594).

CONCLUSIONS

Children with CF had morphological and functional changes of oesophageal mucosal integrity even in the absence of GORD.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Outcomes of fundoplication for paediatric gastroesophageal reflux disease

PURPOSE

Outcomes of fundoplication in children.

METHODS

In this monocentric retrospective study, chart review was performed on children who underwent fundoplication between 2006 and 2013. Outcomes were defined as the need for redo fundoplication and recommencement of anti-reflux medication (ARM) at 6-month follow-up.

RESULTS

119 patients underwent fundoplication with a mean age of 4.76 years and 55.5% of these were male. At 6-month follow-up, 21 (17.6%) required redo fundoplication and 64 (53.8%) were recommenced on ARM. Post-operative complications occurred in 50 (42.2%) of children; 30% of those with complications had surgery at less than 1 year of age, and 36% had an associated comorbid condition. Neither being under the age of one nor associated comorbidity was significantly associated with a poor outcome. Concurrent gastrostomy was associated with a higher risk of being back on ARM at 6-month follow-up (p = 0.003). Neither gastrointestinal or respiratory symptoms pre-surgery nor abnormal pre-operative investigations including pH monitoring and endoscopy were predictive of poor outcome post-fundoplication.

CONCLUSION

Although fundoplication has a role in the treatment of severe GORD in children, the majority of children in this study needed to restart their anti-reflux medications within 6 months of surgery.

Temporal Association Between Reflux-like Behaviors and Gastroesophageal Reflux in Preterm and Term Infants

OBJECTIVES

Multichannel intraluminal impedance studies (MII-pH) have become the criterion standard for the diagnosis of gastroesophageal reflux (GER). Several clinical signs and symptoms that are attributed to GER during infancy may not be related to true reflux. Our objective was to correlate the observed reflux-like behaviors to reflux events on MII-pH studies.

METHODS

This is a retrospective study on infants being evaluated for GER with MII. During the MII-pH study, the infants were observed for clinical behaviors. Symptom Index (SI), symptom sensitivity index (SSI), and symptom association probability were used to correlate symptoms with reflux events.

RESULTS

Of 58 infants (40 preterm, 18 term) included in the study, only 6 infants (10%) had an abnormal MII-pH study. Irritability (32 infants), bradycardia (20), and desaturation (18) were the common signs and symptoms. A total of 2142 (755 acidic and 1386 nonacidic) reflux episodes and 953 clinical reflux behaviors were recorded. The incidence and pattern of GER was similar in preterm and term infants. There was no significant difference in GER episodes and acid exposure in preterm infants fed orally or via nasogastric tube. The symptom association probability was abnormal in only 6 (19%), 1 (5%), and 5 (28%) infants with irritability, bradycardia, and desaturation, respectively.

CONCLUSIONS

The prevalence of GER as detected by MII-pH was low (10%) in symptomatic preterm and term infants. The incidence and pattern of GER was similar in preterm and term infants. The majority of suspected clinical reflux behaviors did not correlate with reflux events.

Clinical Practice Guidelines From the Cystic Fibrosis Foundation for Preschoolers With Cystic Fibrosis

Cystic fibrosis (CF) clinical care guidelines exist for the care of infants up to age 2 years and for individuals ≥6 years of age. An important gap exists for preschool children between the ages of 2 and 5 years. This period marks a time of growth and development that is critical to achieve optimal nutritional status and maintain lung health. Given that disease often progresses in a clinically silent manner, objective and sensitive tools that detect and track early disease are important in this age group. Several challenges exist that may impede the delivery of care for these children, including adherence to therapies. A multidisciplinary committee was convened by the CF Foundation to develop comprehensive evidence-based and consensus recommendations for the care of preschool children, ages 2 to 5 years, with CF. This document includes recommendations in the following areas: routine surveillance for pulmonary disease, therapeutics, and nutritional and gastrointestinal care.

Functional gastro-intestinal disorder algorithms focus on early recognition, parental reassurance and nutritional strategies

Up to 50% of infants present with symptoms of regurgitation, infantile colic and/or constipation during the first 12 months of life. Although they are often classed as functional disorders, there is an overlap with cows' milk allergy. We present practical algorithms for the management of such disorders, based on existing evidence and general consensus, with a particular focus on primary health care. Management consists of early recognition of warning signs of organic disease, parental reassurance and nutritional strategies.

CONCLUSION

The proposed algorithms aim to help healthcare providers manage frequent gastrointestinal and cows' milk-related symptoms in infants safely and effectively.

Recurrent abdominal pain in children: a clinical approach

The term 'recurrent abdominal pain', or RAP, refers mainly to the duration of painful period and frequency of pain. The commonly accepted duration is at least three months in the preceding period, and over this three-month period, there are at least three episodes of pain that are severe enough to affect the daily activities of the affected patients. Over the years, with advances in medical technology and better understanding of the pathophysiology of abdominal pain, more and more organic causes have been identified. However, the most common cause of RAP in children is still functional in origin.

Effects of carob-bean gum thickened formulas on infants’ reflux and tolerance indices

AIM: To examine the effect of carob-bean gum (CBG) thickened-formulas on reflux and tolerance indices in infants with gastro-esophageal reflux (GER).

METHODS: Fifty-six eligible infants (1-6 mo old) were randomly allocated to receive for two weeks a formula with either 0.33 g/100 mL (Formula A) or 0.45 g/100 mL (Formula B) of cold soluble CBG galactomannans respectively, or a formula with 0.45 g/100 mL of hot soluble CBG galactomannans (Formula C). No control group receiving standard formula was included in the study. Data on the following indices were obtained both at baseline and follow-up from all study participants: 24 h esophageal pH monitoring indices, anthropometrical indices (i.e., body weight and length) and tolerance indices (i.e., frequency of colics; type and frequency of defecations). From the eligible infants, forty seven were included in an intention-to-treat analysis to examine the effects of the two-week trial on esophageal 24 h pH monitoring, growth and tolerance indices. Repeated Measures ANOVA was used to examine the research hypothesis.

RESULTS: Regarding changes in 24 h pH monitoring indices, significant decreases from baseline to follow-up were observed in the “Boix Ochoa Score” (i.e., an index of esophageal acid exposure), in the total number of visible refluxes and in all symptoms related indices due to acid reflux only for infants provided with Formula A, while no significant changes were observed for infants provided with Formulas B and C. In addition, the significant decreases observed in two symptoms related pH monitoring indices (i.e., “Symptom index for reflux” and “Percentage of all reflux”) for infants provided with Formula A were also found to differentiate significantly compared to the changes observed in the other two groups (P = 0.048 and P = 0.014 respectively). Concerning changes in anthropometric indices, body weight significantly increased among infants provided with Formulas A and C, but not for infants provided with Formula B. As far as tolerance indices were concerned, the numbers of total and diarrheic defecations increased significantly only in infants provided with Formula B and these changes were significantly higher compared to the decreases observed in infants fed with Formulas A and C (P = 0.003 and P = 0.015 respectively. Lastly the number of colics significantly decreased in all infants, irrespective of the tested formula.

CONCLUSION: Formula A (i.e., 0.33 g/100 mL of cold galactomannans) was effective in reducing certain pH-monitoring indices of uncomplicated GER, increased body weight and was well-tolerated by infants.

The feasibility and efficacy of multi-channel intraluminal impedance monitoring in children

INTRODUCTION

The diagnosis of gastro-oesophageal reflux is currently based on clinical presentation and oesophageal pH monitoring. In recent years, the use of multi-channel intraluminal impedance (MII) monitoring has gained increasing attention in the adult population. However, its use in the paediatric population is still in the developing stage with only limited number of publications. This study aims to review our early experience of MII application in children.

METHODS

A retrospective study of all patients who underwent MII monitoring between 2011 and 2014 at a tertiary referral centre was performed. Patients' medical records were reviewed with demographic data extracted. Number of reflux episodes and other MII parameters were analysed.

RESULTS

In total, 34 patients were identified during the study period, with 20 males and 14 females. Indication for study included previous aspiration pneumonia (n = 13), persistent reflux or vomiting symptom (n = 10) and as part of routine assessment before gastrostomy (n = 11). At the time of study the average age was 69 months (range 9-216 months). 28 patients showed significant gastro-oesophageal reflux. On average patient has 36.1 acidic and 22.3 non-acidic reflux episodes during the 24 h monitoring period. Non-acidic reflux accounts for 38.1 % of the overall reflux episodes. The sensitivity of MII monitoring to detect reflux was higher compared to conventional pH study (73 vs 50 %, p = 0.1).

CONCLUSION

MII monitoring is safe and feasible in children. Non-acid reflux should not be underestimated in paediatric population. MII appears to be more sensitive than conventional pH monitoring in our study, but its true significance is yet to be confirmed by larger study in the future.