Correlation of esophageal lengths in children with height: application to the Tuttle test without prior esophageal manometry

A new formula proposal for placing pH-impedance catheters in pediatric patients

INTRODUCTION

Esophageal pH-impedance monitoring is a tool for diagnosing gastroesophageal reflux in children. The position of the pH catheter is essential for a reliable reading and the current formulas for calculating catheter insertion length are not completely accurate. The aim of the present study was to develop a new formula for adequate insertion of the pH catheter.

MATERIAL AND METHODS

A cross-sectional study was conducted on children that underwent pH-impedance monitoring and later radiographic control, to calculate the correct catheter insertion length. The documented variables were age, sex, weight, height, naris to tragus distance, tragus to sternal notch distance, sternal notch to xiphoid process distance, and initial insertion length determined by the Strobel and height interval formulas. A multivariate regression analysis was carried out to predict the final insertion length. Regression ANOVA and Pearson's adjusted R-squared tests were performed.

RESULTS

Forty-five pH-impedance studies were carried out, 53% of which were in males. The age and weight variables were not normally distributed. In the initial regression model, the variables that did not significantly correlate with the final insertion length were: sex (P 0.124), length determined by the Strobel or height interval formulas (P 0.078), naris to tragus distance (P 0.905), and tragus to sternal notch distance (P 0.404). The final equation: 5.6 + (height in cm * 0.12) + (sternal notch to xiphoid process distance * 0.57) produced an R2 of 0.93 (P 0.000).

CONCLUSIONS

This formula can be considered a valid option for placement of the pH-impedance monitoring catheter in pediatrics.

Study on Nocturnal Infant Crying Evaluation (NICE) and Reflux Disease (RED)

BACKGROUND

Nocturnal infant crying is often empirically treated with acid suppressants. The aim of this study was to evaluate the prevalence and characteristics of gastroesophageal reflux (GER) in infants with unexplained persistent crying.

METHODS

We enrolled all infants (0-12 months) referred for suspected GER disease who underwent esophageal impedance-pH monitoring (MII-pH) for unexplained persistent crying not improved by parental reassurance, dietary modification or alginate. Gastrointestinal malformation/surgery, neurological impairment and infections were exclusion criteria. Demographic and anthropometric parameters, GER symptoms and questionnaires (I-GERQ-R) and MII-pH data were recorded and analyzed. Normal MII-pH was defined when acid exposure was <3%, symptom index was <50% and symptom association probability was <95%. Acid exposure >5% and >10% was also considered. Statistical analysis was performed using Chi-Square and univariate and multivariable regression analysis.

RESULTS

We included 50 infants (median age 3.5 months) who fulfilled the study criteria: 30 (60%) had normal MII-pH. I-GERQ-R score was abnormal in 33 (66%) infants, and 21/33 (64%) had normal MII-pH (p = 0.47). In the 26 (52%) infants with nocturnal crying, MII-pH was normal in 16 (54%) (p = 0.82). Associated regurgitation (>3 or >10 episodes/die) did not predict abnormal MII-pH (p = 0.74, p = 0.82, respectively). Univariate and multivariable regression analysis did not identify any clinical variable significantly associated with abnormal MII-pH.

CONCLUSIONS

Infants with persistent unexplained and nocturnal crying should not be empirically treated with acid inhibitors.

Multichannel intraesophageal impedance with pH metry in Saudi children

BACKGROUND

Multichannel Intraesophageal Impedance with pH (MII-pH) provides complete characterization of gastroesophageal reflux (GER). The aim of this study was to report our experience in this relatively new technique, emphasizing the challenges in the performance and interpretation of the results.

METHODS

The study was conducted at King Khalid University Hospital at King Saud University in Riyadh. A retrospective review of the medical records of children who underwent MII-pH was performed. The procedure was performed and interpreted according to the recommended methodology. The impedance catheter was introduced nasally. The use of event markers and diary were explained to the accompanying person. At the end of the recording, the data were downloaded to the software analysis system.

RESULTS

MII-pH was performed on 98 children, and 16 studies were excluded from analysis for technical reasons. The median age was 32 (range 2-168) months and 44 (54%) were male. The prevalence of nonacid gastroesophageal reflux (NAGER), proximal extent of GER, and postprandial NAGER were 55%, 50%, and 70%, respectively. One hundred and fifty-three symptoms were reported during the study, but only two were significant.

CONCLUSION

The MII-pH was well-tolerated but the performance and interpretation were technically demanding. The main advantage was the detection of NAGER. However, the lack of normal values and the reliance on symptom association make the interpretation of the results challenging.

Simple Formula for pH/Impedance Probe Positioning in Children-Time to Update Standard Practice?

OBJECTIVE

To develop a novel formula for pH probe placement with adequate accuracy.

METHODS

Children (3-18 y) undergoing pH-metry were prospectively evaluated. Their height and corrected pH probe position under X-ray (2 vertebrae above the diaphragm) was recorded and the linear-regression analysis was performed to derive a novel formula. Its accuracy was checked on an additional group of prospectively included children. The success rate of a newly developed formula was estimated and compared to the performance of previously used formulae. The difference in the suggested placement of the probe (cm from nostrils) was calculated.

RESULTS

Based on 670 children with pH probe placed under X-ray, the following formula was developed using the linear-regression analysis: L = 0.184x + 4.4 (cm) (L = probe placement depth, x = body height). Its accuracy was confirmed on additional 111 children resulting in almost 85% success rate. The formula showed significant difference in the suggested placement from formulae used previously: +4.9 ± 0.8 cm, +2.4 ± 0.1 cm, +0.7 ± 0.6 cm, +1.1 ± 0.4 cm, +1.8 ± 0.3 cm, +2.2 ± 0.5 cm from the one by the Strobel, Moreau, Wilson, Nowak, Staiano-Clouse formulae, and the GOSH table with the calculated success rates of 1.8%, 43.2%, 65.8%, 77.5%, 65.8% and 54.1%, respectively. A table suggesting placement depth based on the body height was developed.

CONCLUSION

The present formula provides 85% success of pH probe placement in children ≥ 3 y suggesting its use in routine practice. More data are needed to confirm that probe adjustment under X-ray is unnecessary.

How Best to Estimate Insertion Length of Multichannel Intraluminal Impedance pH Probes in Children

OBJECTIVE

To assess the reliability of the KidZ Health Castle formula (KHC-F) to determine the correct probe position of a multichannel intraluminal impedance pH.

STUDY DESIGN

A retrospective cohort study was performed on 222 children between 1 month and 18 years of age undergoing multichannel intraluminal impedance pH. The primary outcome was the comparison of the pH sensor location determined by the KHC-F with the radiological target position. The margin of error was defined as 1 cm from the target position. Performance of the KHC-F and existing formulas was determined via the percentage with a correct position, mean error, 95% limits of agreement (Bland-Altman plots), and Spearman correlation. A post hoc analysis was performed with an updated KHC-F v2, subtracting -0.5 cm from the KHC-F.

RESULTS

Positioning with KHC-F was correct in two-thirds of the participants, with a very strong correlation (ρ = 0.91) with the target position. Bland-Altman plots showed good agreement between KHC-F and target position (mean error of -0.44 cm, lower limit -3.2 cm, upper limit 2.3 cm). A post hoc analysis with the KHC-F v2 showed a correct positioning in 74% of patients. Comparison with other formulas showed a stronger performance of KHC-F and KHC-F v2 on correct positioning, mean error, and 95% limits of agreement.

CONCLUSIONS

The KHC-F leads to reliable results. KHC-F v2 outperforms all other existing formulas in children, thereby reducing the need for repositioning and the amount of x-ray exposure. The age distribution of the sample may be a limitation, as well as the retrospective nature of the study.

Defining the Patchy Landscape of Esophageal Eosinophilia in Children With Eosinophilic Esophagitis

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is a patchy disease of the esophagus with significant variability in intraepithelial eosinophilia. Three biopsies each from distal and proximal esophagus are recommended for identification of active EoE. Recent work suggests 3 biopsy sites are more optimal. We sought to evaluate 2-site vs 3-site esophageal biopsy combinations for utility to identify active EoE.

METHODS

We prospectively obtained 3-site esophageal biopsies based on rigorous endoscopic measurements of the proximal, mid, and distal esophagus and gastroesophageal junction. Biopsies were reviewed by a pathologist, and those with at least 15 eosinophils per high-power field were considered active EoE. The sensitivity of one or more sites to identify active EoE was determined, and endoscopic measurements were correlated to height and age.

RESULTS

Five hundred ninety-six endoscopies were performed in 217 patients; of these, 304 endoscopies in 167 patients had active EoE. Among the initial esophagogastroduodenoscopies with active EoE, distal biopsies had greater than 80% sensitivity, whereas mid and proximal biopsies had sensitivity of 65% and 62%, respectively, and distal + proximal biopsies had the highest diagnostic sensitivity for a 2-site combination. Among the 304 endoscopies with active EoE, 9 had focal eosinophilia restricted to the mid esophagus, and 8 were restricted to the proximal esophagus. For patients with multiple endoscopies with active EoE, nearly one fourth had reduced sites with eosinophilia at the second time point. Endoscopic measurements strongly correlated with height and age.

CONCLUSIONS

This study supports endoscopic measurement-guided 3-site biopsies for optimal disease assessment of active EoE in children.

Symptom Scores and pH-Impedance: Secondary Analysis of a Randomized Controlled Trial in Infants Treated for Gastroesophageal Reflux

BACKGROUND AND AIMS

To evaluate and compare gastro-esophageal reflux (GER) symptom scores with pH-impedance and test the effects of acid-suppressive medications with or without feeding modifications on pH-impedance in high-risk infants.

METHODS

Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and 24-hour pH-impedance data were analyzed from 94 infants evaluated in a tertiary care setting for GER disease. Longitudinal data from 40 infants that received randomized GER therapy (proton pump inhibitor [PPI] with or without feeding modifications) for 4 weeks followed by 1-week washout were analyzed. Relationships between I-GERQ-R and pH-impedance metrics (acid reflux index, acid and bolus GER events, distal baseline impedance, and symptoms) were examined and effects of treatments compared.

RESULTS

(A) Correlations between I-GERQ-R and pH-impedance metrics were weak. (B) I-GERQ-R sensitivity, specificity, and positive predictive values were suboptimal when correlated with pH-impedance metrics. I-GERQ-R negative predictive value (NPV) was high for acid symptom-association probability (NPV = 84%) and distal baseline impedence (NPV = 86%) thresholds. (C) PPI with feeding modifications (vs PPI alone) did not alter pH-impedance metrics or symptom scores (P > .05); however, bolus clearance metrics worsened for both treatment groups (P < .05).

CONCLUSIONS

In high-risk infants (1) I-GERQ-R may be a helpful clinical screening tool to exclude acid-GER disease diagnosis and minimize unnecessary acid-suppressive treatment, but further testing is needed for diagnosis. (2) Acid-suppressive therapy with feeding modifications has no effect on symptom scores or pH-impedance metrics. Clearance of refluxate worsened despite PPI therapy, which may signal development of pharyngoesophageal dysmotility and persistence of symptoms. (3) Placebo-controlled trials are needed in high-risk infants with objective pH-impedance criteria to determine efficacy, safety, and underlying mechanisms. Clinicaltrials.gov ID: NCT02486263.

Low Mean Nocturnal Baseline Impedance is Associated With a Pathological Acid Exposure Time in Children

BACKGROUND

The baseline impedance (BI) and the mean nocturnal baseline impedance (MNBI) serve as markers of mucosal integrity in patients with pathologic acid exposure time (AET). This work aims to investigate the association between the BI and MNBI with the AET in children.

METHODOLOGY

A retrospective study was performed in children ≤18 years old with suspicion of gastroesophageal reflux disease who underwent both endoscopy and pH-impedance monitoring (pH-MII). Esophagitis was graded according to the Los Angeles classification. The pathological AET was determined depending on the age (≥5% in patients >1 year and ≥10% in those ages ≤1 year). For the BI, 60 s measurements were taken every 4 h, and for the MNBI, 3 10 min measurements were taken between 1.00 and 3:00 am; then, they were averaged. The means of BI and MNBI were compared with each other, with the AET, and other variables.

RESULTS

Sixty-eight patients were included, 25% of patients presented pathological AET. The mean of the MNBI was higher than BI in channels 6 (2195 vs 1997 Ω, P = 0.011) and 5 (2393 vs 2228 Ω, P = 0.013). BI and MNBI at channel 6 were lower in patients with pathological AET than in those with normal AET (1573 vs 2138 Ω, P = 0.007) and (1592 vs 2396 Ω, P = 0.004), respectively.

CONCLUSIONS

Children with pathological AET had lower impedance values than those with normal AET. BI and MNBI measurements should be part of the routine MII-pH assessment in children.

Esophageal length in children: Reference data and a novel predictive equation

Minimal information exists on the length of the child's esophagus, namely the distance from the cricopharyngeus to the esophagogastric junction (EGJ). We aimed to investigate the relationship between esophageal length (EL) and the age, height, and weight of the child. Children undergoing upper gastrointestinal endoscopy between February 2019 and May 2021 at our institution were prospectively audited. Children with anatomical esophageal disorders were excluded. Endoscopic distances from the incisors to the cricopharyngeus and EGJ were obtained, and novel predictive equations derived to predict EL. Intra-observer agreement for endoscopic measurements showed an intra-class correlation coefficient of 0.99. A total of 290 children aged 0.4-17.3 years were included in the analysis; they were divided into a model development cohort (n = 261) and a model validation cohort (n = 29). Measured EL correlated best with height (r = 0.92) as compared to age (r = 0.90) or weight (r = 0.83). The optimal equation for predicting EL was 0.156 × height (cm) - 1.336 (adjusted R²  = 0.841); this had a success rate of 76% in the validation cohort. The optimal equation for predicting distance from incisors to EGJ was 0.199 × height (cm) + 6.470 (adjusted R²  = 0.889); this had a success rate of 69% in the validation cohort. This is the first study to report a predictive equation for estimating esophageal length in children. Accurate prediction of esophageal length may assist with clinical esophageal procedures in children such as nasogastric and pH probe placement.

Oesophageal pH-Impedance for the Diagnosis of Gastro-Oesophageal Reflux Disease: Validation of General Population Reference Values in Children with Chronic Neurological Impairments

Diagnosis of gastro-oesophageal reflux disease (GORD) in children with chronic neurological impairment (NI) remains a clinical challenge. The study aimed to validate the relevance of the reference values used to assess gastro-oesophageal reflux (GOR) in children with NI and to determine the optimal cut-off level of the pH-impedance parameter with the best predictive value for outcomes associated with endoscopic assessments of the oesophagus. Sixty-seven children (32 male, 35 female; age: interquartile range, 5 years 6 months-14 years 10 months; median, 11 years 3 months) with NI were prospectively recruited for the study. The exclusion criteria were previous fundoplication and lack of consent for the study. All patients underwent evaluations for GOR disease, including pH-impedance and gastroscopy. Based on endoscopy, oesophagitis was diagnosed in 22/67 children (32.8%); 9/67 (13.4%) were classified as having Hetzel-Dent grade III or IV. GOR was present in 18/67 children (26.9%), as determined by pH-impedance. Patients with endoscopic lesions had a significantly higher number of total reflux (p = 0.0404) and acidic episodes (p = 0.0219). The total number of reflux episodes, with a cut-off level of 44 episodes, was the pH-impedance parameter most strongly predictive of the presence of lesions in gastroscopy (specificity: 50%, sensitivity: 73%). These findings suggest that endoscopic lesions may be present in children with chronic NI with a low number of GOR episodes, as recorded by pH-impedance. The use of standardised reference norms determined for the general population may underestimate GOR episodes in this group of patients.

Multichannel Intraluminal Impedance and pH Monitoring: A Step Towards Pediatric Reference Values

Background/Aims

Combined multichannel intraluminal impedance and pH monitoring (MII/pH) is considered the most accurate test to detect gastroesophageal reflux (GER), however lacking reference values. We aim to determine reference values for the pediatric population and to correlate these values with age and postprandial/fasting period.

Methods

We evaluated MII/pH traces from patients (newborns, infants, and children) admitted to 3 Italian hospitals and who underwent MII/ pH for suspected GER disease. Patients with MII/pH traces that showed significant symptom-reflux associations and/or a pathological reflux index (> 6% for newborns and infants, > 3% for children) were excluded. Traces were analysed in their entirety, and in the postprandial period (first hour after a meal) and the fasting period (the following hours before the next meal) separately.

Results

A total of 195 patients (46 newborns, 83 infants, and 66 children) were included. Age positively correlated with frequency of acidic GER events (r = 0.37, P < 0.05) and negatively associated with weakly acidic GER events (r = 0.46, P < 0.05).

Conclusions

This study describes the distribution of MII/pH values in a pediatric population with normally acidic GER exposure and no significant association between GER events and symptoms. These MII/pH values may be used as reference values in clinical practice for a corrected GER disease diagnosis in the pediatric population.

Simple calculation of the optimal insertion depth of esophageal temperature probes in children

Placing an esophageal temperature probe (ETP) in the optimal esophageal site is important in various anesthetic and critical care settings to accurately monitor the core temperature of a pediatric patient. However, no reported study has provided a formula to calculate the optimal insertion depth of ETP placement in children based on direct measurement of the optimal depth. The aim of this study was to develop a simple and reliable method to determine the optimal depth of ETP placement in children via their mouth. Using preoperative chest computed tomography scans, intraoperative chest X-rays, and the actual depth of ETP insertion, we measured the optimal depth of ETP placement retrospectively in 181 children aged 3-13 years who underwent minimally invasive repairs of the pectus excavatum and removal of a pectus bar. A linear regression analysis was performed to assess the correlation of the optimal depth of ETP placement with the children's age, weight, and height. The optimal depth of ETP placement had a greater correlation with height than with age or weight, and the best-fit equation was '0.180 × height + 6.749 (cm) (R² = 0.920).' We obtained three simplified formulae, which showed no statistically significant difference in predicting the optimal depth of ETP placement: height/6 + 8 (cm), height/5 + 4 (cm), and height/5 + 5 (cm). The optimal depth of ETP via children's mouths has a close correlation with height and can be calculated with a simple formula 'height/5 + 5 (cm)'.

Using multidimensional scaling in model choice for congenital oesophageal atresia: similarity analysis of human autopsy organ weights with those from a comparative assessment of Aachen Minipig and Pietrain piglets

Swine models had been popular in paediatric oesophageal surgery in the past. Although being largely replaced by rodent models, swine experienced a revival with the establishment of minipig models. However, none of them has ever been investigated for similarity to humans. We conducted a pilot study to determine whether three-week old Pietrain piglets and three-month old Aachen Minipigs are suitable for experimental paediatric oesophageal atresia surgery. We tested the operation's feasibility, performed a necropsy, weighed organs, measured organ length and calculated relative weights and lengths, and measured laboratory parameters. We used multidimensional scaling to assess the similarity of the swine breeds with previously published human data. Pietrain piglets had a higher a priori bodyweight than Aachen Minipigs (Δ = 1.31 kg, 95% confidence interval (CI): 0.37-2.23, p = 0.015), while snout-to-tail length was similar. Pietrain piglets had higher absolute and relative oesophageal lengths (Δ = 5.43 cm, 95% CI: 2.2-8.6; p = 0.0062, q1* = 0.0083 and Δ = 11.4%, 95% CI: 5.1-17.6; p = 0.0025, q3* = 0.0053). Likewise, absolute and relative small intestinal lengths were higher in Pietrains, but all other parameters did not differ, with the exception of minor differences in laboratory parameters. Multidimensional scaling revealed three-week old Pietrain piglets to be similar to two-month old humans based on their thoracoabdominal organ weights. This result indicates three-week old Pietrain piglets are a suitable model of paediatric oesophageal atresia surgery, because clinically many procedures are performed at around eight weeks age. Three-month old Aachen Minipigs were more dissimilar to eight-week old humans than three-week old Pietrain piglets.

Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group

Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.

Standard protocol devised by the Japanese Pediatric Impedance Working Group for combined multichannel intraluminal impedance-pH measurements in children

Multichannel intraluminal impedance-pH measurements (MII-pH) are useful for evaluating acid and non-acid gastroesophageal reflux (GER). However, the use of MIH-pH is not yet established in Japan. The Japanese Pediatric Impedance Working Group (Japanese-PIG) convened to devise a standard protocol for MII-pH in Japanese children. The expert members of the Japanese-PIG collected data on pediatric MII-pH from the relevant literature in English, including the standard protocol of MII-pH presented by the European PIG, and the insights of international experts. The resultant consensus was included in the contents of the standard protocol of MII-pH. The standard protocol included standardization of the indication, methodology, and interpretation of MII-pH in Japanese children. The criteria for abnormal GER by MII-pH were defined using the Reflux Index and number of total reflux episodes independently in children aged < 1 year and those aged ≥ 1 year. Moreover, a significant relationship between GER and symptoms was identified using the symptom index and symptom association probability approach. We conclude that the current version of the protocol for MII-pH is tentative because it is not based on data from Japanese children. Further studies are needed to render this protocol clinically beneficial and expand its use in Japan.

What is the best method for calculating the optimal position of an esophageal pH probe in children?

In assessment of distal esophageal pH, the sensor of the probe should be placed above the upper border of the lower esophageal sphincter. There are several methods to estimate the distance from the nose where the probe should be fixed according to the patient's height. We studied the accuracy of these methods. Data of patients who underwent esophageal monitoring were collected prospectively. The esophageal pH electrode was set with the aid of fluoroscopy in all cases, considering the location recommended by the current guideline. Esophageal probe position and anthropometric data of each patient were recorded. We compared the actual esophageal pH electrode distance from the nose with that estimated by Nowak's, Strobel's, Staiano-Clouse's, and Moreau's formulae and the Great Ormond Street Hospital (GOSH) table. A total of 98 patients were included, with ages ranging from 2 months to 19 years old. The highest success rate (67%) for all age groups was achieved by Nowak's formula (3.2 + 0.2 × height in cm). Considering only children under 3 years old, the GOSH table reached the highest-yet probably overestimated-fraction of adequate predictions. A corrected Staiano and Clouse's formula (4.28 + 0.191 × height in cm) had a slightly lower success rate than Nowak's due to a poorer performance in younger children. In conclusion, Nowak's formula is the most accurate regardless of age. It can help reduce radiation due to systematic fluoroscopy, as well as the subsequent manipulation of the esophageal probe. However, it still leads to pH sensor misplacements in more than one-third of children. In consequence, a confirmatory X-ray is advisable even after using the formula.

Bodyweight, not age, determines oesophageal length and breaking strength in rats

BACKGROUND/PURPOSE

Delayed primary repair is still the method of choice in the management of long-gap oesophageal atresia in many centres, but the timing of anastomoses varies. Some assume the infant's bodyweight to be an important factor, whereas others prefer age. We therefore aimed to clarify whether age or bodyweight determined oesophageal length in a rodent model.

METHODS

We explanted the oesophagi of 20 Sprague-Dawley rats, aged 15 to 444 days (n = two per time point), measured bodyweight, oesophageal length, weight, and linear breaking strength to measure tissue resilience. Univariate and multivariate regression analyses were conducted to determine the influence of age and bodyweight on oesophageal length and linear breaking strength.

RESULTS

All parameters were highly correlated (R > 0.8), except for age and linear breaking strength (R = 0.65). Both age and bodyweight were univariate significant predictors of oesophageal length, weight, and linear breaking strength (p < 0.0001). Multivariate analyses showed bodyweight to be a significant predictor of oesophageal length (p < 0.0001), whereas age was not (p = 0.18) [adjusted R² = 0.9031]. This was also true for linear breaking strength (p = 0.0007 and p = 0.97, respectively) [adjusted R² = 0.71]. Moreover, the influence of age was negligible, as the adjusted R² and the regression coefficient of bodyweight and its 95% confidence interval were almost identical between univariate und multinomial regressions.

CONCLUSIONS

Only weight determines oesophageal length and tissue resilience in rodents, whereas age is irrelevant. If a similar relationship exists in humans, it may facilitate choosing the optimum time point for delayed primary anastomosis.

LEVEL OF EVIDENCE

IV - Experimental Paper.

Blind esophageal brushing offers a safe and accurate method to monitor inflammation in children and young adults with eosinophilic esophagitis

Patients with eosinophilic esophagitis (EoE) require frequent evaluation of mucosal inflammation via endoscopy. Instead of endoscopy, mucosal evaluation in adults with esophageal cancer and candidiasis is achieved using a cytology brush inserted through a nasogastric tube (NGT). We conducted a prospective cross-sectional study in children and young adults scheduled for routine esophagogastroduodenoscopy (EGD) where in Phase 1, we performed esophageal brushing through the endoscope under direct visualization and in Phase 2, we inserted the brush through a Cortrak® NGT prior to endoscopy. Eosinophil-derived neurotoxin (EDN) measured by ELISA in the samples extracted from brushes was validated as the sensitive biomarker. We collected 209 esophageal brushing samples from 94 patients and we found that EDN in brushing samples collected via EGD or NGT was significantly higher in patients having active EoE (n = 81, mean EDN 381 mcg/mL) compared with patients having gastroesophageal reflux disease (n = 31, mean EDN 1.9 mcg/mL, P = 0.003), EoE in remission (n = 47, mean EDN 3.7 mcg/mL, P = 0.003), or no disease (n = 50, mean EDN 1.1 mcg/mL, P = 0.003). EDN at a concentration of ≥10 mcg/mL of brushing sample was found to accurately detect active EoE. NGT brushing did not cause any significant adverse effects. We concluded that blind esophageal brushing using an NGT is a fast, less invasive, safe, and well-tolerated technique compared with EGD to detect and monitor EoE inflammation using EDN as the sensitive biomarker.

Effects of Smoking Exposure in Infants on Gastroesophageal Reflux as a Function of the Sleep-Wakefulness State

OBJECTIVE

To determine whether perinatal smoking exposure is associated with gastroesophageal reflux (GER)-related changes in sleep-wakefulness states in neonates.

STUDY DESIGN

Thirty-one neonates, referred for the investigation of suspected GER, were recruited and underwent multichannel impedance-pH monitoring and synchronized 8- to 12-hour polysomnography. The infants' exposure to tobacco smoke was estimated by means of a urine cotinine assay. The total number, frequency (h^-1), and mean duration (minutes) of GER-pH (reflux events detected by the pH electrode only) and GER-imp (reflux events with bolus movement detected by impedance) events were determined. Intergroup differences (smoking-exposed group vs nonexposed group) were probed with nonparametric, unpaired Mann-Whitney U tests. A χ² test was used to assess a possible intergroup difference in bolus retrograde migration during GER-imp events.

RESULTS

According to the urine cotinine assay, 21 of the 31 neonates had been exposed to cigarette smoke during the perinatal period. The number (and frequency) of GER-imp was significantly greater (P = .016) in the exposed group (29 [0-90]) than in the nonexposed group (12 [2-35]). Migration of the esophageal bolus from the distal segment to the most proximal segment was significantly more frequent (P = .016) in the exposed group (83% of GER) than in the nonexposed group (41%). The GER pattern associated with smoking exposure was particularly obvious during Rapid eye movement sleep.

CONCLUSIONS

The more frequent occurrence and greater proximal migration of GER-imp in the smoking-exposed group (especially during rapid eye movement sleep) may have clinical relevance. Smoking exposure is a preventable risk factor for limiting the occurrence of GER in neonates.

Cardiorespiratory events in infants with gastroesophageal reflux symptoms: Is there any association?

BACKGROUND

Cardiorespiratory (CR) events (apnea, bradycardia, oxygen desaturation) and gastroesophageal reflux (GER) symptoms often coexist in infants admitted to Neonatal Intensive Care Unit, leading to over-prescription of drugs and delayed discharge. We aimed to evaluate the relationships between CR and GER events.

METHODS

The temporal associations between CR and GER events were analyzed in symptomatic infants who underwent synchronized CR and pH-impedance monitoring. The symptom association probability (SAP) index was used to identify infants with a significant number of temporal associations. Gastroesophageal reflux characteristics and the chronological sequence of CR and GER events occurring within 30 seconds of each other were evaluated according to SAP index.

KEY RESULTS

Of the 66 infants enrolled, aged 29 (18-45) days, 58 had CR events during monitoring. From these 58 patients, a total of 1331 CR events and 5239 GER (24% acidic) were detected. The SAP index was positive in seven (12%) infants. These infants had greater GER frequency, duration, and proximal extent (P < .05). The number of temporal associations was 10 times greater in the positive SAP group. Gastroesophageal reflux events preceded CR events in 83% of these associations. These GER events had a higher proximal extent (P = .004), but showed no differences in pH values.

CONCLUSIONS & INFERENCES

The simultaneous evaluation of CR and GER events could be useful to identify infants with severe GER and significant temporal associations between these events. Treatment of GER could be indicated in these infants, but as the GER events involved are mainly non-acidic, empirical treatment with antacids is, often, inappropriate.

Detection of gastro-oesophageal reflux in the neonatal unit

AIM

To determine whether a pH probe or multichannel intraluminal impedance (MII) more frequently detected gastro-oesophageal reflux and test the hypothesis that acid reflux was associated with lower baseline impedance.

METHODS

A prospective study of infants in whom reflux was suspected and evaluated using combined pH and multichannel impedance. Studies were considered abnormal if the acid index was >10% or there were >79MII reflux events in 24 hours. The acid index was the percentage of total study time with a pH

RESULTS

Forty-two infants [median gestational age 31 (range 23-42) weeks] were assessed. Only nine infants (21%) had abnormal studies, seven detected by pH monitoring, one by MII monitoring and one by both techniques (p = 0.04). After correcting for gestational age and post-natal age, baseline impedance remained negatively correlated with the acid index (r = -0.34, p = 0.038) and the maximum ACT (r = -0.44, p = 0.006).

CONCLUSION

Clinical suspicion of reflux was frequently incorrect, and reflux was more frequently detected by a pH probe. The inverse relationship of acid reflux to baseline impedance suggests that mucosal disruption may result from acid reflux in this population.

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Key Words

• Baseline oesophageal impedance
• Multichannel intraluminal impedance
• pH study

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MESH Headings Collapse

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Affiliation(s)

Thomas Rossor MRC Centre in Allergic Mechanisms of Asthma, King's College London, London, UK Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
Ingran Lingam Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
Abdel Douiri Department of Primary Care and Public Health Sciences, King's College London, London, UK NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
Ravindra Bhat Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
Anne Greenough MRC Centre in Allergic Mechanisms of Asthma, King's College London, London, UK Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK

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Gastro-Oesophageal Reflux and Apnoea: Is There a Temporal Relationship?

BACKGROUND

Gastro-oesophageal reflux (GOR) and apnoea are common in infants; whether there is a causal relationship is controversial.

OBJECTIVES

To determine whether there was a temporal relationship between GOR and apnoea, in particular, the frequency of obstructive apnoeas and if the frequency of GOR episodes correlated with apnoea frequency when maturity at testing was taken into account.

METHODS

Polysomnography and pH/multichannel intraluminal impedance (MII) studies were performed. Apnoeas were classified as central, obstructive, or mixed. MII events were classified as acidic (pH <4) or weakly acidic (4 < pH < 7). Apnoea frequency in the 5-min period after a reflux event was compared to that in the 5-min period preceding the event and that in a 5-min reflux-free period (control period).

RESULTS

Forty infants (median gestational age 29 [range 24-42] weeks) were assessed at a post-conceptional age of 37 (30-54) weeks. Obstructive (n = 580), central (n = 900), and mixed (n = 452) apnoeas were identified; 381 acid reflux events were detected by MII and 153 by the pH probe only. Apnoeas were not more frequent following GOR than during control periods. Both the frequency of apnoeas (p = 0.002) and GOR episodes (p = 0.01) were inversely related to post-conceptional age at testing, but were not significantly correlated with each other when controlled for post-conceptional age.

CONCLUSIONS

These results suggest that GOR does not cause apnoea.

Correlation of Gastroesophageal reflux disease Assessment Symptom Questionnaire to impedance-pH measurements in children

Background

Esophageal multichannel intraluminal impedance-pH monitoring has become one of the preferred tests to correlate observed reflux-like behaviors with esophageal reflux events. The Gastroesophageal reflux disease Assessment Symptom Questionnaire is a validated tool used to distinguish infants with gastroesophageal reflux disease from healthy children. The aim of this study was to determine whether the Gastroesophageal reflux disease Assessment Symptom Questionnaire composite symptom scores and individual symptom scores correlate with outcomes in esophageal multichannel intraluminal impedance-pH monitoring.

Methods

A total of 26 patients with gastroesophageal reflux disease-associated symptoms, aged 0-2 years, for whom both esophageal multichannel intraluminal impedance-pH monitoring and Gastroesophageal reflux disease Assessment Symptom Questionnaire survey results were available were included in the study. Gastroesophageal reflux disease Assessment Symptom Questionnaire score data were collected from a 7-day recall of parent's responses about the frequency and severity of gastroesophageal reflux disease symptoms, which determined the individual symptom scores. The composite symptom scores is the sum of all individual symptom scores. Multichannel intraluminal impedance-pH study results were compared to Gastroesophageal reflux disease Assessment Symptom Questionnaire data using Pearson correlation.

Results

Among 26 patients, a total number of 2817 (1700 acid and 1117 non-acid) reflux episodes and 845 clinical reflux behaviors were recorded. There were significant correlations between the reflux index and the individual symptom scores for coughing/gagging/choking (r² = 0.2842, p = 0.005), the impedance score and individual symptom scores for coughing/gagging/choking (r² = 0.2482, p = 0.009), the reflux symptom index for acid reflux-related coughing/gagging/choking and the individual symptom scores for coughing/gagging/choking (r² = 0.1900, p = 0.026), the impedance score and individual symptom scores for vomiting (r² = 0.1569, p = 0.045), and the impedance score and the composite symptom scores (r² = 0.2916, p = 0.004). However, there were no significant correlations between fussiness, irritability, or abdominal pain-related multichannel intraluminal impedance-pH results and the individual symptom scores for abdominal pain.

Conclusion

The impedance scores from multichannel intraluminal impedance-pH studies correlate with coughing/gagging/choking and vomiting in infants with gastroesophageal reflux disease. There are no significant correlations among the reflux index and impedance score versus the Gastroesophageal reflux disease Assessment Symptom Questionnaire scores for abdominal pain. We conclude that in infants with gastroesophageal reflux disease, multichannel intraluminal impedance-pH studies are more likely to demonstrate an association between gastroesophageal reflux disease and symptoms of coughing, gagging, or choking compared to an association between gastroesophageal reflux disease and pain in infants.

BSPGHAN Motility Working Group position statement: paediatric multichannel intraluminal pH impedance monitoring-indications, methods and interpretation

BACKGROUND

Combined pH-impedance monitoring has been suggested as the investigation of choice for diagnosing gastro-oesophageal reflux in children. Although it is superior to oesophageal pH monitoring in detecting all types of reflux episodes (acid, weakly acidic and alkaline) with the ability to evaluate symptom association with reflux events, it is still limited by the lack of true paediatric normal value and the high cost involved (equipment and personnel).

OBJECTIVE

To produce a position statement on behalf of the Motility Working Group of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition on the indications and practical application of combined oesophageal pH-impedance monitoring in children.

METHODS

Up-to-date review of available evidence.

RESULTS

This document provides a practical guide to clinician on indications, methods and results interpretation of paediatric multichannel intraluminal impedance pH (MII-pH).

CONCLUSIONS

MII-pH is increasingly used by paediatricians as the diagnostic tool for assessing gastro-oesophageal reflux disease and symptom association. There is wide variation in paediatric practice and a need for standardised practice.

Effects of Esophageal Acidification on Troublesome Symptoms: An Approach to Characterize True Acid GERD in Dysphagic Neonates

To quantify and compare maximal extent (height) of acid reflux events (AREs) on symptom generation in dysphagic neonates. Dysphagic neonates (N = 53), born at 30 ± 5.3 weeks gestation, underwent 24-hour pH-impedance study for the evaluation of troublesome symptoms purported to be due to gastroesophageal reflux disease (GERD). AREs (pH < 4 for >4 s) detected by impedance (Z) were categorized by maximal extent as refluxate reaching distal (Z6, Z5), middle (Z4, Z3), or proximal (Z2, Z1) impedance channels. AREs reaching the pH sensor only were categorized as distal. Symptom correlation (%, symptom index, symptom sensitivity index, and symptom associated probability) and temporal characteristics (clearance times) of AREs were analyzed using linear mixed and GEE models comparing height categories presented as mean ± SEM, median (IQR), and OR (95% CI). Of the 2003 AREs, 1) distal extent AREs (n = 1642) had increased frequency (p < 0.05), decreased ACT (p < 0.05), and decreased acidity (p < 0.05); 2) in middle and proximal AREs, acid clearance was longer than bolus clearance, (p < 0.01); and 3) the odds of having cardiorespiratory (cough or sneeze) symptoms are increased with proximal and middle AREs (p < 0.05). Most proximal ascent of AREs into middle or proximal esophagus likely activates protective aerodigestive reflexes (peristalsis) or vigilant states to facilitate bolus and chemical clearance. Heightened esophageal sensitivity, acid neutralization delays, or clearance mechanism delays may accentuate multi-systemic troublesome symptoms.

Patterns of reflux in gastroesophageal reflux disease in pediatric population of New South Wales

This study is to determine the association of ambulatory pH monitoring (24hr pH) with symptoms of gastroesophageal reflux and its other investigations. The clinical and epidemiological profiles of subjects referred for reflux disorders are also studied. Symptoms or group of symptoms, profiles and prior investigations of 1259 consecutive pediatric subjects (with 1332 24hr pH studies performed) referred for evaluation of reflux disorders between 1988 and 2012 were retrospectively studied. Chi-square or fisher exact test was used for hypothesis testing, student t-test for the comparison of means and the Wilcoxon rank-sum test for comparing medians of continuous variables. Gastroesophageal reflux disease (GERD), defined as reflux causing major symptoms and complications, was diagnosed in 57.5% subjects of the total sample. Forty-three percent were girls and 56.7% were boys. The most common age group was between 4 months and 2 years (51.2%). Vomiting (64.4%) and irritability (74%) were the most common symptoms with the neurological conditions (23.2%) being the most frequent underlying condition. The parameters used in 24hr pH were significantly higher in those diagnosed with GERD (P < 0.0001). The prevalence of GERD was found to be significantly higher when both gastrointestinal and respiratory symptoms were present (P = 0.008) at 66.4% than when compared with gastrointestinal (56.5%) and respiratory (52.2%) symptoms in isolation. Symptoms alone were not reliable in diagnosing GERD. Only 57.5% had GERD among patients referred for reflux disorders. 24hr pH is reliable and should be considered routine in reflux disorders, as it identifies patients with pathologic reflux and avoids a needless surgery.

Pepsin in saliva as a biomarker for oropharyngeal reflux compared with 24-hour esophageal impedance/pH monitoring in pediatric patients

BACKGROUND

Pepsin in saliva is a proposed biomarker for oropharyngeal reflux. Pepsin may be prevalent in saliva from subjects with gastro-esophageal reflux and may correlate with proximal reflux by intraluminal impedance/pH monitoring (MII/pH).

METHODS

Patients (3 days to 17.6 years, n=90) undergoing 24-hour MII/pH monitoring and asymptomatic controls (2 months to 13.7 years, n=43) were included. Salivary pepsin was determined using a pepsin enzyme-linked immunosorbent assay. Eight saliva samples were collected from patients undergoing 24-hr MII/pH: (i) before catheter placement, (ii) before and 30 minutes after each of three meals, and (iii) upon awakening. One sample was collected from each control.

KEY RESULTS

In MII/pH subjects, 85.6% (77/90) had at least one pepsin-positive sample compared with 9.3% (4/43) in controls. The range of pepsin observed in individual subjects varied widely over 24 hours. The average pepsin concentration in all samples obtained within 2 hours following the most recent reflux event was 30.7±135 ng/mL, decreasing to 16.5±39.1 ng/mL in samples collected more than 2 hours later. The frequency of pepsin-positive samples correlated significantly with symptom index (r_S =0.332, P=.0014), proximal (r_S =0.340, P=.0010), and distal (r_S =0.272, P=.0095) MII events.

CONCLUSIONS & INFERENCES

Concentration of salivary pepsin may not be an accurate measure of severity of reflux because of the wide range observed in individuals over 24 hours. Saliva samples must be obtained soon after a reflux event. Defining a regimen for optimal saliva collection may help to achieve the goal of using salivary pepsin as a biomarker for oropharyngeal reflux.

CLINICAL TRIAL REGISTRY

NCT01091805.

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.

Esophageal Inlet Patch: An Under-Recognized Cause of Symptoms in Children

OBJECTIVES

To determine the incidence of inlet patch (IP) and to assess the clinical and pathological features, role of the diagnostic workup in treatment decision making, efficacy of medical and endoscopic therapy, and natural history in a pediatric population.

STUDY DESIGN

Consecutive patients aged <18 years (n = 1000) undergoing esophagogastroduodenoscopy were enrolled prospectively. Biopsy specimens were obtained from IPs and the proximal and distal esophagus, stomach, and duodenum. Multichannel intraluminal impedance and pH monitoring (MII-pH) was performed in all symptomatic patients. Symptomatic patients were treated with proton pump inhibitors for 8 weeks, and IP ablation by argon plasma coagulation (APC) was performed in unresponsive patients.

RESULTS

The endoscopic incidence of IP was 6.3%, with a cumulative missing rate of 5.8%. Thirty-five of the 63 patients (56%) were asymptomatic, 11 (17%) had symptoms clearly related to the underlying digestive disorder, and 17 (27%) had chronic IP-related symptoms. MII-pH was positive in 10 of the 28 symptomatic patients. All 17 patients with IP-related symptoms were unresponsive to proton pump inhibitors and were treated with APC, and all had achieved complete remission by the 3-year follow-up. Patients with underlying disorders were successfully treated with medical therapy, and asymptomatic patients remained symptom-free, with no endoscopic or histological changes seen at the 3-year follow-up.

CONCLUSION

IP is an under-recognized cause of symptoms in children with unexplained esophageal and respiratory symptoms. MII-pH and bioptic sampling are needed to exclude entities mimicking IP symptoms and to direct therapy. APC is safe and effective for treating IP-related symptoms.

Radiographic and Endoscopic Measurements of Esophageal Length in Pediatric Patients

Objectives:

Knowledge of the length between the upper esophageal sphincter (UES) and the lower esophageal sphincter (LES) in pediatric patients is essential for intraluminal impedance and dual pH probe recordings.

Methods:

We measured the vertical distance between the true vocal cords (TVCs) and the LES in chest x-rays (CXRs) of 118 children (ages, 6 weeks to 13 years) and measured the vertical distance between the UES and the LES during endoscopy in 31 patients (ages, 14 months to 17 years) and correlated the measurements to height, weight, and age.

Results:

Esophageal length correlated best with patient height (R = 0.96 by CXR, R = 0.88 by endoscopy) and less well with weight (R = 0.87, R = 0.67) and age (R = 0.94, R = 0.86). Linear regression analyses using radiographic measurements revealed that esophageal length (TVC to LES) can be estimated from a patient's height by the following equation: 1.048 + 0.167 × height (in centimeters). With the upper pH probe placed in the hypopharynx at the TVC level and the inferior probe placed in the esophagus 3 to 6 cm above the LES, the patients were divided into 6 groups corresponding to the currently available number of sizes of dual pH-impedance probes. With the patients' heights between 71.5 and 161.3 cm, 64.7% to 100% of patients were within 1 cm of the desired location with preselected probes. Confirmation of placement was performed with CXR.

Conclusions:

A pediatric patient's height can be used to estimate the esophageal length (TVC to LES) and facilitate the selection of dual pH—impedance probes. Our method decreases the risk of morbidity while increasing the accuracy of the study of extraesophageal reflux disease.

Gastroesophageal Reflux Affects Sleep Quality in Snoring Obese Children

PURPOSE

This study was performed to evaluate the quality of sleep in snoring obese children without obstructive sleep apnea (OSA); and to study the possible relationship between sleep interruption and gastroesophageal reflux (GER) in snoring obese children.

METHODS

Study subjects included 13 snoring obese children who were referred to our sleep lab for possible sleep-disordered breathing. Patients underwent multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria included history of fundoplication, cystic fibrosis, and infants under the age of 2 years. Significant association between arousals and awakenings with previous reflux were defined by symptom-association probability using 2-minute intervals.

RESULTS

Sleep efficiency ranged from 67-97% (median 81%). A total of 111 reflux episodes (90% acidic) were detected during sleep, but there were more episodes per hour during awake periods after sleep onset than during sleep (median 2.3 vs. 0.6, p=0.04). There were 279 total awakenings during the sleep study; 56 (20.1%) of them in 9 patients (69.2%) were preceded by reflux episodes (55 acid, 1 non-acid). In 5 patients (38.5%), awakenings were significantly associated with reflux.

CONCLUSION

The data suggest that acid GER causes sleep interruptions in obese children who have symptoms of snoring or restless sleep and without evidence of OSA.

Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children

BACKGROUND

Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation.

METHODS

All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes.

RESULTS

Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%.

CONCLUSIONS

The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.

Esophageal pH Monitoring in Children: A Simple Mathematical Formula for pH Probe Positioning

Correct pH probe placement is vital for the precision of esophageal pH monitoring. This study aimed at finding the optimal formula for placement of pH probe in the locus proposed by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition European Pediatric Impedance Working Group, that is, 2 vertebrae above the diaphragm. An analysis of data regarding 353 children ages 0-18 years in whom the position of the pH sensor was determined radiographically revealed that a mathematical formula (3.2 + 0.2 × body length or height, centimeter) could guide the probe to within 1/12 of thoracic spine length of the desired location in 71.7% of all of the patients.

Pharmacokinetics and Acid-suppressive Effects of Esomeprazole in Infants 1-24 Months Old With Symptoms of Gastroesophageal Reflux Disease

OBJECTIVES

To evaluate the pharmacokinetics and acid-suppressive effects of esomeprazole in infants with gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

In this single-blind, randomized, parallel-group study, 50 infants 1 to 24 months old with symptoms of GERD, and ≥ 5% of time with intraesophageal pH <4 during 24-hour dual pH monitoring, received oral esomeprazole 0.25 mg/kg (n = 26) or 1 mg/kg (n = 24) once daily for 1 week. Intraesophageal and intragastric pH were recorded at 1 week, and blood samples were taken for pharmacokinetic analysis.

RESULTS

At baseline, mean percentages of time with intragastric pH > 4 and intraesophageal pH < 4 were 30.5% and 11.6%, respectively, in the esomeprazole 0.25 mg/kg group and 28.6% and 12.5% in the esomeprazole 1 mg/kg group. After 1 week of treatment, times with intragastric pH >4 were 47.9% and 69.3% in the esomeprazole 0.25 mg/kg and 1 mg/kg groups, respectively (P < 0.001 vs baseline), and times with intraesophageal pH < 4 were 8.4% (P < 0.05 vs baseline) and 5.5% (P < 0.001 vs. baseline), respectively. The mean number of acid reflux episodes of > 5 minutes duration decreased from 6 at baseline to 3 and 2 with esomeprazole 0.25 mg/kg and 1 mg/kg, respectively. The geometric mean AUC0-t of esomeprazole were 0.24 and 1.79 μmol · h/L for the 0.25 mg/kg and 1 mg/kg dosages of esomeprazole, respectively. Both esomeprazole dosages were well tolerated.

CONCLUSIONS

Oral treatment with esomeprazole 0.25 mg/kg and 1 mg/kg was well tolerated and provided dose-related acid suppression, dose-related exposure to esomeprazole, and decreased esophageal acid exposure in infants 1-24 months old with GERD.

Chemical clearance in infants and children with Acid reflux in the physiologic range

BACKGROUND AND AIM

We reported that chemical clearance (CC) of acid gastroesophageal reflux (AGER) is relatively prolonged in children with cystic fibrosis (CF). Disparity in CC values within our CF cohort sparked curiosity as to what CC looks like in infants and children with AGER in the physiologic range. The aim of the study was to assess CC in infants and children with normal AGER.

METHODS

Impedance-pH tracings from our database for infants (≤ 12 months) and children (>12 months-18 years) were manually scanned for 2-phase AGER episodes. Tracings were excluded for patients who had AGER Indices >3% (children) or >6% (infants), had positive GER-symptom associations, were on antireflux medications, had a fundoplication, or had impedance studies shorter than 18 hour. In addition to medians (25%-75% interquartile range), we calculated the 95th percentile for the CC duration and the fifth percentile for the CC rate.

RESULTS

Two-phase AGER episodes were detected in 44 infants and 60 children. The median CC duration was 64.3 seconds (51.0-91.6 seconds) for infants and 37.5 seconds (27.7-52.4 seconds) for children. The median CC rate was 0.0622 pH units/second (PU/second) (0.0354-0.0946 PU/second) for infants and 0.0928 PU/second (0.0631-0.2057 PU/second) for children. The CC duration at the 95th percentile was 148.5 seconds for infants and 114.4 seconds for children. The CC rate at the fifth percentile was 0.0088 PU/second for infants and 0.0465 PU/second for children.

CONCLUSIONS

We report reference values for CC in infants and children who have normal acid reflux. These values should not be used as "cutoff values" because they were derived from infant and children cohorts that did not include individuals with intermediate AGER.

A new method to estimate catheter length for esophageal multichannel intraluminal impedance monitoring in children

BACKGROUND

Multichannel intraluminal impedance combined with pH (MII-pH) is the gold standard test for diagnosing gastro-esophageal reflux disease (GERD). It provides an opportunity to study acid and non-acid GOR and temporal association between symptoms and reflux. Accurate catheter placement is essential to prevent erroneous recording of reflux events. The aims of our study were to assess the accuracy of our devised method in predicting the catheter length for MII-pH in children (Great Ormond Street Hospital (GOSH) Table) and to compare the results with Strobel and Monreau methods.

METHODS

Retrospective review of all records of infants and children who underwent MII-pH studies between January to October 2014. Desired catheter position was calculated using Strobel, Monreau and GOSH formulas and compared to X ray position.

KEY RESULTS

One hundred and forty-four children were included; mean age was 5.1 (±4.5) years, 73 males and 71 females. In the whole group, the correlation between desired catheter position and GOSH Table was 0.95, for Strobel was 0.84, and Monreau was 0.85. In the first group (age <3 years), the correlation was: GOSH Table 0.91, Strobel 0.56, and Monreau 0.6; in the second group (3-10 years): GOSH Table 0.78, Strobel 0.82, and Monreau 0.82; the third group (>10 years): GOSH 0.81, Strobel 0.43, and Monreau 0.43.

CONCLUSIONS & INFERENCES

GOSH Table is an accurate method to estimate the insertion length of MII-pH catheters from nares to a point of approximately two vertebral bodies above the diaphragm in children. Although radiography is required to confirm final catheter position, using GOSH Table will reduce the need for repeated catheter manipulation after initial insertion and will reduce the use of a mathematically complicated formulae.

An antiregurgitation milk formula in the management of infants with mild to moderate gastroesophageal reflux

BACKGROUND

Thickened milk formulas are used to treat infants with gastroesophageal reflux (GER), but these substances often increase the duration of reflux episodes and worsen symptoms, and they have been associated with diarrhea, constipation, and cough.

OBJECTIVES

The aims of this study were to determine the efficacy of an antiregurgitation milk formula in the clinical and laboratory setting in infants with proved GER, to investigate any possible adverse events (cough and change in the number of bowel movements or the consistency of stools), and to identify its effects on height and body weight.

METHODS

Infants with recurrent vomiting and GER who were not responsive to standard treatment were eligible for the study. Infants in the treatment group (group A) were managed for 4 weeks with a specific antiregurgitation milk formula (with cornstarch and an increased amount of casein), and those in the control group (group B) were given a standard milk formula. The number of episodes of vomiting, regurgitation, and cough, as well as the frequency and consistency of stool, height, and body weight were noted at least 10 days before and during the study. A second pH monitoring was performed after 4 weeks in both groups.

RESULTS

Fifty-six infants (30 boys, 26 girls; mean [SD] age, 3.1 [1.2] months) were included in the study; 30.4% had mild GER; 44.6%, moderate GER; and 25.0%, severe GER. Significantly more infants in group A than in group B (50.0% vs 14.3%, respectively) with mild or moderate GER had normal findings on the second pH monitoring (P<0.05). Changes in the reflux index and in the mean number of vomiting and regurgitation episodes were significantly different between the 2 groups (P<0.05). No significant differences in changes in the mean number of bowel movements and cough events or in the consumption time of the 2 formulas were found between the 2 groups.

CONCLUSION

Infants with mild or moderate GER can be managed effectively with this antiregurgitation milk formula. Improved clinical and laboratory findings were seen in the majority of infants, and the formula was well tolerated, without adverse events.

Cystic fibrosis: a surgical matter?

BACKGROUND

Gastroesophageal reflux disease (GERD) is very common in patients with chronic lung diseases. We evaluated the incidence of GERD in young patients with cystic fibrosis (CF) and defined the characteristics of gastroesophageal reflux episodes analyzed by pH-multichannel intraluminal impedance (pH-MII) and esophagogastric scintigraphy.

PATIENTS AND METHODS

Since 2010, 31 patients with CF underwent pH-MII. Scintigraphy and upper endoscopy were performed in positive GERD patients. Forced expiratory volume in 1 second (FEV1%) predicted was detected.

RESULTS

pH-MII was positive in 17/31 (54.8%) patients (mean age: 12.4 years; range: 4-17 years). pH monitoring detected an average of 64.6 acid reflux events 4.4 episodes >5 minutes in duration. The DeMeester score was 38.5. Impedance identified a mean number of reflux episodes of 66 (65.2% acid; 32% weakly acidic; 2.8% nonacidic), 28% of which reached the proximal esophagus. Esophageal transit and gastric emptying were delayed in 6/13 (46.1%) and in 5/15 (33.3%) cases, respectively. No differences were found in lung function between positive and negative GERD patients (P=0.88).

CONCLUSIONS

Pediatric patients with CF have a high incidence of GERD with acidic events. These patients should be investigated with pH-MII and scintigraphy in order to make an early diagnosis and determine the most appropriate follow-up.

[Anthropometric measures for the introduction of the nasogastric tube for enteral nutrition employing the esophagogastroduodenoscopy]

BACKGROUND

The correct placement of a nasogastric tube for enteral nutrition is subject of several investigations, demonstrating the controversy of the procedure.

AIM

To establish an external measure that can correspond to the internal measurement which determines the insertion length of nasogastric feeding tube up to the stomach.

METHODS

External measures were obtained between points: nose tip vs earlobe vs xiphoid appendix vs umbilicus and height correlated with the standard measures obtained from patients undergoing diagnostic esophagogastroduodenoscopy.

RESULTS

It was found a significative statistical correlation between esophagogastric junction, identified during the esophagogastroduodenoscopy, with the distance measured between the anatomic points of the earlobe and xiphoid appendix (r= 0.75) and from this line with the orthostatic height (r=0.72).

CONCLUSION

The distance between the earlobe to the xiphoid appendix (0.75) and the distance between the earlobe to the xiphoid appendix to the midpoint of the umbilicus, subtracting the distance from tip of nose to earlobe, were safe anatomical parameters to reach the esophagogastric junction. The height in the standing position (r= 0.72) also can be used as an indicator of the length necessary to insert the tube into the stomach. The height in the standing position (r= 0.72) also can be used as an indicator of the length necessary to insert the tube into the stomach.

Esophageal pH and Combined Impedance-pH Monitoring in Children

Esophageal pH monitoring is considered the gold standard for the diagnosis of gastroesophageal reflux disease because of the normal ranges across the pediatric age range. However, this method can only detect acid reflux. Multichannel intraluminal impedance-pH (MII-pH) monitoring has recently been used for the detection of bolus reflux in infants and children. This method allows for the detection of liquid, gas or mixed reflux in addition to acid, weakly acidic or weakly alkaline reflux. MII-pH monitoring can record the direction of flow and the height of reflux, which are useful parameters to identify an association between symptoms and reflux. However, the technique is limited by its high cost and the lack of normative data of MII-pH in the pediatric population. Despite certain limitations, MII-pH monitoring will become more common and gradually replace pH monitoring in the future, because pH monitoring is part of MII-pH.

Clinical characteristics and sensitivity to food and inhalants among children with eosinophilic esophagitis

Background

To understand the clinical characteristics and the diagnostic procedures in pediatric patients with eosinophilic esophagitis and to evaluate the sensitivity of the patients to food and inhalant allergens. A cross-sectional study was performed in 35 children with eosinophilic esophagitis during the time period from January 2010 to January 2011. The clinical and epidemiological data were obtained using a questionnaire and medical chart analysis. The body mass index for age was used for the nutritional evaluation (via the Z score). The sensitivity to foods and inhalants was evaluated by performing a skin prick test and atopy patch test.

Results

Patients (35 in total, median age 10 years) with a diagnosis of eosinophilic esophagitis were evaluated. The most prevalent symptoms in the patients were vomiting (71.4%) and abdominal pain (51.4%). Endoscopic alterations were observed in 97.2% of the patients. A good nutritional state was observed in 82.8% of the children. The tests demonstrated the presence of food sensitivities and/or aeroallergens in 27 (77.1%) patients, whereas 8 (22.9%) patients did not test positive in any of the tests performed. Among the patients with positive tests, 24 (68.5%) exhibited sensitivity to aeroallergens and 16 (45.7%) were sensitive to foods. The comparison between the sensitive and insensitive groups displayed statistically significant results with respect to sex, symptom prevalence, and 24-hour esophageal pH monitoring.

Conclusions

The patients evaluated in this study displayed clinical characteristics of eosinophilic esophagitis similar to those reported in the literature. The sensitivity to foods determined by the tests was less than that observed in prior studies; however, a marked sensitivity to aeroallergens was observed. The different allergen sensitivity profiles observed in this study suggests that, similar to asthma, the eosinophiic esophagitis disease may exhibit several phenotypes.

Involvement of autonomic nervous activity changes in gastroesophageal reflux in neonates during sleep and wakefulness

BACKGROUND

It has been suggested that disturbed activity of the autonomic nervous system is one of the factors involved in gastroesophageal reflux (GER) in adults. We sought to establish whether transient ANS dysfunction (as assessed by heart rate variability) is associated with the occurrence of GER events in neonates during sleep and wakefulness.

METHODS

Nineteen neonates with suspected GER underwent simultaneous, synchronized 12-hour polysomnography and esophageal multichannel impedance-pH monitoring. We compared changes in HRV parameters during three types of periods (control and prior to and during reflux) with respect to the vigilance state.

RESULTS

The vigilance state influenced the distribution of GER events (P<0.001), with 53.4% observed during wakefulness, 37.6% observed during active sleep and only 9% observed during quiet sleep. A significant increase in the sympathovagal ratio (+32%, P=0.013) was observed in the period immediately prior to reflux (due to a 15% reduction in parasympathetic activity (P=0.017)), relative to the control period. This phenomenon was observed during both wakefulness and active sleep.

CONCLUSION

Our results showed that GER events were preceded by a vigilance-state-independent decrease in parasympathetic tone. This suggests that a pre-reflux change in ANS activity is one of the factors contributing to the mechanism of reflux in neonates.

Esophageal length: esophageal manometry remains superior to mathematical equations

BACKGROUND AND OBJECTIVES

Many mathematical equations based on height have been developed to estimate the esophageal length (EL) in children. The aim of this study was to confirm whether the preexisting and most frequently used equation by Strobel et al is accurate in calculating the EL in our pediatric population. Our secondary goal was to evaluate whether a new formula could be developed using our nonsurgical and surgical populations' data for the correlation between patients' height and measured EL by esophageal manometry (EM).

METHODS

From 2000 to 2009, 116 children between the ages of 3 and 18 years without previous esophageal surgery underwent EM (n = 31) at the Montreal Children's Hospital. During the same period, 55 EMs were performed on 34 children with a previous history of esophageal surgery. For both groups, we collected the following data: height, EL calculated by the Strobel formula, and EL measured by EM.

RESULTS

The Strobel equation was inaccurate in predicting the EL. The calculated EL was 3.0 ± 0.32 cm longer than the EM measurements (P < 0.001). The height (H) of nonsurgical children was found to be highly predictive of the lower esophageal sphincter location (L), and the derived linear regression equation is L = 0.216 (H) + 7.13 [r² = 0.85].

CONCLUSIONS

This study confirmed that the Strobel formula is not sufficiently accurate to predict EL in the pediatric population that is between 3 and 18 years old. A correlation exists between height and esophageal sphincter location position. If EM is unavailable, the use of a new mathematical equation like ours can be considered.

Prognostic values of multichannel intraluminal impedance and pH monitoring in newborns with symptoms of gastroesophageal reflux disease

OBJECTIVE

To evaluate the relationship between multichannel intraluminal impedance and pH monitoring (MII/pH) values in newborns with symptoms of gastroesophageal reflux disease (GERD) and clinical history in their first 3 years of life.

STUDY DESIGN

Sixty-four newborns with GERD symptoms who underwent MII/pH in the first weeks of life were enrolled into a clinical follow-up program. Follow-up visits were programmed at 1, 3, 6, 9, 12, 18, 24, and 36 months. Patients were divided into 3 groups according to duration of symptoms: short (1-3 months), medium (4-9 months), and long (>9 months), and MII/pH values in these groups were compared.

RESULTS

Fifty-three patients completed the 3-year follow-up. The number of patients with GERD symptoms decreased each month. A comparison of MII/pH values of the 3 lifetime symptom groups revealed differences in the impedance bolus exposure index (F = 83; P = .012) and proximal reflux frequency (F = 410; P = .022). These 2 MII variables showed an increasing trend from the short lifetime symptom group to the long lifetime symptom group. Weakly acidic reflux events, but not acidic events, were responsible for these differences.

CONCLUSION

MII/pH in newborns has prognostic value regarding the duration of GERD symptoms and provides useful information that clinicians may give parents about the prognosis of symptomatic infants. Impedance bolus exposure index and proximal reflux frequency seem to be the variables with the highest predictive value. Weakly acidic reflux events play an important role in determining the duration of GERD symptoms in newborns.

Serum interleukin--4 and tumor necrosis factor alpha concentrations in children with primary acid gastroesophageal reflux and acid gastroesophageal reflux secondary to cow's milk allergy

AIM

The possible role of serum interleukin 4 (IL-4) and tumor necrosis factor alpha (TNF- α) in pathogenesis of the reflux symptoms in children with primary acid gastroesophageal reflux (GER) and acid GER secondary to cow's milk allergy (CMA).

MATERIAL AND METHODS

Out of 264 children, 76 (28.8%) patients with primary GER and 62 (23.5%) patients with GER secondary to CMA (pH - monitoring) serum IL-4 and TNF- α concentrations were assessed before treatment, 1 and 2 years after the initiation of the periodically administered pharmacotherapy.

RESULTS

Children with primary GER had mean IL-4 concentrations 0.17 ± 0.06 pg/ml before treatment, 0.08 ± 0.07 pg/ ml after 1-year and 0.07 ± 0.06 pg/ml after 2-years of treatment. The mean IL-4 concentrations were 1.07 ± 0.24, 0.5 ± 0.22 and 0.44 ± 0.19 pg/ml respectively in children with GER secondary to CMA. The mean serum TNF- α concentrations was 3.62 ± 1.30 pg/ml before treatment , 2.16 ± 1,35 pg/ ml after 1 year and 1.65 ± 1.16 pg/ml after 2 years of treatment in children with primary GER. In group with GER secondary to CMA mean serum TNF- α concentrations were 4.95 ± 1.88, 2.53 ± 0.80 and 2.02 ± 0.78 pg/ml respectively. Statistical analysis of the concentration of both cytokines showed their differentiation between them and in the study groups.

CONCLUSIONS

The highest mean serum IL-4 and TNF-α concentrations were observed in children with GER secondary to CMA and in children in control group (with cow's milk allergy and/or other food allergy diagnosed - CMA/FA) before the treatment administration.