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)

Is it an eating disorder, gastrointestinal disorder, or both?

PURPOSE OF REVIEW

The authors examine the differential diagnosis for gastrointestinal disorders that should be considered in individuals who present with nonspecific gastrointestinal and nutritional complaints suggestive of an eating disorder.

RECENT FINDINGS

This review first identifies diseases with which eating disorders are often confused and then explores features in the history, physical examination, and laboratory studies, which can provide clues to the cause of the patient's symptoms. In addition, it discusses the recommended evaluation and treatments for the gastrointestinal diseases that most commonly mimic the presentation of eating disorders including Crohn disease (CrD), celiac disease, gastroesophageal reflux disease (GERD), and eosinophilic esophagitis (EoE).

SUMMARY

The ubiquitous nature of the gastrointestinal complaints requires the clinician to consider a broad differential diagnosis when evaluating a patient for an eating disorder.

Symptom index P-value and symptom sensitivity index P-value to determine symptom association between apnea and reflux in premature infants at term

The current method to determine temporal association (TA) between reflux and symptoms is the symptom association probability (SAP), but this method has limitations due to the constraints of binning and the violation of statistical principles of the Fisher's exact test that lead to an invalid estimation of TA. The aim of this study is to develop improved methods of computing the TA between apneic and reflux events using simulation and permutation methods and to compare these to the SAP. TA was analyzed between polysomnographic obstructive apneas and multichannel intraluminal impedance (MII) reflux events. Three new numerical methods were compared to the SAP in four former premature infants with persistent apneas at term. The experimentally found association was compared to the association observed in simulated or permuted data consistent with the lack of association beyond what is expected by chance alone. Temporal association was computed based on symptom and symptom sensitivity indices, SI and SSI, with varying window of association (WA) times from 15 to 300 s. The three new methods estimated P-values at varying WA that generally followed the same pattern of the SAP which had a more erratic pattern. The WA that gave the lowest P-value was approximately 120 s. Each of the novel methods produced P-value results consistent with each other and the SAP yet not subject to its limitations. The variation of WA gave a temporal profile of TA providing clues to its etiology. These new metrics are called Symptom Index (SIP) and Symptom Sensitivity Index (SSIP) P-values.

The binomial symptom index: toward an optimal method for the evaluation of symptom association in gastroesophageal reflux

BACKGROUND

The evaluation of symptom association in gastroesophageal reflux is an open problem. The scientific literature reports important deficiencies and clinicians are claiming a new methodology. This article provides an optimal method for the evaluation of symptom association, the binomial symptom index (BSI).

METHODS

A mathematical description of the BSI was presented for the study of association and causality. A total of n = 850,000 patients were simulated using a Monte Carlo model to perform a two-way sensitivity analysis. The average and the standard deviation of the BSI were evaluated in groups of 5000 patients with the same values of the reflux rate, symptom rate, association ratio, window of association, and monitoring time in order to contrast their influence on the estimator.

KEY RESULTS

The BSI decreased with the number of reflux episodes when there was association, and remained constant and below 40% when there was not. The standard deviation was no higher than 40% and decreased with the reflux or symptom rates, and more sharply with the monitoring time, reaching approximately 0% for 50 days. A window length matching the characteristic reflux-symptom lag maximized the overall BSI and minimized its dispersion. Twenty-four hour and 96-h monitorings allowed detecting association ratios of 50% and 25%, respectively.

CONCLUSIONS & INFERENCES

The BSI is a simple and reliable index for the evaluation of symptom association that considers all the parameters under analysis. Defining an appropriate cut-off value, the BSI can provide a measure of probability and strength of association simultaneously.

Baseline esophageal impedance according to different time intervals

Baseline impedance (BImp) reflects esophageal integrity. The study aims to identify the optimal method to calculate BImp. Mean BImp was calculated in 20 consecutive multichannel intraluminal impedance recordings including and excluding impedance events (IEs) (reflux, swallows, and gas episodes) in all channels during the full recording and during the first period of 1 minute without an IE every hour (method 1), every 2 hours (method 2), or 4 hours (method 3). BImp obtained during the total recording was set at 100%, and the variation (difference in BImp for the different methods) and variability (difference in BImp during one analysis period) were assessed. All children underwent endoscopy. No child had esophagitis. The mean difference over the six channels, in percentage, between BImp over the total recording with and without IE was ≈ 1.2% and comparable for each channel (range -5.87-6.99%). A mean of 980 IE were excluded in each tracing, and it took between 4 and 24 hours to delete all events in one tracing. The difference of BImp obtained with and without IE was mainly caused by the gas episodes at the upper and swallows in the lower channel. The mean BImp according to the three 1-minute analysis methods was comparable with the mean BImp according to the 24-hour analysis. The automatic determination of the mean BImp over the total tracing including the IE is an adequate method. In isolated tracings with numerous IE, the calculation of the mean BImp over 1 minute every 4 hours is an alternative option. Companies should develop software to calculate the mean BImp during the whole registration deleting all IE for the analysis.

Pharmacological therapy of gastroesophageal reflux in preterm infants

Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.

Anastomotic strictures and endoscopic dilatations following esophageal atresia repair

PURPOSE

To identify risk factors that can predict prevalence of anastomotic strictures (AS) following esophageal atresia (EA) repair.

METHODS

Of 46 consecutive patients with EA managed at our institution between 2004 and 2012, 35 underwent esophageal anastomosis and were included in this retrospective longitudinal study. Routine endoscopy was performed 1 month after surgical repair. According to stricture index (SI), endoscopically calculated as SI = (D - d)/D, where D is the diameter of the esophageal pouch and d the stricture diameter, population was divided into Group 1, SI ≤ 0.1 (no evidence of stricture); Group 2, 0.3 > SI > 0.1 (mild stricture); Group 3, SI ≥ 0.3 (high-grade stricture). Trends of subsequent endoscopic esophageal dilatations were compared between the groups using Wilcoxon-Mann-Whitney or Pearson's tests. Cox regression analysis was performed to estimate the hazard ratio.

RESULTS

Gastro-esophageal reflux disease (P = 0.04), tension on the anastomosis (P = 0.02) and long-gap form (P = 0.008) have an increased risk of developing AS. SI at 1 month after surgery correlates with the average number of future dilatations: Group 2 and 3 compared to Group 1 required more dilatations (hazard ratio 2.291 and 12.765).

CONCLUSION

AS remain frequent complications of esophageal surgery, especially in specific subgroups of patients. SI at 1 month after surgery could already predict the severity of the stricture and the need for subsequent endoscopic esophageal dilatations.

Efficacy and safety of proton pump inhibitors in the management of pediatric gastroesophageal reflux disease

Proton pump inhibitors (PPIs) are commonly prescribed to infants and children for managing gastroesophageal reflux disease (GERD). Recently published literature illustrates conflicting evidence on the efficacy of PPIs in infants and children. Randomized controlled trials and systematic reviews have demonstrated a lack of efficacy of PPIs, specifically in young infants. Furthermore, emerging evidence also suggests that PPIs are not as benign as once thought, with newer data implicating a potential association of PPIs with an increased risk of respiratory tract infections, gastrointestinal infections, bone fractures, hypomagnesemia, and the occurrence of rebound hyperacidity after discontinuation of PPI therapy. To summarize the emerging data in children, we reviewed the literature to assess the efficacy and safety of PPIs in managing pediatric GERD. Despite conflicting evidence on the efficacy of PPIs, most studies in children demonstrated some benefit when compared with placebo. With respect to the safety of PPIs in children, only a few small studies and case reports indicated a potential association of PPIs with an increased risk of respiratory tract or gastrointestinal infections, bone fractures, and hypomagnesemia; however, many of those studies had their own limitations. From the review, it is clear that further well-designed trials and observational studies are needed to shed more light on the efficacy and safety of PPIs in the pediatric population.

Gastroesophageal reflux: management guidance for the pediatrician

Recent comprehensive guidelines developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition define the common entities of gastroesophageal reflux (GER) as the physiologic passage of gastric contents into the esophagus and gastroesophageal reflux disease (GERD) as reflux associated with troublesome symptoms or complications. The ability to distinguish between GER and GERD is increasingly important to implement best practices in the management of acid reflux in patients across all pediatric age groups, as children with GERD may benefit from further evaluation and treatment, whereas conservative recommendations are the only indicated therapy in those with uncomplicated physiologic reflux. This clinical report endorses the rigorously developed, well-referenced North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines and likewise emphasizes important concepts for the general pediatrician. A key issue is distinguishing between clinical manifestations of GER and GERD in term infants, children, and adolescents to identify patients who can be managed with conservative treatment by the pediatrician and to refer patients who require consultation with the gastroenterologist. Accordingly, the evidence basis presented by the guidelines for diagnostic approaches as well as treatments is discussed. Lifestyle changes are emphasized as first-line therapy in both GER and GERD, whereas medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. Recent black box warnings from the US Food and Drug Administration are discussed, and caution is underlined when using promoters of gastric emptying and motility. Finally, attention is paid to increasing evidence of inappropriate prescriptions for proton pump inhibitors in the pediatric population.

Influence of "GERD" label on parents' decision to medicate infants

BACKGROUND

The factors that drive overtreatment of gastroesophageal reflux disease (GERD) are not well understood, but it has been proposed that the use of the "GERD" disease label could perpetuate use of medication in otherwise healthy infants.

METHODS

To determine if use of the disease label GERD influences parents' perceived need to medicate an infant, we surveyed parents in a general pediatric clinic. Parents were given a hypothetical clinical scenario describing an infant who cries and spits up excessively but is otherwise healthy. Using a 2 × 2 factorial design, parents were randomized to receive a scenario in which the doctor either gave a diagnosis of GERD or did not provide a disease label; additionally, half of parents were told that existing medications are probably ineffective, whereas the rest were not given any effectiveness information. We measured parent interest in medication, perception of illness severity, and appreciation of medication offer.

RESULTS

Parents who received a GERD diagnosis were interested in medicating their infant, even when they were told that the medications are likely ineffective. However, parents not given a disease label were interested in medication only when medication effectiveness was not discussed (and hence likely assumed).

CONCLUSIONS

Labeling an otherwise healthy infant as having a "disease" increased parents' interest in medicating their infant when they were told that medications are ineffective. These findings suggest that use of disease labels may promote overtreatment by causing people to believe that ineffective medications are both useful and necessary.

Anti-reflux surgery for patients with esophageal atresia

Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long-term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one-fifth have Barrett's metaplasia. Close to 100%, GER of pure and long-gap cases require fundoplication. In the long run, these patients have 50-fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long-gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.

Stability of extemporaneously prepared lansoprazole suspension at two temperatures

OBJECTIVE

The purpose of this study was to examine the stability of a generic lansoprazole product in a 3 mg/mL sodium bicarbonate suspension under room temperature and refrigerated conditions.

METHODS

Lansoprazole suspensions (3 mg/mL) were prepared in triplicate using an 8.4% sodium bicarbonate vehicle for each storage condition (room temperature and refrigerated). During 1 month, samples from each replicate were periodically removed and analyzed for lansoprazole concentration by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Each sample was spiked with 10 mg/L omeprazole to serve as the internal standard. A positive electrospray LC-MS/MS method was validated over the calibration range of 5 to 25 mg/L using Food and Drug Administration Guidance. The identities of the analyte and internal standard in the samples were verified by monitoring the MS/MS transitions of m/z 370 to m/z 252 and m/z 346 to m/z 198 for lansoprazole and omeprazole, respectively. Additionally, the pH of the suspensions was monitored throughout the study.

RESULTS

The stability of lansoprazole in the oral sodium bicarbonate suspension under refrigeration is compromised prior to what has been previously reported in the literature. Samples kept at room temperature lost >10% of the lansoprazole after 48 hours compared with the refrigerated samples, which maintained integrity up to 7 days. No statistically significant difference was found between the pH of the room temperature and refrigerated suspension samples, indicating that this factor is not the cause for the differences in stability at these two conditions.

CONCLUSIONS

This study suggests that the extemporaneously compounded lansoprazole oral suspension prepared in 8.4% sodium bicarbonate should not be stored in plastic oral syringes longer than 48 hours at room temperature and no longer than 7 days when refrigerated. These data indicate an expiration time earlier than that previously reported for the refrigerated product (14 days).

Mewling and puking: infantile gastroesophageal reflux in the 21st century

Infantile gastroesophageal reflux is challenging because of the difficulties in differentiating normal developmental physiology from disease, the imprecision of diagnostic tests and the paucity of evidence-based therapies for clinicians to implement. Careful clinical assessment is central to avoidance of inappropriate diagnosis and utilisation of ineffective or dangerous therapies, and at the same time, identification of those infants who warrant intervention.

Gastroesophageal reflux causing sleep interruptions in infants

BACKGROUND AND AIM

Little is known about the relation between gastroesophageal reflux (GER) episodes and sleep interruptions in infants. The aim of the study was to evaluate the relationship between GER and the incidence of sleep interruptions in infants.

METHODS

Study patients included 24 infants (younger than 1 year) referred for multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria were a previous fundoplication and studies lasting <20 hours. Tests were clinically indicated to investigate suspicion of GER-related apnea (17, 70.8%), stridor (6, 25%), noisy breathing (2, 8.3%), and cyanotic spells (1, 4.2%). Most patients presented with significant comorbidities (19, 79.2%).

RESULTS

The number of nonacid GER (NAGER) per hour was greater during sleep time than during daytime and awakening following sleep onset (median 0.27 vs 1.85 and 1.45, P<0.01). A total of 1204 (range 7-86 per infant) arousals in 24 infants was detected, 165 (13.7%) that followed GER episodes, and 43 (3.6%) that preceded GER episodes. Seven patients presented with a positive symptom association probability for arousals; 5 were exclusively because of NAGER. A positive symptom association probability for awakenings was detected in 9 patients; 4 were because of NAGER, 4 were because of AGER, and 1 was because of both NAGER and GER. Patients with awakenings related to GER presented longer mean clearance time of AGER during sleep (165.5 vs 92.8 seconds, P=0.03).

CONCLUSIONS

GER was a frequent cause of interrupting sleep among our infant patients, and NAGER proved to be equally important as AGER for causing arousals and awakenings in infants.

Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry a lot in the first few months overlooks feeding problems

This paper explores two areas in which the translation of research into practice may be improved in the management of cry-fuss behaviours in the first few months of life. Firstly, babies who cry excessively are often prescribed proton pump inhibitors, despite evidence that gastro-oesophageal reflux disease is very rarely a cause. The inaccuracy of commonly used explanatory mechanisms, the side-effects of acid-suppressive medications, and the failure to identify treatable problems, including feeding difficulty when the diagnosis of 'reflux' is applied, are discussed. Secondly, crying breastfed babies are still prescribed lactase or lactose-free formula, despite evidence that the problem of functional lactose overload is one of breastfeeding management. The mechanisms and management of functional lactose overload are discussed. These two problems of research translation need to be addressed because failure to identify and manage other causes of cry-fuss problems, including feeding difficulty, may have adverse outcomes for a small but significant minority of families.

Physiology of esophageal sensorimotor malfunctions in neonatal neurological illness

We aimed to define the sensorimotor characteristics of aero-digestive reflexes evoked upon midesophageal provocations in neuropathology infants. Provocative esophageal motility testing was performed in 20 neuropathology infants and 10 controls at 42.3 ± 0.6 and 38.9 ± 0.9 wk postmenstrual age. Data from 1,073 infusions were examined for the sensory thresholds, response frequencies, response magnitude of upper esophageal sphincter (UES) contractile reflexes, lower esophageal sphincter (LES) relaxation reflexes, and peristaltic reflexes using mixed statistical models. Threshold volumes for air and liquid in neuropathology and control infants were similar for all reflexes. Graded air- and liquid volume-dependent UES contractile reflex, LES relaxation reflex, and peristaltic reflex frequency recruitment were present in neuropathology and control subjects for the media (P < 0.0001) and the reflexes (P < 0.0001). In neuropathology infants (vs. controls), UES contractile magnitude is higher (P < 0.0001); LES relaxation reflex occurred earlier (P = 0.008); LES nadir duration lasted longer (P = 0.006); secondary peristalsis is the chief method of esophageal clearance (P < 0.0001); pharyngeal swallows and deglutition apneas are less frequent (P = 0.001); proximal, midesophageal waveform magnitudes and duration are exaggerated (P < 0.008). UES contractile reflex was longer with liquid than air in both groups (P = 0.03). We concluded that 1) perception to midesophageal provocation remains preserved in neuropathology neonates; 2) sustained and exaggerated myogenic response from afferent activation is evident by increased excitatory efferent outputs to the UES and esophageal body and increased inhibitory efferent outputs to the LES; 3) dysfunctional regulation of pharyngeal swallowing and infrequent deglutition responses indicate the possibility of impaired descending modulation and central malfunctions of brainstem and vagal nuclei.

Effect of lateral positioning on gastroesophageal reflux (GER) and underlying mechanisms in GER disease (GERD) patients and healthy controls

BACKGROUND

Posture has been shown to influence the number of transient lower esophageal sphincter relaxation (TLESRs) and gastroesophageal reflux (GER), however, the physiology explaining the influence of right lateral position (RLP), and left lateral position (LLP) is not clear. The aim of this study was to determine the influence of RLP and LLP on TLESRs and GERD after a meal in GER disease (GERD) patients and healthy controls (HC) while monitoring gastric distension and emptying.

METHODS

Ten GERD patients and 10 HC were studied for 90 min (30 min test meal infusion, 30 min postprandial in either RLP or LLP (randomly assigned) and 30 min in alternate position). The study was repeated on a separate day in reverse position order. TLESRs, GER, and gastric emptying rate were recorded using manometry, multichannel intraluminal impedance, and (13) C-octanoate breath tests. Gastric distension was visualized by five serial gastric volume scintigraphy scans during the first 30 min.

KEY RESULTS

Gastroesophageal reflux, (GER) disease patients had increased numbers of TLESRs in RLP compared to LLP in the first postprandial hour [5 (4-14) and 4.5 (2-6), respectively, P = 0.046] whereas the number of TLESRs was not different in RLP and LLP [4 (2-4) and 4 (3-6), respectively, P = 0.7] in HC. Numbers of GER increased similar to TLESRs in GERD patients. In GERD patients, gastric emptying reached peak (13)CO(2) excretion faster and proximal gastric distension was more pronounced.

CONCLUSIONS & INFERENCES

In GERD patients, TLESRs, GER, distension of proximal stomach, and gastric emptying are increased in RLP compared to LLP. This effect is not seen in HC.

Evaluation of esophageal motor function in clinical practice

Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics.

Proton pump inhibitors for irritable infants

QUESTION

Crying is common in infants; however, caring for infants with inconsolable crying, previously also known as colic or reflux, is often extremely distressing for parents. Is there a benefit to using gastric acid suppression (eg, proton pump inhibitors [PPIs]) in these infants?

ANSWER

The use of PPIs in infants and children has increased in recent years. The efficacy of proton pump inhibitors has not been demonstrated in the treatment of irritability and excessive crying in otherwise healthy infants younger than 3 months of age. Conversely, while PPIs are generally well tolerated, there is some evidence to link the use of PPIs with increased susceptibility to acute gastroenteritis, community-acquired pneumonia, and disorders of nutrient absorption and utilization. Irrespective of treatment, crying and irritability in infancy generally improve with time. Proton pump inhibitors do not improve symptoms in the interim.

Gastroesophageal reflux disease in neonates and infants : when and how to treat

Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. It is a frequently experienced physiologic condition occurring several times a day, mostly postprandial and causes no symptoms. These infants are also called 'happy spitters'. GER disease (GERD) occurs when reflux of the gastric contents causes symptoms that affect the quality of life or pathologic complications, such as failure to thrive, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, apnea, and apparent life-threatening events. About 70-85 % of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95 % of infants by 1 year of age. The predominant mechanism causing GERD is transient lower esophageal sphincter (LES) relaxation, which is defined as an abrupt decrease in LES pressure to the level of intragastric pressure, unrelated to swallowing and of relatively longer duration than the relaxation triggered by a swallow. Regurgitation and vomiting are the most common symptoms of infant reflux. A thorough history and physical examination with attention to warning signals suggesting other causes is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER. Choking, gagging, coughing with feedings or significant irritability can be warning signs for GERD or other diagnoses. If there is forceful vomiting, laboratory and radiographic investigation (upper gastrointestinal series) are warranted to exclude other causes of vomiting. Irritability coupled with back arching in infants is thought to be a non-verbal equivalent of heartburn in older children. Other causes of irritability, including cow's milk protein allergy, neurologic disorders, constipation and infection, should be ruled out. The presentation of cow's milk protein allergy overlaps with GERD, and both conditions may co-exist in 42-58 % of infants. In these infants, symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein from the diet. For non-complicated reflux, no intervention is required for most infants. Effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux. Sandifer syndrome, apnea and apparent life-threatening events are the extraesophageal manifestations of GERD in infants. Pharmacotherapeutic agents used to treat GERD encompass antisecretory agents, antacids, surface barrier agents and prokinetics. Currently, North American Society for Pediatric Gasroenterology, Hepatology and Nutrition (NASPGHAN) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) practice guidelines concluded that there is insufficient evidence to justify the routine use of prokinetic agents. Esomeprazole (Nexium) is now approved in the US for short-term treatment of GERD with erosive esophagitis in infants aged from 1 to 12 months. Although Nissen fundoplication is now well established as a treatment option in selected cases of GERD in children, its role in neonates and young infants is unclear and is only reserved for selective infants who did not respond to medical therapy and have life-threatening complications of GERD.

Outcomes of endoscopy and novel pH-impedance parameters in children: is there a correlation?

OBJECTIVES

Discordance exists between outcomes of endoscopy, multichannel intraluminal impedance monitoring (pH-MII), MII baselines, and gastroesophageal reflux symptoms. The aim of the present study was to determine the association between endoscopy, pH-MII and MII baselines, in children with gastroesophageal reflux symptoms.

METHODS

Endoscopies were graded for reflux esophagitis (RE). Biopsies of the distal esophagus were assessed for signs suggestive of esophagitis. Reflux index (RI), symptom association probability (SAP), number of reflux episodes, and mean baseline values were calculated. pH-MII was considered positive in children when RI was ≥ 3% and/or SAP was ≥ 95% and for infants when RI was ≥ 10% and/or SAP was ≥ 95%. Baselines were manually calculated and compared with an automated analysis. For MII baselines, patients were divided in 3 groups: normal endoscopy and negative overall pH-MII; normal endoscopy and an overall positive pH-MII; and RE.

RESULTS

A total of 26 children and 14 infants were included, median age: 26.5 months (2 months-16.2 years). Thirteen (32.5%) had RE. A significant negative association was found for RI and MII baselines (P = 0.009) and between SAP and RE (P = 0.039, odds ratio 1.018). MII baseline values were predictive for neither conventional pH-MII parameters nor RE. Manual analysis and automated calculation of MII baselines showed a perfect correlation. Distal MII baselines were significantly lower in children with a positive overall pH-MII outcome compared with the proximal esophagus (P = 0.049). No significant changes were found in baselines among the different groups 1 to 3.

CONCLUSIONS

Acid-related parameters are significantly related to MII baselines. A perfect correlation between manual- and automated analysis of MII baselines was found. Large prospective studies are needed to confirm the exact role of endoscopy and MII baselines.

Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children

BACKGROUND

The effect of proton pump inhibitors on the characteristics of gastroesophageal reflux (GER) in children and adolescents was evaluated.

METHODS

Twenty-one children and adolescents with symptoms suggesting GER disease (GERD) underwent upper endoscopy and a 24-hour multichannel intraluminal impedance/pH (MII-pH) monitoring before and at the end of 2 months of therapy with proton pump inhibitors (PPIs).

RESULTS

Fourteen (67%) patients reported clinically relevant symptom improvement after 2 months of PPIs intake. At the first endoscopy, 8 (38%) patients had macroscopic signs of reflux esophagitis; after two months of therapy, 6/8 (75%) patients had a complete mucosal recovery. There was a significant reduction in the total percentage of mean acid reflux time (from 13.1% to 3.8%), and the De Meester score dropped to normal (from 46.4 to 13.1). The mean number of acid refluxes decreased significantly from 48 to 15 per 24 hours, while inversely, the mean number of weakly acid refluxes increased significantly from 26 to 64 per 24 hours. PPI therapy did not affect the total number of reflux episodes, the number of liquid and mixed refluxes, the duration of esophageal bolus exposure and proximal extent of the reflux.

CONCLUSIONS

In children and adolescents with GERD, PPIs do not affect the total number of reflux episodes. PPIs only decrease the acidity of refluxate. Nevertheless, the majority of patients with typical reflux symptoms may report symptom improvement. Esophagitis can be healed after PPI treatment. The treatment of weakly acid and weakly alkaline reflux remains a challenge for physicians in the future.

Biologic mechanisms of environmental tobacco smoke in children with poorly controlled asthma: results from a multicenter clinical trial

BACKGROUND

Environmental tobacco smoke (ETS) negatively affects children with asthma. The prevalence of ETS exposure among children with poor asthma control may be changing. Importantly, the mechanisms by which ETS worsens asthma control are poorly understood.

OBJECTIVE

We describe how ETS affects gastroesophageal reflux (GER), respiratory infections, and leukotriene production among children with poor asthma control.

METHODS

We analyzed data from 306 children between 6 and 17 years of age with poorly controlled asthma enrolled in a 6-month clinical trial. We evaluated prevalence and determinants of ETS exposure by interview, questionnaire, and urinary cotinine and the association of ETS exposure on leukotriene production, respiratory infections, GER, lung function, and asthma control. We used multivariable linear, logistic, and Poisson regressions to assess outcomes.

RESULTS

ETS prevalence estimates ranged from 6% to 30%. Children with domestic indoor exposure had worse asthma control (c-Asthma Control Test, 17.8 vs 21.5; P = .04), worse FEV1 % predicted (84.1 vs 90.7; P = .02), and a trend for increased mean urinary leukotriene E4. ETS from any setting was associated with increased symptomatic respiratory infections (adjusted incidence rate ratio: 1.30; P = .02). However, children exposed to ETS did not have symptoms or pH probe results, suggestive of heightened GER.

CONCLUSIONS

Domestic smoking exposure was associated with both higher rates of symptomatic respiratory infection and poorer asthma control despite generally intensive controller therapy. ETS exposure is common among asthmatic children with poor control and may worsen asthma control by promoting respiratory infections. Further investigation is required to elucidate ETS mechanisms in poor asthma control.

Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease?

BACKGROUND

It has become common practice to empirically treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications. However, evidence to support the effectiveness of these medications in the pediatric population is limited. With multiple studies in adult patients indicating increased risk of infection, we reviewed the literature to determine the association between acid-suppressive medications and serious adverse effects in infants and children.

METHODS

We conducted a PubMed search on the adverse effects of H2 antagonists and proton pump inhibitors in pediatric patients. The studies selected were original research and systematic reviews with control groups and study objectives evaluating the relationship between acid-suppressive medications and serious adverse effects (namely, infections).

RESULTS

Fourteen studies met our inclusion criteria. The majority of studies found a significant association between acid-suppressive medications and the risk of necrotizing enterocolitis, sepsis/bacteremia, pneumonia, and gastrointestinal infections in infants and children.

CONCLUSIONS

Given the questionable efficacy of H2 antagonists and proton pump inhibitors and the growing evidence of increased risk of serious infections, acid-suppressive medications should be used cautiously in infants and children suspected of having gastroesophageal reflux disease.

Antireflux surgery in children with neurological impairment: caregiver perceptions and complications

OBJECTIVES

The aim of the present study was to report caregiver perceptions to antireflux surgery and gastrostomy in children with severe neurological impairment and to report the complications of the surgery.

METHODS

Children were identified from a clinic database and clinical information and surgical complications were extracted from the database and hospital medical records. A cross-sectional questionnaire addressing severity of symptoms was administered to parents/caregivers and scored with a 5-point Likert scale (1 is much better to 5, much worse).

RESULTS

A total of 122 children, median age 74 months (interquartile range 29-124), 63% spastic quadriplegic cerebral palsy, had antireflux surgery. Laparoscopic surgery was performed in 77 of 122 (63%) and 117 of 122 (96%) had gastrostomy insertion. Questionnaire was completed by 89 of 122 (73%) children; median duration of time from fundoplication to questionnaire was 77 months (43-89). The majority of caregivers indicated that surgery improved or greatly improved weight gain, chest infections, vomiting, and feeding tolerance. Only 2 caregivers reported that they regretted consenting to surgery. Serious surgical complications occurred in 10%.

CONCLUSIONS

Serious complications were uncommon in this series of antireflux surgery in neurologically impaired children. Although gagging and retching were common following surgery, a high percentage of caregivers reported improved nutrition, reflux-related symptoms, and high levels of satisfaction.

Rhinosinusitis in children

Rhinosinusitis is the inflammation of the mucous membranes of nose and paranasal sinus(es). 5-13% of upper respiratory tract infections in children complicate into acute rhinosinusitis. Though not life threatening, it profoundly affects child's school performance and sleep pattern. If untreated, it could progress to chronic rhinosinusitis (CRS). The pathogens involved in perpetuation of CRS consist of multidrug-resistant mixed microflora. CRS is challenging to manage and could further extend to cause eye or intracranial complications. In children, CRS diagnosis is often either missed or incomprehensive. Due to this, morbidity and strain on healthcare budget are tremendous. Flexible fiberoptic endoscopy has revolutionized management of CRS. Its utility in children is being increasingly recognized. Optimal management entails specific appropriate antimicrobials as well as treatment of underlying causes. The aim is to normalize sinus anatomy and physiology and regain normal mucociliary function and clearance.

Newborn lamb as a new model for studying gastroesophageal reflux

We aimed to determine whether the newborn lamb at term is a valid model for studying gastroesophageal reflux. Seven bottle-fed lambs, ages 2 to 3 days, underwent esophageal multichannel intraluminal impedance-pH monitoring (MII-pH). A total of 196 reflux episodes were recorded, including 73% alkaline and 27% weakly acidic. No acid refluxes were observed. Median bolus clearance time was 4  seconds (3; 5.5), and proximal reflux extent was 35% (26). This first report of MII-pH in the newborn mammal sets the foundations for future studies with physiological and clinical relevance to human neonates.

Gastro-esophageal reflux disease in healthy older children and adolescents

Gastro-esophageal reflux disease (GERD) in otherwise healthy older children and adolescents is commonly encountered in pediatric clinics and poses a complex treatment problem involving changes of diets and lifestyle. After an initial history taking and a physical examination, typical symptoms of GERD in older children and adolescenct are initially treated with the trials of acid suppressants. With an increase of severe cases, more and more GERD children have been evaluated with endoscopy, which helps to delineate an erosive esophagitis from a non-erosive reflux disease as they are presumed to have different pathogenesis. For the pediatric patients without a significant underlying disease, a reflux esophagitis can be treated adequately with acid suppressants. Recently, the rapid increase of children who are taking anti-reflux medication has brought up a serious alarm among pediatricians. Some at risk pediatric patients with recurrent and/or chronic GERD have been linked to adulthood GERD. In this paper, pediatric GERD with and without erosive esophagitis was reviewed along with treatment options and issues specifically for the otherwise healthy older children and adolescents in the primary clinics or the secondary hospitals.

Gastrointestinal manifestations of cow's milk protein allergy and gastrointestinal motility

Cow's milk protein allergy (CMPA) may cause gastrointestinal motility disorders. Symptoms of both conditions overlap and diagnostic tests do not reliably differentiate between both. A decrease of symptoms with an extensive hydrolysate and relapse during challenge is not a proof of allergy, because hydrolysates enhance gastric emptying, a pathophysiologic mechanism of gastro-oesophageal reflux (GER). Thickened formula reduces regurgitation, and failure to do so suggests CMPA. A thickened extensive hydrolysate may induce more rapid improvement, but does not always differentiate between CMPA and GER. Different hypotheses are discussed: is the overlap between CMPA and functional disorders coincidence, or do both entities present with identical symptoms, or does the fact that symptoms are identical indicates that there is only one entity involved? Studies on the prevention of CMPA focused on 'at-risk families', and resulted in a decrease of CMPA and atopic dermatitis, but did not provide data on the incidence of GER.

CONCLUSION

  As long as there are no objective diagnostic tools to separate GER from CMPA, the physician has two options: first treat the most likely diagnosis, and switch if after 2-4 weeks there is no improvement, or treat both conditions with one intervention, what will not result in a diagnosis.

The role of the 5-hydroxytryptamine pathway in reflux-induced esophageal mucosal injury in rats

BACKGROUND

Dysfunction of the 5-hydroxytryptamine (5-HT) signaling pathway can lead to gastrointestinal motility and secretion abnormalities and to visceral hypersensitivity. The aim of this study is to investigate the role of 5-HT in reflux-induced esophageal mucosal injury.

METHODS

Fifty 8-week-old male Sprague-Dawley (SD) rats were randomly divided into a gastroesophageal reflux (GER) model group (30 rats) and a sham surgery control group (20 rats). Four weeks after surgery, the esophageal mucosa was collected for histological evaluation, 5-HT concentrations, and 5-HT selective reuptake transporter (SERT) mRNA and 5-HT4 receptor (5-HT4R) protein expressions.

RESULTS

Twenty-seven rats in the GER model group survived, and three rats died. Histologically, in the GER model group, 20 rats had reflux esophagitis (RE group), and 7 rats had non-erosive reflux disease (NERD group). The 5-HT levels in the esophageal tissue from the RE group were significantly higher than those from the control and NERD groups. Both the RE and NERD groups showed significant increases in SERT mRNA expression of the esophageal mucosa than that of the controls, and the SERT mRNA level in the RE group was significantly higher than that in the NERD group. The 5-HT4R protein level of the esophageal mucosa in the RE group was significantly lower than that in the controls and the NERD group.

CONCLUSIONS

We conclude that a 5-HT signaling pathway disorder could be a major factor in the pathogenesis of GER and RE.

Are contrast swallows a relevant investigation for paediatric stridor?

The contrast swallow has traditionally been used in the investigation of paediatric stridor with the aim of identifying pathology such as vascular rings and confirming the presence of gastro-oesophageal reflux. Currently, a laryngotracheobronchoscopy (LTB) is the gold standard investigation for stridor and frequently, a child is commenced on antireflux medications based on clinical history. We seek to identify whether a contrast swallow has a valuable and cost effective role in the investigation of paediatric stridor. This was a retrospective audit study. All the children who underwent a contrast swallow as part of the investigation for stridor were identified from 2008 to 2011. All requests were made by clinicians from the ENT department at Birmingham Children's Hospital. All patient demographics and radiological reports were reviewed. The final patient list was cross referenced with theatre records to identify those that underwent a LTB The cost of the contrast swallow was identified by the contracting department at Birmingham Children's Hospital. A total of 117 contrast swallows were requested during the study period. The age range was 1 week to 50 months with an average patient age of 6 months. 45/117 (38 %) of contrast swallows identified pathology. 33/45 (73 %) demonstrated reflux. Only 12/117 (10 %) of all cases suggested pathology other than reflux. A total of 51 patients underwent LTB. 22/51 (43 %) had a subsequent contrast swallow. Since the average cost per contrast swallow in the outpatient setting was £ 77, and only 9 cases demonstrated significant unexpected pathology, 108 children had a contrast swallow that did not significantly alter the management of their stridor. 9 cases were identified in which the contrast study results altered the management of the child. An estimated £ 8,000 were spent on investigations that made no impact on the subsequent management of the child. Contrast swallows requested for the investigation of paediatric stridor identified 33 cases of gastro-oesophageal reflux and 12 cases of alternative pathology. Among those children with radiological evidence of reflux, 70 % (23/33) had already been commenced on antireflux medication based on their clinical symptoms. Only 8 % of findings from a contrast swallow investigation resulted in a change to the management of the stridulous child. The authors suggest that it is more cost effective to reserve requests for a contrast swallow until the diagnostic LTB is performed. This strategy will not only reduce exposure to ionising radiation in a significant number of children, but also identifies airway pathology more effectively and ensures that contrast swallows are used as an appropriate adjunctive diagnostic investigation.

Pathophysiology of aerodigestive pulmonary disorders in the neonate

No test can provide a definitive diagnosis of aerodigestive disease. When interpreting tests, one should weigh the benefits and weaknesses of different technologies and methods, scientific appropriateness of the testing conditions, clinicopathologic correlation, and pharmacologic approaches. Gastroesophageal reflux disease (GERD) symptoms and airway symptoms can coexist, and they cannot be distinguished without specific testing and direct observations. Important aerodigestive disorders include dysphagia, GERD, and aggravation of airway injury due to malfunctions of swallowing or airway protection mechanisms. Objective evaluation of aerodigestive reflexes and symptom correlation may provide support for evidence-based personalized management of feeding and airway protection strategies.

Managing gastroesophageal reflux disease in children: The role of endoscopy

Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.

Indications, methodology, and interpretation of combined esophageal impedance-pH monitoring in children: ESPGHAN EURO-PIG standard protocol

AIM

The aim of the study was to provide an updated position statement from the ESPGHAN European Pediatric Impedance Working Group on different technical aspects such as indications, methodology, and interpretation of multichannel intraluminal impedance-pH monitoring (MII-pH).

METHODS

Evidence was used where available, but the article is based mainly on expert opinion and consensus.

RESULTS

MII-pH provides more information than simple pH monitoring because reflux detection is not limited to acid reflux. Different companies provide commercialized MII-pH recording systems, making the method widely available and useable in daily clinical practice; however, the technique still has limitations: high cost, limited additional value regarding therapeutic implications, and lack of evidence-based parameters for the assessment of gastroesophageal reflux and symptom association in children.

CONCLUSIONS

MII-pH recording is a promising procedure needing further validation and development to increase its additional benefit over conventional investigation techniques. The added value of the technique regards mainly clinical circumstances in which nonacid or weakly acid reflux may be relevant such as persisting symptoms during antireflux treatment with proton pump inhibitors and feeding-related reflux; and assessing specific discontinuous symptoms thought to be associated with gastroesophageal reflux; and research.

Esophageal impedance baselines in infants before and after placebo and proton pump inhibitor therapy

BACKGROUND

Esophageal impedance monitoring records changes in conductivity. During esophageal rest, impedance baseline values may represent mucosal integrity. The aim of this study was to assess the influence of acid suppression on impedance baselines in a placebo-controlled setting.

METHODS

Impedance recordings from 40 infants (0-6 months) enrolled in randomized placebo-controlled trials of proton pump inhibitor (PPI) were retrospectively analyzed. Infants underwent 24 h pH-impedance monitoring prior to and after 2 weeks of double blind therapy with placebo or a PPI. Typical clinical signs of gastro-esophageal reflux (GER) were recorded and I-GERQ-R questionnaire was completed.

KEY RESULTS

Median (IQR) impedance baseline increased on PPI treatment (from 1217 (826-1514) to 1903 (1560-2194) Ω, P < 0.001) but not with placebo (from 1445 (1033-1791) to 1650 (1292-1983) Ω, P = 0.13). Baselines before treatment inversely correlate with the number of GER, acid GER, weakly acid GER, acid exposure, and symptoms. The change in baseline on treatment inversely correlates with acid exposure and acid GER. Patients with initial low baselines have no improved symptomatic response to treatment.

CONCLUSIONS & INFERENCES

Impedance baselines are influenced by GER and increase significantly more with PPI therapy than with placebo. Clinical impact of this observation remains undefined as targeting therapy at infants with low baselines does not improve symptomatic response to treatment.

Adverse outcomes associated with gastroesophageal reflux disease are rare following an apparent life-threatening event

OBJECTIVE

To evaluate for adverse outcomes associated with gastroesophageal reflux disease (GERD) following an apparent life-threatening event (ALTE) and potential risk factors of these outcomes.

STUDY DESIGN

Retrospective cohort study of well-appearing infants (<12 months) admitted for ALTE. Patients were followed for adverse outcomes associated with GERD (including aspiration pneumonia, failure-to-thrive, or anti-reflux surgery), second ALTE, or death. Risk factors evaluated included: age, prematurity, gender, previous event, diagnosis of GERD, gastrointestinal (GI) testing positive for gastroesophageal reflux, length of stay (LOS), and neurologic impairment diagnosed in follow-up.

RESULTS

Four hundred sixty-nine patients met inclusion criteria, mean age was 45 days, 110 (22%) were premature. Patients were followed for an average of 7.8 years; 3.8% of all patients had an adverse outcome associated with GERD. The only significant risk factors were a longer LOS, and development of neurological impairment. A diagnosis of GERD and positive reflux testing during the initial hospitalization were not associated with adverse outcomes associated with GERD.

CONCLUSIONS

Adverse outcomes associated with GERD are rare following an ALTE. Patients who developed neurological impairment and a longer initial LOS were at higher risk for developing these outcomes. Positive testing for gastroesophageal reflux during hospitalization for ALTE did not predict adverse outcomes associated with GERD.

Esophageal impedance baseline according to different time intervals

Background

The impedance baseline has been shown to reflect esophageal integrity, and to be decreased in patients with esophagitis. However, different methods for the determination of the impedance baseline have not been compared.

Methods

The median impedance baseline was calculated in 10 consecutive multichannel intraluminal impedance recordings in children with non-erosive reflux disease. All children underwent an endoscopy with a biopsy as part of the clinical work-up to exclude esophagitis. The impedance baseline was obtained both by including and excluding all impedance episodes (IE; reflux, swallows and gas episodes) during the full recording, and during the first 1-minute period without an IE every hour (method 1), every 2 hours (method 2) or every 4 hours (method 3). The impedance baseline obtained during the full recording was set at 100%, and the variation (difference in impedance baseline for the different methods) and variability (difference in impedance baseline during one analysis period) were assessed.

Results

None of the participants had esophagitis. The mean difference over the six channels between the impedance baseline over the total recording with and without IE was approximately 2.5%, and comparable for each channel (range 0.47% to 5.55%). A mean of 1,028 IEs were excluded in each tracing, and it took between 4 and 24 hours to delete all events in one tracing. The difference in the impedance baseline obtained with and without IEs was mainly caused by the gas episodes in the upper channels and swallows in the lower channels. The median impedance baseline according to the three one-minute analysis methods was comparable to the median impedance baseline according to the 24 hour analysis.

Conclusions

The automatic determination of the median impedance baseline over the total tracing including IEs is an adequate method. In isolated tracings with numerous IEs, the calculation of the median impedance baseline over one minute every 4 hours is an alternative option. Companies should develop software to calculate the median impedance baseline during the whole registration deleting all IEs for the analysis.

Gastroesophageal reflux disease and airway hyperresponsiveness: concomitance beyond the realm of chance?

Gastroesophageal reflux disease and asthma are both quite common the world over, and they can coexist. However, the nature of the relationship between these two diseases remains unclear. In this study, we review controversial aspects of the relationships among asthma, airway hyperresponsiveness, and gastroesophageal reflux disease in adults and in children.

Clinical Perspectives on Esophageal Disorders in Infants

Esophageal pathologies are complex and lend themselves to multivariable analysis before a definitive diagnosis can be considered. It is imperative that the clinician establish a methodology for selecting the appropriate technological assessment within scientific testing parameters to establish optimal clinicopathological presentation and determine best practice for patient care.

US in the diagnosis of gastroesophageal reflux in children

Several techniques have been used to diagnose gastroesophageal reflux (GER) in children, but no single test is sufficiently accurate to completely investigate the problem. Gastroesophageal US has been described as a widely available, noninvasive and sensitive method. It provides morphological and functional information, but its role in the diagnosis of GER in children is still debated. In this paper we review diagnostic approaches to GER in children. We focus on current use of US in the management of children with suspected GER. Reports suggest that US allows exclusion of several non-GER causes of symptoms and that it provides morphological and functional data with high sensitivity and positive predictive value for the diagnosis of GER. Sonographic assessment of findings such as abdominal esophageal length, esophageal diameter, esophageal wall thickness and gastroesophageal angle provide important diagnostic indicators of reflux and related to the degree of GER. There is a need for standardization of the procedure and for defining diagnostic criteria.

Effects of domperidone on QTc interval in infants

AIM

To prospectively evaluate the effects of oral domperidone on the QTc interval in infants.

METHODS

Infants (0-1 year) with a diagnosis of gastro-oesophageal reflux (GOR) disease were included. A 12-lead electrocardiography (ECG) was performed in all infants at baseline and 1 h after the intake of domperidone after 7-14 days; the corrected QTc interval was calculated by one investigator (MV) according to Bazett's formula.

RESULTS

Forty-five infants were enrolled in this study. The mean gestational age was of 38.6 weeks (35.5-42.0), and the mean age at the start of domperidone was 75.3 days (19-218 days). No statistically significant difference in corrected QTc was observed between baseline and the second ECG (0.389 ± 0.02 vs. 0.397 ± 0.31; p 0.130)). A trend was observed regarding gender: Although there was no difference in QTc change in girls (p 0.622), there was a strong trend in boys (p 0.051). Two infants (both boys) had a clinically significant QTc prolongation (> 460 msec) without symptoms. The Spearman correlation test showed no relation between the QTc change and age (r: -0.05822; p 0.7284). There was no relation between domperidone dosage and QTc change.

CONCLUSION

Overall, the group-analysis showed no statistical significant difference in QTc duration induced by domperidone. However, 2/45 (4.4%) infants had a prolonged QTc interval (> 460 msec) induced by domperidone. As a consequence, QTc measurement should be recommended in routine in infants when domperidone is started.

Pediatric patients with dyspepsia have chronic symptoms, anxiety, and lower quality of life as adolescents and adults

BACKGROUND & AIMS

Little is known about long-term health outcomes of children with dyspeptic symptoms. We studied the natural history of pediatric patients with dyspeptic symptoms, with and without histologic reflux, compared with healthy controls.

METHODS

We performed a prospective study of consecutive new patients, ages 8-16 years, who underwent evaluation for dyspepsia, including upper endoscopy. Patients were assigned to groups with histologic evidence of reflux esophagitis (n = 50), or normal histology results (n = 53). Healthy children were followed up as controls (n = 143). Patients and controls were evaluated 5-15 years later. They provided self-reports on severity of dyspeptic symptoms, use of acid suppression, quality of life, anxiety, and depression.

RESULTS

When the study began, the groups with histologic evidence of esophagitis and normal histologies did not differ in severity of dyspeptic symptoms, functional disability, or depression. After a mean 7.6-year follow-up period, each group had significantly lower quality-of-life scores and more severe dyspeptic symptoms and functional disability than controls, but did not differ significantly from each other; both groups were significantly more likely than controls to meet criteria for an anxiety disorder. At time of follow-up evaluation, use of acid-suppression medication was significantly greater in the group with histologic evidence for esophagitis, compared with patients who had normal histology findings when the study began.

CONCLUSIONS

Among pediatric patients with dyspepsia evaluated by endoscopy and biopsy, those with histologic evidence for esophagitis or normal histology findings are at increased risk for chronic dyspeptic symptoms, anxiety disorder, and reduced quality of life in adolescence and young adulthood.

The relationship between percutaneous endoscopic gastrostomy and gastro-oesophageal reflux disease in children: a systematic review

BACKGROUND

The relationship between percutaneous endoscopic gastrostomy (PEG) insertion and gastro-oesophageal reflux disease (GERD) is widely disputed in the current literature. The aim of this systematic review is to examine the available evidence documenting the association between PEG and GERD.

METHODS

The following databases were searched: MEDLINE (1950 to week 2, January 2011), PubMed, ISI Web of Knowledge (1898 to week 2, January, 2011), EMBASE (1980 to week 2, January 2011) and The Cochrane Central Register of Controlled Trials (CENTRAL) using the terms "gastroesophageal reflux", "gastroesophageal disease", "GERD", "GERD", "GER", "GER" and "percutaneous endoscopic gastrostomy", "PEG", "gastrostomy". In addition, the reference lists of all included studies were reviewed for relevant citations. Studies examining children pre and post insertion of PEG for GERD and written in English language were included. Data extraction was performed by two authors, and the methodology and statistical analysis of each study were assessed.

RESULTS

Eight studies were included in this systematic review. Two reported increased incidence of GERD after PEG. However, neither was of high methodological quality. The remaining six reported no change or decreased GERD. Nonetheless, few demonstrated rigorous methodology.

CONCLUSIONS

The current evidence examining the effect of PEG insertion on GERD has been inconsistent and is not of high quality and therefore is unconvincing, preventing a definitive conclusion. Overall, the available literature on this topic does not demonstrate a causal effect of PEG insertion on GERD.

Association between otitis media and gastroesophageal reflux: a systematic review

OBJECTIVE

To systematically review the association between otitis media and gastroesophageal/laryngopharyngeal reflux in children.

DATA SOURCES

Cochrane library, MEDLINE (1966-September 2011), EMBASE (1974-September 2011), proceedings of International Symposia on Recent Advances in Otitis Media, and reference lists of relevant selected articles.

REVIEW METHODS

Studies with planned data collection, in children with chronic otitis media with effusion/recurrent acute otitis media, assessing gastroesophageal/laryngopharyngeal reflux, pepsin/pepsinogen in middle ear, or antireflux therapy, were included.

RESULTS

Of 242 initial studies, 15 met inclusion criteria. The authors found a mean prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion of 48.4% (range, 17.6%-64%) and in children with recurrent acute otitis media of 62.9% (range, 61.5%-64.3%). A mean prevalence of laryngopharyngeal reflux of 48.6% (range, 27.3%-70.6%) was found in children with otitis media. Mean pepsin/pepsinogen presence in otitis media was 85.3% (range, 60%-100%) and of enzymatic activity was 34.2% (range, 14.5%-73%). Two randomized trials could not find benefit after antireflux treatment for 3 months, with an absolute rate difference (95% confidence interval) of 0.23 (0.023-0.42) and 0.13 (-0.086 to 0.34), respectively. Reporting of adverse events was limited, or absent, in most studies.

CONCLUSION

The prevalence of gastroesophageal reflux disease in children with chronic otitis media with effusion/recurrent acute otitis media may be higher than the overall prevalence for children. Presence of pepsin/pepsinogen in the middle ear could be related to physiologic reflux. A cause-effect relationship between pepsin/pepsinogen in the middle ear and otitis media is unclear. Antireflux therapy for otitis media cannot be endorsed based on existing research.

Clinical utility of esomeprazole for treatment of gastroesophageal reflux disease in pediatric and adolescent patients

Gastroesophageal reflux is a common condition in the pediatric population, with an increasing incidence in the last few years. It can be defined as an effortless retrograde movement of gastric contents into the esophagus related to complex multifactorial pathogenesis, involving anatomical, hormonal, environmental, and genetic factors. In some cases, it may be associated with esophageal or extraesophageal symptoms (heartburn and regurgitation), and is defined as gastroesophageal reflux disease (GERD). The therapeutic approach to gastroesophageal reflux in infants and children is often conservative, including changes in lifestyle (eg, posture and thickening of meals). If these children remain symptomatic after lifestyle changes (nutrition, feeding, and positional modification), or present with clinical red flags (poor weight gain, recurrent respiratory symptoms, or hematemesis) and complications of GERD (esophagitis, bleeding, stricture, Barrett’s esophagus, or adenocarcinoma) it may be necessary to set up a proper diagnostic protocol. Proton pump inhibitors have been recommended as the most effective acid suppression therapy for adults and pediatric patients. Esomeprazole, the S-isomer of omeprazole, is the only single-isomer proton pump inhibitor available. The paper assesses the safety and tolerability of esomeprazole in pediatric and adolescent patients.

Lipid-Laden Alveolar Macrophages and pH Monitoring in Gastroesophageal Reflux-Related Respiratory Symptoms

Lipid-laden alveolar macrophages and pH monitoring have been used in the diagnosis of chronic aspiration in children with gastroesophageal reflux (GER). This study was conducted to prove a correlation between the detection of alimentary pulmonary fat phagocytosis and an increasing amount of proximal gastroesophageal reflux. It was assumed that proximal gastroesophageal reflux better correlates with aspiration than distal GER. Patients from 6 months to 16 years with unexplained recurrent wheezy bronchitis and bronchial hyperreactivity, or recurrent pneumonia with chronic cough underwent 24-hour double-channel pH monitoring and bronchoscopy with bronchoalveolar lavage (BAL). Aspiration of gastric content was determined by counting lipid laden alveolar macrophages from BAL specimens. There were no correlations between any pH-monitoring parameters and counts of lipid-laden macrophages in the whole study population, even when restricting analysis to those with abnormal reflux index expressing clinically significant GER. Quantifying lipid-laden alveolar macrophages from BAL in children with gastroesophageal-related respiratory disorders does not have an acceptable specificity to prove chronic aspiration as an underlying etiology. Therefore, research for other markers of pulmonary aspiration is needed.

Acid and non-acid reflux during physiotherapy in young children with cystic fibrosis

BACKGROUND

Gastro-esophageal reflux (GOR) may contribute to lung disease in children with cystic fibrosis (CF). There is conflicting evidence regarding the effect of chest physiotherapy (CPT) in the head-down position on GOR. Furthermore, there is currently no evidence on the impact of physiotherapy on GOR as assessed by pH-multichannel intraluminal impedance (pH-MII).

AIMS

(1) To characterize GOR in young children with CF. (2) To determine whether the head-down position during physiotherapy exacerbates GOR.

METHODS

Children were studied using pH-MII monitoring over 24-hr, during which they received two 20-min sessions of CPT. One session was performed in "modified" drainage positions with no head-down tilt and the alternate session in "gravity-assisted" drainage positions, which included 20° head-down tilt.

RESULTS

Twenty children with CF (8 males), median age 12 months (range 8-34) were recruited. A total of 1,374 reflux episodes were detected in all children, of which 869 (63%) were acid and 505 (37%) were non-acid. Seventy-two percent of the episodes migrated proximally. During CPT, there was no significant difference between total number of reflux episodes in the modified or gravity-assisted positions, median [inter-quartile range (IQR)] 1 (0-2.5) compared to 1 (0.75-3) episode, respectively, P = 0.63. There was also no significant difference between the number of reflux episodes which migrated proximally, median (IQR) 1 (0-2) compared to 0 (0-2) episodes, respectively, P = 0.75.

CONCLUSION

In young children with CF, GOR is primarily acidic and proximal migration is common. Physiotherapy in the head-down position does not appear to exacerbate GOR. The impact of GOR on lung disease remains to be elucidated.

The presence of pepsin in the lung and its relationship to pathologic gastro-esophageal reflux

BACKGROUND

Pepsin has been proposed as a biomarker of reflux-related lung disease. The goal of this study was to determine (i) if there is a higher reflux burden as measured by pH-MII in patients that are pepsin positive in the lung, and (ii) the sensitivity of pepsin in predicting pathologic reflux by pH, MII, and EGD.

METHODS

We recruited children between the ages of 1-21 with chronic cough or asthma undergoing bronchoscopy, esophagogastroduodenoscopy (EGD), and multichannel intraluminal impedance (pH-MII) probe placement. The reflux profiles were compared between those patients who were pepsin positive and negative; proportions were compared using Chi-squared analyses and means were compared using t-testing.

KEY RESULTS

Only the mean number of non-acid reflux events was associated with pepsin positivity (0.04). The sensitivity and specificity of pepsin in predicting pathologic reflux by pH-MII or EGD was 57% and 65%, respectively. The positive predictive value of pepsin in predicting pathologic reflux by pH, MII or EGD was 50% (11/22), and the negative predictive value was 71% (20/28). There was a significantly higher mean LLMI in patients who were pepsin positive compared with pepsin negative patients (81 ± 54 vs 47 ± 26, P = 0.001).

CONCLUSIONS & INFERENCES

Lung pepsin cannot predict pathologic reflux in the esophagus, but its correlation with lung inflammation suggests that pepsin may be an important biomarker for reflux-related lung disease.