Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease

Breastfeeding support among re-hospitalized young children: a survey from Italy

BACKGROUND

In 2021, the Task Force on Breastfeeding of the Italian Ministry of Health released a document calling for the provision of breastfeeding support in case of re-hospitalization of the child after birth. Since type and quality of breastfeeding support during re-hospitalization in Italian Pediatric Units (PUs) is largely unknown, the Breastfeeding Section of the Italian Society of Pediatrics (TASIP) conducted an ad hoc national survey.

METHODS

In March 2023, a specifically designed electronic questionnaire was sent to the Directors of 328 PUs, who were requested to fill it online.

RESULTS

Data from 161 PUs were received, with a response rate of 48.7%. Our results highlighted that 18.6% of units do not provide training on breastfeeding for healthcare professionals and 46% of PUs lack of an ad hoc policy on breastfeeding support in case of re-hospitalization of the child. Although 88.2% of PUs provide breast pumps to the mothers of the re-hospitalized young children, 34.8% lack of a protocol on the storage of expressed breast milk.

CONCLUSIONS

Breastfeeding support for the mothers of hospitalized breastfed young children appears to be suboptimal in Italian PUs. Interventions aimed to structure and improve the quality of breastfeeding support for the mother-child dyad are needed, particularly developing protocols and providing a training on breastfeeding to the majority of healthcare professionals.

Acid-suppressive therapy among infants and risk of anemia at 12 months of age

Objectives:

Numerous studies have shown that links exist between exposure to acid suppression among adults and nutritional deficiencies, especially vitamin B12 and iron. While the use of acid suppression among children and infants is common, nutritional deficiency remains a concern but does not have numerous studies to support it. We conducted a cohort study to examine this concern; the hypothesis we proposed is that acid-suppressive therapy (AST) during infancy is linked to anemia in the first year of life.

Methods:

This retrospective cohort study included infants born between 2017 and 2018 who visited Legacy Community Health. The inclusion criteria were exposure to acid suppression for a minimum of 1 month and a hemoglobin reading at 12–15 months. Infants who had hemoglobinopathies, failure to thrive, or malabsorption syndromes were excluded. Mean hemoglobin was calculated, and student’s t-test was applied to find statistical differences between the two groups. Change in weight before and after treatment was recorded. Occurrence of respiratory and gastroenterological adverse events was recorded in the exposed group.

Results:

Overall, 135 exposed infants were identified 135 controls were selected. The majority of the sample included Hispanic girls. Ranitidine was the most commonly prescribed medicine. The duration of treatment was 3 months. Weight improved significantly at termination of the treatment. There was no significant difference between the hemoglobin level of cases and controls, and both were not considered anemic.

Conclusion:

AST was not linked to anemia, despite the slightly lower hemoglobin in some cases. There were few weaknesses in our study; therefore, further studies can examine this link by focusing further on medication type and close follow-up. We found that although proton pump inhibitors are considered the first line of treatment, histamine-2 receptor antagonists were more frequently prescribed. Strategies to familiarize general pediatricians with the NSAPGHAN guidelines might be needed.

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.

Association between body positioning and gastroesophageal reflux in paediatric age

AIM

Postural measures are frequently recommended for gastroesophageal reflux (GER) symptoms, despite limited evidence. This was the first study to assess the impact of upright and recumbent body positions on GER episodes in children and adolescents, not just infants.

METHODS

We retrospectively assessed the pH-impedance parameters of paediatric patients referred for possible GER-related symptoms to two hospitals in Naples and Rome, Italy, from September 2016 to September 2018. Data were separately obtained for the time that the patients spent in upright and recumbent positions.

RESULTS

Data from 187 patients under the age of 18 were collected, at a mean age of just over seven years. We found that the acid exposure time was stable irrespective of changes in body position (P > .05). The mean number of reflux episodes per hour was 2.99 during the upright position and 1.21 during the recumbent position (P < .05), and the mean oesophageal acid clearance time was 44.4 and 93.4 seconds, respectively (P < .05).

CONCLUSION

Most paediatric patients experienced reflux in the upright rather than recumbent position, probably as a result of frequent transient lower oesophageal sphincter relaxations while they were awake. In particular, our findings provide new insights into postural measures for reflux in children and adolescents.

Significance of Extra-Esophageal Symptoms in Pediatric Gastroesophageal Reflux Disease

Introduction  Current practice guidelines in gastroesophageal reflux disease (GERD) often require invasive diagnostic testing.

Objective  The aim of the present study was to evaluate the significance of extra-esophageal symptoms and reliability of a screening risk score that is simple to use.

Methods  A longitudinal retrospective single-institution cohort study. Setting: A university clinical hospital tertiary referral center. The present study enrolled pediatric patients with symptoms suggestive of GERD: epigastric pain, occasional nausea, regurgitation, tasting acid in the oral cavity, chronic cough, hoarseness of voice, frequent throat clearing. The patients underwent 24-hour esophageal pH monitoring and fiber-optic laryngoscopy. The correlations between the local findings, anamnestic and objective measurement data were analyzed.

Results  The present study evaluated 89 pediatric patients. Patients with asthma presented significantly more often with adjoining gastrointestinal symptoms ( p  = 0.0472). Patients that were obese were linked to a higher rate of reports of gastrointestinal symptoms ( p  = 0.0495). After the patients had been assigned to newly developed risk groups, obesity showed to be significantly more frequent in patients placed in higher risk groups ( p  < 0.0001) for a positive GERD diagnosis.

Conclusion  Patients with leading symptoms of asthma presented significantly more often with adjoining gastrointestinal symptoms. Obesity showed to be significantly more frequent in patients placed in higher risk groups for a positive GERD diagnosis.

Awareness, experience, and practice of physicians regarding adult gastroesophageal reflux disease (GERD) in Riyadh, Saudi Arabia

Background and Aims:

Gastroesophageal reflux disease (GERD) was frequently managed by residents as they are the first physician who encounter the patient. This study was conducted to explore the knowledge and practice of physicians in the treatment of GERD and to compare between residents and consultants regarding their knowledge and practice.

Methodology:

A cross-sectional study, self-administered questionnaire.

Results:

Esophagogastroduodenoscopy (EGD) was the most commonly used method to screen for Barrett's esophagus for symptoms for 5 or more years. The most frequent guideline used was the American College of Gastroenterology (ACG) guideline. The most commonly used diagnostic tool for evaluating uncomplicated reflux disease was upper endoscopy with biopsy. Empiric trial with acid suppression was the most commonly used and proton pump inhibitors (PPIs) was the first-line treatment. The most common combination with PPI was prokinetic drugs, most often domperidone. The preferred maintenance strategy was the 'on demand' maintenance mode. Step-down strategy was commonly recommended. A total of 26% of residents and 37% of consultants could achieve a score of good knowledge. Overall patterns of knowledge and practice of GERD diagnosis and management were comparable between residents and consultants with only minor controversy in their knowledge and practice.

Conclusion:

The overall patterns of knowledge and practice of GERD diagnosis and management are comparable among residents and consultants but still there are areas of controversy and confusion. A good knowledge score was found among only a quarter of residents and 37% of consultants.

Recommendations:

The public health implications of deviations from evidence-based practice should be studied and implementing evidence-based practice should be emphasized.

Mechanisms of Aerodigestive Symptoms in Infants with Varying Acid Reflux Index Determined by Esophageal Manometry

OBJECTIVE

To test whether symptom generation in infants is related to the severity of gastroesophageal reflux disease (GERD) symptoms as determined by the Acid Reflux Index (ARI), stimulus media, and stimulus volume during provocative esophageal manometry.

STUDY DESIGN

Symptomatic neonates (n = 74) born at a median of 28.9 weeks gestation (range, 23.4-39.4 weeks) were studied at a median of 41.0 weeks (range, 34.6-48.0 weeks) postmenstrual age using 24-hour pH-impedance methods to determine ARI severity, followed by provocative esophageal manometry with graded mid-esophageal infusions (0.1-5.0 mL) of air, water, and apple juice. Peristaltic reflexes and symptom characteristics were compared among ARI severity categories using linear mixed models and generalized estimating equations.

RESULTS

The effects of 2635 separate esophageal stimuli on reflexes and symptoms were analyzed. Peristaltic reflexes occurred in 1880 infusions (71%), and physical, cardiorespiratory, sensory symptoms were seen in 439 infusions (17%). Symptom prevalence did not differ across the ARI severity categories (ARI <3, 18%; ARI 3-7, 17%; ARI >7, 16%; P = 1.0). Symptom and peristaltic responses increased with incremental stimulus volumes (all media, P < .001).

CONCLUSIONS

Symptoms and peristaltic reflexes are manifestations of the recruitment of several neurosensory and neuromotor pathways evoked by mid-esophageal infusions. ARI severity grade plays no role in symptom generation, indicating that GERD should not be diagnosed and severity should not be assigned based on symptoms alone. An increase in symptom occurrence was noted with increasing stimulus volumes, which provided increased activation of receptors, afferents, and efferents in evoking peristaltic clearance reflexes.

Survey on the Adherence to the 2009 NASPGHAN-ESPGHAN Gastroesophageal Reflux Guidelines by Brazilian Paediatricians

OBJECTIVE

The aim of the study was to evaluate the management of gastroesophageal reflux in children among Brazilian pediatricians and adherence to the 2009 North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Guideline in Brazil.

METHODS

An observational cross-sectional study was conducted, applying a standard questionnaire with 12 questions about gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) management in infants, children, and adolescents to the pediatricians during the 37th Brazilian Pediatrics Congress in October, 2015. Adherence to the 2009 NASPGHAN-ESPGHAN Guideline was verified through analyses of interviewees' answers. Pediatricians' demographic and professional characteristics were screened.

RESULTS

A total of 390 Brazilian pediatricians answered the questionnaire. None showed complete adherence to Guideline recommendations. GERD diagnosis by history alone was reported by 67%, irrespective of the child's age. The mean score for diagnostic adherence to the guidelines was 0.94 ± 0.86 (range 0-4). Working in public health services (P = 0.026) was the only variable retained as a significant predictor of poor adherence for GER/GERD diagnosis after multivariate logistic regression analysis. No significant statistical differences were found between Brazilian regions on total score (P = 0.774). Proton pump inhibitors were prescribed by 28.4% of the pediatricians independent of child's age, and 59% use proton pump inhibitors to treat babies with unexplained crying and/or distressed behavior.

CONCLUSIONS

2009 NASPGHAN-ESPGHAN Guideline recommendations had poor adherence by Brazilian pediatricians. Studies evaluating the reasons for the poor adherence to NASPGHAN/ESPGHAN guidelines are urgently needed.

Functional Gastrointestinal Disorders in Children: A Survey on Clinical Approach in the Mediterranean Area

OBJECTIVES

Childhood functional gastrointestinal disorders (FGIDs) are common conditions associated with significant morbidity and high healthcare costs. This multicenter study aimed at assessing the clinical approach to infants (0-6 months) and children/adolescents (4-18 years) with suspected FGIDs by pediatricians from the Mediterranean Area.

METHODS

A survey evaluating the diagnostic approach, including the use of Rome II and III criteria, and the therapeutic management of some of the most prevalent FGIDs, such as irritable bowel syndrome (IBS), functional constipation (FC), and functional regurgitation (FR), was distributed to a sample of pediatricians.

RESULTS

We collected 278 questionnaires from 9 countries (Croatia, Greece, Israel, Italy, Lebanon, Montenegro, Serbia, Slovenia, and Spain). Rome III criteria are used to diagnose FC by 28.8%. Treatment of FC is based on dietary modifications (97.5%) and osmotic laxatives (93.5%). Rome III criteria are used to diagnose FR by 22.3% of the responders, in contrast to 79.5% who rely on personal experience for diagnosis. Reported treatments mainly consist of reassurance (96.8%) and thickened feedings (77.3%). Nevertheless, 21.2% prescribe proton pump inhibitors or H2-blockers to infants with FR. Rome III criteria are used to diagnose IBS by only 25.9%. Moreover, 86% of the pediatricians base IBS therapy on the predominant symptom. The most prescribed treatments are analgesics (36.6%) for pain control, dietary advice (41.5%) for diarrhea-predominant IBS, and dietary advice (47.8%) for constipation-predominant IBS.

CONCLUSIONS

Our data show that the use of Rome III diagnostic criteria is not sufficiently widespread among pediatricians, and that large variability remains in the management of FGIDs within the different Mediterranean countries surveyed.

Questionnaire-based survey in a developing country showing noncompliance with paediatric gastro-oesophageal reflux practice guidelines

AIM

This 2015 study investigated whether Lebanese paediatricians diagnosed and managed gastro-oesophageal reflux disease (GERD) in infants and children in accordance with the 2009 guidelines from the North American and European Societies for Paediatric Gastroenterology, Hepatology and Nutrition.

METHODS

Paediatricians members of the Lebanese Order of Physicians with updated email addresses were invited to complete a web-based survey between September and November 2015, to assess their knowledge and management of GERD.

RESULTS

Responses were received from 114 of the 543 paediatricians, and 96 were analysed. Only two respondents complied fully with the international guidelines. The majority diagnosed GERD in infants based solely on their medical history and examination. Moreover, nearly two-thirds of the respondents would start an empiric trial with acid suppression. Around half of the respondents considered proton pump inhibitors to be the mainstay of GERD treatment.

CONCLUSION

This was the first Lebanese study that surveyed the management of paediatric GERD. Only 2.1% of the paediatricians followed the guidelines on the evidence-based management of GERD. This highlights the need for studies to assess barriers to guideline implementation and the development of new guidelines accounting for regional factors, mainly the cost of investigations and prevalence of medical insurance.

Infant gastro-oesophageal reflux disease (GORD): Australian GP attitudes and practices

AIM

The aim of this study was to evaluate the attitudes and practices of Australian general practitioners (GPs) regarding infant gastro-oesophageal reflux disease (GORD) diagnosis and management.

METHODS

A national cross-sectional survey, involving a random sample of currently practising Australian GPs (n = 2319) was undertaken between July and September 2011. GPs attitudes and management of infant GORD were surveyed via an online and paper-based 41-item questionnaire.

RESULTS

In total, 400 responses were analysed (17.24% response rate). The majority of GPs employed empirical trials of acid-suppression medication and/or lifestyle modifications to diagnose infant GORD. GPs frequently recommended dietary modification despite the belief that they were only moderately effective at best. In addition, GPs frequently prescribed acid-suppression medication, despite concerns regarding their safety in the infant population. Other GP concerns included the lack of clinical guidelines and education for GPs about infant GORD, as well as the level of evidence available for the safety and efficacy of diagnostic tests and treatments.

CONCLUSION

Despite the important role Australian GPs play in the diagnosis and management of infant GORD, high-level evidence-based guidelines for GPs are lacking. Consequently, GPs engage in diagnostic and management practices despite their concerns regarding the safety and effectiveness.

Gastro-oesophageal reflux in young babies: who should be treated?

Recent guidelines focus on a non-interventionist approach to management of gastro-oesophageal reflux in infancy and emphasise the importance of explanation, reassurance and simple measures such as attention to feeding. Relying on clinical history alone leads to over diagnosis of disease, and widely used medications are often ineffective for symptom relief and carry significant risk of harm. The association between vomiting in infancy and other problems such as crying and poor feeding should not be interpreted as implying causality. When there are strong pointers to underlying gastro-oesophageal reflux disease, invasive investigations are required in order to formulate appropriate intervention.

Italian survey on general pediatricians' approach to children with gastroesophageal reflux symptoms

The aim of the present study was to investigate the current approach of Italian general pediatricians to children with gastroesophageal reflux (GER) symptoms, evaluating the implementation of the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines. One hundred randomly identified Italian general pediatricians were asked to complete a case report-structured questionnaire investigating their approach to infants, children, and adolescents with symptoms suggestive of GER. Only 2 % of them showed complete adherence to the guidelines. Thirty-nine percent of them diagnosed GER disease based on clinical symptoms, irrespective of the age of the child; 56 % prescribed proton pump inhibitors (PPIs) in infants with unexplained crying and/or distressed behavior and 38 % in infants with uncomplicated recurrent regurgitation and vomiting; 57 % prescribed PPIs in children younger than 8-12 years of age with vomiting and heartburn, without specific testing; and 54 % discontinued PPI therapy abruptly. The overall rate of pediatricians over-prescribing PPIs was 79 %.

CONCLUSION

According to our findings, most Italian general pediatricians do not seem to follow the recommendations of the 2009 NASPGHAN-ESPGHAN reflux guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. We are well aware that the guidelines address the average situation and that the evaluation of individual patients may frequently reveal reasons for opening criteria for exceptions. Nevertheless, the over-diagnosis of gastroesophageal reflux disease (GERD) places undue burden on both families and national health system which has not been impacted by the publication of international guidelines.

[Knowledge and practice of Brazilian pediatricians concerning gastroesophageal reflux disease in infants]

OBJECTIVE

To assess the knowledge and practice of pediatricians about infants with physiological reflux and gastroesophageal reflux disease.

METHODS

140 pediatricians were interviewed during two scientific events in 2009 and 2010. The questions referred to two clinical cases of infants. One with symptoms of infant regurgitation (physiological reflux) and another with gastroesophageal reflux disease.

RESULTS

Among 140 pediatricians, 11.4% (n=16) and 62.1% (n=87) would require investigation tests, respectively for infant regurgitation (physiological reflux) and gastroesophageal reflux disease. A series of upper gastrointestinal exams would be the first requested with a higher frequency. Medication would be prescribed by 18.6% (n=26) in the case of physiological reflux and 87.1% (n=122) in the case of gastroesophageal reflux disease. Prokinetic drugs would be prescribed more frequently than gastric acid secretion inhibitors. Sleeping position would be recommended by 94.2% (n=132) and 92.9% (n=130) of the respondents, respectively for the case of physiological reflux and gastroesophageal reflux disease; however, about half of the respondents would recommend the prone position. Only 10 (7.1%) of the pediatricians would exclude the cow's milk protein from the infants' diet.

CONCLUSIONS

Approaches different from the international guidelines are often considered appropriate, especially when recommending a different position other than the supine and prescription of medication. In turn, the interviews enable us to infer the right capacity of the pediatricians to distinguish physiologic reflux and gastroesophageal reflux disease correctly.

Do pediatricians apply the 2009 NASPGHAN-ESPGHAN guidelines for the diagnosis and management of gastroesophageal reflux after being trained?

BACKGROUND

According to a recent survey, the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines are poorly adhered to by European primary care pediatricians. The main issue raised from the survey was the prescription of unnecessary acid suppressive medications, especially in infants. No inquiry into the reasons was made. The primary objective of the present study was to assess the applicability of the guidelines in European primary care pediatricians undergoing specific trainings.

METHODS

One hundred pediatricians involved in the previous survey agreed to participate and were randomly divided into 2 groups: one group was trained in the guidelines through an online podcast and the other group was trained through a synopsis. During the following 3 months, each involved pediatrician was asked to enroll every consecutive infant, child, or adolescent with suggestive reflux symptoms. For every enrolled patient, pediatricians filled in a report concerning their diagnostic and therapeutic choices.

RESULTS

A total of 382 patients (boys/girls 186/196, infants/children/adolescents 194/123/65) were enrolled by pediatricians. Infants with unexplained crying and/or distressed behavior who were prescribed proton-pump inhibitors were 3.7% compared with 45.2% of the survey data obtained before the training (P < 0.05). Infants with uncomplicated recurrent regurgitation and vomiting who were prescribed proton-pump inhibitors were 4.5% against 37.1% of the baseline survey data (P < 0.05). The overall rate of children managed in full compliance with the guidelines was 46.1% after the training compared with 1.8% before the training (P < 0.05). No significant differences were seen between pediatricians from podcast and synopsis group.

CONCLUSIONS

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines have good applicability, despite that they are presently poorly adhered to by European primary care pediatricians. Simple, inexpensive trainings were proven to be effective in increasing adherence by pediatricians. The increase in compliance clearly favors the role of continuous medical education through simple educational tools and subsequent assessment of practice.

European pediatricians' approach to children with GER symptoms: survey of the implementation of 2009 NASPGHAN-ESPGHAN guidelines

OBJECTIVE

The aim of this study was to evaluate the current implementation of the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines, and to assess proton pump inhibitors' (PPIs) prescribing patterns among pediatricians from different European countries.

METHODS

A randomly identified sample of general pediatricians distributed across 11 European countries. They were asked to complete a case report-structured questionnaire investigating their approaches to infants, children, and adolescents with symptoms suggestive of gastroesophageal reflux.

RESULTS

A total of 567 European general pediatricians completed the study questionnaire. Only 1.8% of them showed complete adherence to the guidelines. Forty-six percent of them reported that they diagnose gastroesophageal reflux disease based on clinical symptoms irrespective of the age of the child; 39% prescribe PPIs in infants with unexplained crying and/or distressed behavior and 36% prescribe PPIs in infants with uncomplicated recurrent regurgitation and vomiting; 48% prescribed PPIs in children younger than 8 to 12 years with vomiting and heartburn, without specific testing; 45% discontinue PPI therapy abruptly rather than tapering the dose. The overall rate of pediatricians overprescribing PPIs was 82%.

CONCLUSIONS

The overall results of our survey show that the majority of pediatricians are unaware of 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition reflux guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. The overdiagnosis of gastroesophageal reflux disease places undue burden on both families and national health systems, which has not been affected by the publication of international guidelines.

Gastroesophageal reflux disease: exaggerations, evidence and clinical practice

OBJECTIVE

there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children.

DATA SOURCE

a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013.

DATA SYNTHESIS

abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects.

CONCLUSIONS

there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected.

Benefits of massage therapy for infants with symptoms of gastroesophageal reflux disease

OBJECTIVES

This randomized controlled pilot trial was conducted to evaluate the clinical efficacy of massage therapy (MT) for relief of symptoms of gastroesophageal reflux disease (GERD). The hypothesis was that, when compared to infants who received nonmassage therapy, infants who received MT would display fewer GERD symptoms, greater weight gain, greater amount of sleep, lower cortisol levels before and after treatment, and lower daily (area under the curve [AUC]) cortisol secretion.

METHODS

Participants were 36 infants born at term, 4-10 weeks of age at enrollment, healthy except for a diagnosis of GERD by their pediatrician, and with a score of at least 16 on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R). Infants were randomized to receive either MT or a nonmassage sham treatment in their homes for 30 min twice a week for 6 weeks. Data collectors and parents were blind to study condition.

RESULTS

GERD symptoms decreased in both groups and weight increased. Pretreatment salivary cortisol levels decreased significantly over time in the massage group while increasing in the nonmassage group. Daily cortisol level also decreased in the massage group and increased in the nonmassage group, but the difference was not significant.

CONCLUSIONS

MT administered by a professional therapist did not affect symptoms of GERD differently than a sham treatment but did decrease infant stress as measured by cortisol. Research focusing on stress reduction in infants with GERD and multimodal treatments addressing GERD symptoms may yield the most effective treatment.

Neonatal apnea and gastroesophageal reflux (GER): is there a problem?

Apnea of prematurity and gastroesophageal reflux (GER) are both common occurrences in preterm infants and widely perceived to be causally related. We seek in this review to provide a potential guideline for neonatal GER non-pharmacologic and pharmacologic therapy. Available physiologic data suggest that when there is a temporal relationship apnea may be more likely to predispose to GER via esophageal sphincter relaxation than vice versa. Measurement of multiple intraluminal impedance via esophageal catheter in addition to esophageal pH has enhanced our understanding of GER, although it also did not demonstrate a causal relationship between apnea and GER. The incidence of GER may be modified by thickening feeds and position change without adverse effects. In contrast, pharmacotherapy including acid suppression therapy may have adverse effects and should only be used in infants with clear evidence of clinical benefit.

Knowledge and practice of physicians and nutritionists regarding the prevention of food allergy

BACKGROUND & AIMS

To evaluate the knowledge and practice of pediatricians, pediatric gastroenterologists, allergists and nutritionists regarding the primary prevention of food allergy.

METHODS

A descriptive, cross-sectional study that enrolled pediatricians (n = 80), pediatric gastroenterologists (n = 120), allergists (n = 100) and nutritionists (n = 220). A self-administered questionnaire concerning the current recommendations was used.

RESULTS

Despite the lack of current recommendations, 17.1% (n = 89) of all professionals, mainly nutritionists, recommended a maternal exclusion diet during pregnancy. More professionals in the sample group, 40.8% (n = 212), recommended a maternal exclusion diet during breastfeeding, and the rates of recommendation were higher in nutritionists and pediatricians compared to allergists and pediatric gastroenterologists (p < 0.001). Regarding the recommended timing of the introduction of complementary feeding, 41.9% (n = 218) of the professionals recommended modifying the age of introduction to prevent the development of food allergy. The majority of the professionals believed that prebiotics (61.2%; n = 318) and probiotics (44.4%; 231) prevent the development of food allergy. The recommended age of introduction for the main allergenic foods was 12 months.

CONCLUSIONS

This study revealed that there are gaps in the knowledge of professionals about the primary prevention of food allergy.

A review of nonsurgical treatment for the symptom of irritability in infants with GERD

PURPOSE

The purpose of this review was to assess effectiveness of nonsurgical treatment on irritable behavior of infants with gastroesophageal reflux disease.

DESIGN AND METHODS

A systematic literature review was conducted.

RESULTS

Research targeted treatment for irritability in infants with gastroesophageal reflux disease. All interventions including placebo were similar in reducing irritability. Which specific intervention is best for which infant is not yet known. Minor adverse effects that could increase discomfort in infants were found with pharmacologic treatments.

PRACTICE IMPLICATIONS

Knowledge of the effects of treatment on irritability and regurgitation can assist the nurse to work with other care providers in deciding how best to treat an individual infant.

Guidelines for surveys of the American Pediatric Surgical Association

Pediatric surgery is defined by the rare performance of complex operations in children. As a consequence, pediatric surgeons have difficulty identifying high-level evidence to help guide management decisions. The American Pediatric Surgical Association (APSA) Outcomes and Clinical Trials Committee is dedicated to helping our membership identify best practices and appropriate standards for clinical management of pediatric surgical diseases. Often, the best available evidence will be the opinions and experience of our membership, and therefore, quantifying this experience and opinion correctly is of critical importance. The APSA Outcomes and Clinical Trials Committee has therefore developed guidelines for survey development and administration for use by the APSA membership.

Gastroesophageal reflux scintigraphy: interpretation methods and inter-reader agreement

BACKGROUND

Scintigraphic imaging is a useful screening tool for patients with suspected gastroesophageal reflux. New scintigraphic interpretation methods have recently been introduced. This study was undertaken to evaluate the efficiency of various scintigraphic interpretation methods in the detection of gastroesophageal reflux and to measure their influence on inter-reader agreement.

METHODS

Scintigraphic images of 49 children with suspected gastroesophageal reflux were interpreted by three different methods: visual interpretation, time activity curves, and condensed images. The readings were performed by three specialists and a resident. The discordant results were resolved by a consensus reading done together by all interpreters based on the three different methods. The gastroesophageal refluxes were grouped according to their number, location and intensity.

RESULTS

Gastroesophageal reflux scintigraphy revealed 22 patients with negative results and 27 with positive results. The sensitivity, positive predictive value and specificity for each of the three specialists vs. the resident were 96%, 96% and 81% vs. 96%; 93%, 90% and 96% vs. 81%; and 90%, 86%, and 95% vs. 73%, respectively. The mean inter-observer reproducibility (κ value) was 0.910 for visual interpretation, 0.652 for time activity curves and 0.789 for condensed images. Twenty-seven percent of the results were discordant and most of these refluxes were of low grade (92%), low intensity (77%) and localization in the distal esophagus (54%).

CONCLUSION

Gastroesophageal scintigraphy is a useful tool for detecting patients with suspected reflux, and visual interpretation is better than the other two methods in terms of accuracy and inter-observer reproducibility.

Short- and long-term antireflux and asthma medication use in children after nissen fundoplication

PURPOSE

We sought to determine antireflux and asthma medication use after Nissen fundoplication (NF).

METHODS

We performed a retrospective study using hospital discharge and pharmacy data from 1996 through 2005. A total of 342 pediatric patients had ≥1 NF; 336 of those had complete medication data. Use of antireflux medications and asthma medications were reviewed before and after NF.

RESULTS

Short-term (one year after NF) use of antireflux medications decreased (odds ratio [OR] = 0.35; 95% confidence interval [CI], 0.26-0.45). During the entire study period, the decrease in antireflux medication use after NF remained in place (233 to 197 patients; OR = 0.63; 95% CI, 0.47-0.84). Use of antireflux medications decreased in neurologically healthy patients (n = 186) after NF but remained the same in neurologically impaired patients. Short-term use of inhaled and systemic asthma medications did not change (OR = 1.16 [95% CI, 0.89-1.51] and 0.90 [95% CI, 0.69-1.18]), respectively. During the entire study period, inhaled and systemic asthma medication use increased after NF (OR = 2.11 [95% CI, 1.63-2.74] and 1.85 [95% CI, 1.43-2.41]), respectively. Inhaled and systemic asthma medication use increased in both neurologically healthy and impaired children. In older children (age >5 years), short-term use of inhaled and systemic asthma medications decreased after NF (OR = 0.39 [95% CI, 0.25-0.60] and 0.31 [95% CI, 0.19-0.53]), respectively. However, during the entire study period, inhaled and systemic asthma medication use in older children remained the same.

CONCLUSION

NF decreased antireflux medication use in the short and long term, particularly in neurologically healthy children. Inhaled and systemic asthma medication use increased after NF in neurologically healthy and impaired children. NF provided a short-term decrease in inhaled and systemic asthma medication use in older children but showed no change in the long term.

Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons

BACKGROUND/PURPOSE

The purpose of the study was to identify influential factors contributing to the variation with which antireflux procedures (ARPs) are performed at freestanding children's hospitals in the United States.

METHODS

We conducted an online survey of pediatric surgeons working in Child Health Corporation of America (CHCA) member hospitals in which we examined decision making for ARPs.

RESULTS

Thirty-six percent (n = 121) of contacted surgeons responded. Eighty percent reported requiring preoperative upper gastrointestinal series before ARPs, and 13% require a pH probe study. Although surgeons ranked their own opinion as the most important in preoperative decision making, parents and referring physicians played significant roles in hypothetical scenarios. In children with negative/equivocal objective studies, more than half of surgeons reported offering ARP when the referring specialist felt that ARP was indicated. Despite equivocal studies, 20% of the surgeons reported offering ARP when the parents were convinced that ARP would help. In a patient with both a positive pH probe and upper gastrointestinal series, 46% of surgeons reported declining ARP if parents were hesitant.

CONCLUSIONS

These data suggest that a surgeon's final decision to perform ARP may be just as influenced by nonobjective factors, such as referring physician and parental opinions, as it is by objective studies. Our survey reinforces the need for further examination of specific factors in preoperative decision making for ARPs in the pediatric population.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pharmacodynamics and safety of pantoprazole in neonates, preterm infants, and infants aged 1 through 11 months with a clinical diagnosis of gastroesophageal reflux disease

BACKGROUND

Limited data on proton pump inhibitors in infants led regulatory agencies to request sponsors to conduct pediatric studies.

AIM

To determine the pharmacodynamic response to pantoprazole in infants with GERD to aid the dose selection for an efficacy study.

METHODS

In two open-label studies, neonates and preterm infants (study 1, ~1.2 mg/kg [high dose]) and infants 1 through 11 months (study 2, ~0.6 [low dose] or ~1.2 mg/kg [high dose]) received once-daily pantoprazole. Twenty-four-hour dual-electrode pH-metry parameters were compared between predose and steady state (≥5 days) (two-sided paired t test). Treatment was administered for ≤6 weeks.

RESULTS

In studies 1 and 2, 21 and 24 patients, respectively, were enrolled for pharmacodynamic evaluation. The high dose provided similar responses in the two studies and improved these parameters significantly: mean gastric pH and percent time gastric pH > 4 increased (p < 0.05 both studies), normalized area under the curve (AUC) of gastric H(+) activity decreased (p < 0.05 study 2), and normalized AUC of esophageal H(+) activity decreased (p < 0.05 both studies). The AUC of esophageal pH < 4 decreased. Normalized AUC of esophageal H(+) activity decreased (p < 0.05 both studies), indicating refluxate pH increased, although this was not reflected in any change in mean esophageal pH or reflux index. The normalized AUC of esophageal H(+) activity was a more sensitive measure of changes in esophageal pH.

CONCLUSIONS

In neonates, preterm infants, and infants aged 1 through 11 months, pantoprazole (high dose) improved pH-metry parameters after ≥5 consecutive daily doses, and was generally well tolerated for ≤6 weeks.

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

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

Efficacy and safety of pantoprazole delayed-release granules for oral suspension in a placebo-controlled treatment-withdrawal study in infants 1-11 months old with symptomatic GERD

OBJECTIVE

The objective of this study was to assess the efficacy of pantoprazole in infants with gastroesophageal reflux disease (GERD).

MATERIALS AND METHODS

Infants ages 1 through 11 months with GERD symptoms after 2 weeks of conservative treatment received open-label (OL) pantoprazole 1.2 mg x kg(-1) x day(-1) for 4 weeks followed by a 4-week randomized, double-blind (DB), placebo-controlled, withdrawal phase. The primary endpoint was withdrawal due to lack of efficacy in the DB phase. Mean weekly GERD symptom scores (WGSSs) were calculated from daily assessments of 5 GERD symptoms. Safety was assessed.

RESULTS

One hundred twenty-eight patients entered OL treatment, and 106 made up the DB modified intent-to-treat population. Mean age was 5.1 months (82% full-term, 64% male). One third of patients had a GERD diagnostic test before OL study entry. WGSSs at week 4 were similar between groups. WGSSs decreased significantly from baseline during OL therapy (P < 0.001), when all patients received pantoprazole. The decrease in WGSSs was maintained during the DB phase in both treatment groups. There was no difference in withdrawal rates due to lack of efficacy (pantoprazole 6/52; placebo 6/54) or time to withdrawal during the DB phase. The greatest between-group difference in WGSS was slightly worse with placebo at week 5 (P = 0.09), mainly due to episodes of arching back (P = 0.028). No between-group differences in adverse event frequency were noted. Serious adverse events in 8 patients were considered unrelated to treatment.

CONCLUSIONS

Pantoprazole significantly improved GERD symptom scores and was well tolerated. However, during the DB treatment phase, there were no significant differences noted between pantoprazole and placebo in withdrawal rates due to lack of efficacy.

Pediatric specialists' beliefs about gastroesophageal reflux disease in premature infants

BACKGROUND

Wide variation exists in the treatment of suspected gastroesophageal reflux disease (GERD) in premature infants; it is unknown to what degree diagnosis and treatment are affected by the treating physician's medical specialty or interpretation of the medical literature.

METHODS

This study involved an online survey of board-certified neonatologists, pediatric pulmonologists, and pediatric gastroenterologists about their beliefs regarding the symptoms, diagnosis, and treatment of GERD in premature infants in the NICU on the basis of both clinical impression and interpretation of the literature.

RESULTS

A total of 1021 neonatologists, 232 pediatric pulmonologists, and 222 pediatric gastroenterologists participated in the study (47.5% response rate). There was disagreement among specialists in nearly all aspects of the survey. Pulmonologists were most likely to report that respiratory symptoms are caused by GERD (P < .001). Neonatologists were least likely to report that a therapeutic trial of pharmacologic agents would be useful for diagnosing GERD (P < .001) or that lansoprazole, ranitidine, or cimetidine are safe or effective (P < .001). No pharmacologic therapy had >50% of respondents supporting its effectiveness. There was moderate correlation between physician belief based on the medical literature and belief based on clinical impression (Spearman rank correlation: 0.47-0.75). For therapies supported by multiple meta-analyses in infants versus therapies with few infant trials, physicians rated the evidence for effectiveness similarly.

CONCLUSIONS

There is wide variation among pediatric specialists regarding beliefs about GERD in premature infants, as well as about the weight of evidence in the medical literature for this patient population. Physician beliefs do not seem to be driven by the degree of evidence in the neonatal literature. With no agreed-on standard of care in the setting of widespread use of antireflux medications, greater understanding is needed about the ways physicians form clinical impressions, access and process medical evidence, and apply it to patient care.

Tolerability and clinical utility of the Bravo pH capsule in children

GOALS

To prospectively evaluate the tolerability and clinical utility of the Bravo pH capsule in children.

BACKGROUND

Acid reflux is common in children, and pH testing can be used to correlate acid exposure with symptom expression. The tolerability and clinical utility of the Bravo capsule in children has not been prospectively evaluated.

METHODS

This was a prospective, open-label trial conducted at an academic medical center. Patient demographics, symptoms, and medication use were recorded in an outpatient setting. After Bravo capsule placement, patients were followed to determine whether the results of the Bravo capsule study changed clinical management.

RESULTS

Fifty children (mean+/-SD=13+/-3 y; 52% female) were studied; no complications occurred. Reflux symptoms (40%), abdominal pain (18%), and nausea/vomiting (14%) were the 3 most common symptoms leading to Bravo capsule placement. Nearly all studies (96%) were performed off acid-suppressing medications. Results of the Bravo pH study changed clinical care in 88% of children; management changed more frequently in children with an abnormal study (94%) versus those with a normal study (78%; P<0.0001).

CONCLUSIONS

The Bravo pH capsule is a safe, well-tolerated test to evaluate acid reflux symptoms in children, and the data obtained frequently changes patient management.

Prescribing proton-pump inhibitors to irritable infants: where is the evidence?

Infants with gastroesophageal reflux present with multiple symptoms, including irritability. When a physician is evaluating such an irritable infant, she/he would often prescribe a histamine 2 receptor antagonist blocker. When this fails, proton-pump inhibitors (PPIs) are often prescribed. Evidence demonstrates that there has been a fourfold increase in the use of PPIs, which may be prescribed in children as young as 2 weeks of age. This article addresses multiple issues: variable pharmacokinetics, risk of infection, absence of an adequate oral preparation, and lack of clear evidence to support the efficacy of PPIs in irritable infants. Extreme caution should be used in prescribing PPIs to this vulnerable age group, particularly those less than 6 months of age. Until more data are available, we suggest that PPIs should be used only in infants with well-documented gastroesophageal reflux disease or as part of a clinical trial.

A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population

OBJECTIVES

To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.

METHODS

Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.

RESULTS

There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.

CONCLUSIONS

The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.