Diagnosis and Management of Gastroesophageal Reflux Disease in Infants and Children: from Guidelines to Clinical Practice

The consensus of the Asociación Mexicana de Gastroenterología on the diagnosis and treatment of gastroesophageal reflux and gastroesophageal reflux disease in infants

Gastroesophageal reflux (GER) is a frequent normal phenomenon in children of any age. It is more common in infants, in whom the majority of episodes are short-lived and cause no other symptoms or complications, differentiating it from gastroesophageal reflux disease (GERD). The diagnosis and management of GER and GERD continue to be a challenge for the physician. Therefore, the aim of the Asociación Mexicana de Gastroenterología was to adapt international documents to facilitate their adoption by primary care physicians, with the goal of standardizing quality of care and reducing the number of diagnostic tests performed and inappropriate medication use. The ADAPTE methodology was followed, and the recommendations were approved utilizing the Delphi strategy. The executive committee carried out the review of the guidelines, position papers, and international reviews that met the a priori quality criteria and possible applicability in a local context. The recommendations were taken from those sources and adapted, after which they were approved by the working group. The consensus consists of 25 statements and their supporting information on the diagnosis and treatment of GER and GERD in infants. The adapted document is the first systematic effort to provide an adequate consensus for use in Mexico, proposing a practical approach to and management of GER and GERD for healthcare providers.

Infant gastroesophageal reflux disease management consensus

AIM

Infant gastroesophageal reflux is mostly benign; however, when associated with complications like failure to thrive, it may be indicative of gastroesophageal reflux disease. There are currently several unmet needs pertaining to the management of infant gastroesophageal reflux (disease). Reflux in infants is mostly composed of breast milk or formula, so this population is significantly different to older children and adults. The objective of this Delphi consensus was to establish recommendations based on published literature and the experience of clinical experts in paediatric gastroenterology in the context of infant gastroesophageal reflux (disease).

METHODS

The Delphi methodology was used to obtain a consensus on 18 statements relating to clinical aspects of infant gastroesophageal reflux (disease).

RESULTS

The expert panel comprising paediatric gastroenterology clinical specialists reached a consensus for all statements by means of an online, anonymised voting system.

CONCLUSION

It was highlighted that there is generally low awareness of or adherence to guidelines in clinical practice and that acid suppression therapy should not be indicated for non-acid reflux, which constitutes a significant proportion of total gastroesophageal reflux episodes among infants. Furthermore, it was emphasised that there is an unmet medical need for therapy for some symptomatic infants with non-acid reflux disease.

A Review of Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Therapy for Gastroesophageal Reflux Disease in Neonates and Infants

Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are commonly used medications in neonates and infants for the treatment of gastroesophageal reflux disease (GERD), especially in neonatal intensive care units (NICUs). A literature review was conducted to evaluate the efficacy and safety of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) in preterm neonates, term neonates, and infants. A total of 27 studies were included in this review. Antacid medications in studies have consistently shown positive pharmacodynamic effects, including increasing gastric pH, reducing the reflux index, and reducing the number of acidic reflux events. The benefit found in placebo-controlled trials are limited exclusively to these surrogate outcomes. The actual clinically salient outcomes which H2RAs and PPIs are used for, such as reduction in GERD symptoms, especially irritability and improved feed tolerance and weight gain, have consistently shown no clinical benefit. H2RAs and PPIs appear to be extremely well tolerated by the neonatal and infant populations, which would mimic our experience with these medications in our unit. The available data from large, retrospective cohort and case-control studies paint a much more concerning picture regarding the potential for an increased risk in the development of allergies, anaphylactic reactions, necrotizing enterocolitis (NEC), other nosocomial infections, and lower respiratory tract infections. Given the risks associated with and lack of clinical effectiveness of both H2RAs and PPIs, use of these medications should be limited to specific clinical situations. Further studies are required to determine whether antacid pharmacologic therapy might benefit certain neonates and infants, such as those with complex medical issues.

Prediction of gastroesophageal reflux episodes by smooth muscle electromyography: A translational study in rats and adolescents

Aims

Our aim was to measure the myoelectric modifications during gastric acid secretion along with the gastric pH in a rat model and to detect the gastrointestinal (GI) myoelectric changes in adolescents suffering from gastroesophageal reflux disease (GERD) along with the esophageal pH measurement.

Main methods

In anesthetized rats, gastric acid secretion was initiated with intragastric histamine (50 mg/kg), and gastric pH, GI myoelectric activity and mechanical GI contractions were measured with intragastric pH electrode, subcutaneously implanted smooth muscle electromyography (SMEMG) electrodes and organ implanted strain gauges, respectively. In the clinical study, esophageal pH and GI myoelectric activity were measured in adolescents suffering from GERD with intraesophageal pH electrode and SMEMG electrodes placed on the abdominal surface, respectively. The SMEMG records were analyzed by fast Fourier transformation (FFT) and power spectrum density maximum (PsDmax) values were calculated for the GI segments.

Key findings

In rats, histamine initiated an immediate increase in gastric PsDmax, which preceded the significant reduction in gastric pH by 75 min. The myoelectric change was independent of mechanical GI contractions. In adolescents, the GERD episodes were preceded by a significant increase in gastric PsDmax 45 min earlier. These changes were independent of motion or meals.

Significance

Increased gastric myoelectric activity during histamine stimulation or GERD might be linked to the enhanced activity of the gastric proton pump, indicating a link between gastric acid secretion and GERD episodes. It is supposed that SMEMG might be a tool for predicting forthcoming reflux episodes in GERD.

A Multidisciplinary Approach to Infants With GERD-Like Symptoms: A New Paradigm

OBJECTIVES

Infants with gastroesophageal reflux disease (GERD)-like symptoms have been classically defined as having a wide array of symptoms. In these instances, anti-reflux medications are ineffective and overprescribed. Rather these symptoms are more attributable to dysphagia and unsettledness/colic. To address these conditions at our center, both speech language pathologist (SLP) and/or occupational therapist (OT) have contributed to evaluation. We hypothesized that dysphagia and unsettledness/colic are highly prevalent, yet under recognized in this population.

METHODS

Full-term infants with typical development and under 6 months of age (N = 174) were included. Infants with suspected dysphagia and/or evident colic/unsettledness were evaluated by SLP and OT, respectively.

RESULTS

GERD-like symptoms were present in 109 infants with attributes of dysphagia in n = 46, unsettledness/colic in n = 37, and combined in n = 26.

CONCLUSION

A multidisciplinary approach, including SLP and OT, is recommended for the evaluation of infants with GERD-like symptoms.

Paediatric gastroesophageal reflux disease and parental mental health: Prevalence and predictors

OBJECTIVE

The current study aimed to estimate the prevalence of common mental health difficulties in parents who have an infant with Gastroesophageal Reflux Disease (GORD), and to identify psychological predictors of parental anxiety, depression, and well-being, as a platform for subsequent intervention development.

METHODS

Parents of infants with GORD (N = 309) completed online psychometric measures of potential predictors (self-compassion, illness appraisals, and illness uncertainty), potential confounders (sleep quality, relationship satisfaction, social support, and infant feeding satisfaction), and mental health outcomes (anxiety, depression, and wellbeing). The outcome measures were repeated eight-weeks later (N = 103).

RESULTS

At the first time-point, 66% of participants exceed the clinical cut off for generalised anxiety disorder and 63% exceeded that for a depressive disorder. Both had significantly reduced eights-weeks later. Greater self-compassion predicted lower anxiety and depression, and better well-being, in both cross-sectional and longitudinal data, including when all confounders were controlled for. Illness uncertainty and illness appraisals were less consistent predictors. No robust differences were found between parents of infants with silent GORD and those with GORD with visible regurgitation.

CONCLUSIONS

Parents of infants with GORD showed high rates of anxiety and depression, which were elevated compared to those that have been found in perinatal and general population samples. Self-compassion was a consistent predictor of better mental health and has promise as a proximal intervention target. Future research could benefit from examining the efficacy of a compassion-focussed intervention in this population.

Prediction of refractory gastroesophageal reflux disease in young children

BACKGROUND

Many children respond to medical treatment for gastroesophageal reflux disease (GERD). However, some may require invasive intervention for refractory disease. Due to the lack of prognostic tools in children, this study aimed to develop a predictive model for refractory GERD.

METHODS

A retrospective review was performed in children with symptoms of GERD at a university hospital. Refractory GERD was defined as an unresponsive disease after optimal treatment with medication for >8 weeks. The predictive model was constructed based on clinical features and 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring results.

RESULTS

A total of 205 children were included with a median (IQR) age of 0.6 (0.3, 2.0) years. Over half of the patients (59.5%) had motor disabilities. Forty-four children (21.5%) were diagnosed with refractory GERD and subsequently underwent fundoplication. Multivariable analysis suggested that the refractory disease was associated with motor disabilities (OR: 5.35; 95% CI: 2.06-13.91), recurrent aspiration pneumonia (OR: 2.78; 95% CI: 1.24-6.26), prematurity with an onset of GERD at a post-conceptual age <40 weeks (OR: 6.76; 95% CI: 1.96-23.33), and abnormal total reflux episodes according to age (OR: 2.78; 95% CI: 1.24-6.19), but not the acid exposure time or symptom association analysis. The predictive model for refractory GERD based on associated factors revealed an area under the ROC curve of 76.8% (95% CI: 69.2%-84.3%) with a sensitivity of 77.3% and a specificity of 64% when applying a cutoff score of ≥2.5.

CONCLUSIONS

The predictive model, using clinical features and MII-pH, may be an additional tool to predict refractory GERD in young children.

Iron Deficiency Anemia in Pediatric Gastroesophageal Reflux Disease

(1) Background: Gastroesophageal reflux disease (GERD) can cause several complications as a result of the acidic pH over various cellular structures, which have been demonstrated and evaluated over time. Anemia can occur due to iron loss from erosions caused by acidic gastric content. In children, anemia has consequences that, in time, can affect their normal development. This study evaluates the presence of anemia as a result of pediatric gastroesophageal reflux disease. (2) Methods: 172 children were diagnosed with gastroesophageal reflux in the gastroenterology department of a regional children's hospital in northeast Romania by esophageal pH-metry and they were evaluated for presence of anemia. (3) Results: 23 patients with GERD from the studied group also had anemia, showing a moderate correlation (r = -0.35, p = 0.025, 95% confidence interval) and lower levels of serum iron were found in cases with GERD, with statistical significance (F = 8.46, p = 0.012, 95% confidence interval). (4) Conclusions: The results of our study suggest that there is a relationship between anemia or iron deficiency and gastroesophageal reflux due to reflux esophagitis in children, which needs to be further studied in larger groups to assess the repercussions on children's development.

Efficacy and safety of medical and nutritional management of gastroesophageal reflux in formula-fed infants: a narrative review

PURPOSE OF REVIEW

The prescription of proton pump inhibitors has an increasing trend, despite that guidelines recommend nutritional management as first-line management. A thickened antiregurgitation formula is recommended in formula-fed infants. In this review we focus on the novel insights in management of formula-fed infants with gastroesophageal reflux disease (GERD).

RECENT FINDINGS

New data are limited. Concerning thickened antiregurgitation formula, locust bean gum has been the most studied and has limited adverse effects. However, positive results were also obtained with pectin. The effect of pro- and prebiotics on regurgitation is unclear. The overlap between cow's milk allergy and gastroesophageal reflux remains a challenge.

SUMMARY

Very limited new data were published during the last 18 months. Thickened antiregurgitation formula is the first-line approach in formula-fed infants with GERD. No specific thickening agent can be recommended because of lack of comparative trials. Proton pump inhibitors are over prescribed in infants.

Pharmacologic treatment of GERD in adolescents: Is esophageal mucosal protection an option?

BACKGROUND

Gastroesophageal reflux disease (GERD) is still a challenging and difficult to treat condition in children. Although acid suppression represents the mainstay of treatment in adolescents, it is not devoid of adverse events, especially in the long-term.

OBJECTIVES

In this investigation we explored a new therapeutic avenue in GERD, that is esophageal mucosal protection.

DESIGN

To this end, we performed an investigator-initiated, retrospective study to evaluate the efficacy and safety of a short-term treatment with Esoxx™ medical device in 25 adolescents with GERD-related symptoms. This mucoadhesive formulation contains two natural mucopolysaccharides (sodium hyaluronate and chondroitin sulphate) and adheres to the esophageal mucosa, exerting a protective effect against refluxed gastric contents and allowing mucosal healing.

METHODS

Heartburn, epigastric burning and post-prandial regurgitation were scored with a pain VAS scale and re-evaluated after 3-week treatment with Esoxx (one stick post-prandially, three times daily).

RESULTS

All patients completed the treatment without adverse effects and with good tolerability and compliance. All the three major symptoms significantly (p<0.001) improved after treatment. No patient required additional investigation (i.e. upper Gastrointestinal endoscopy) or medication (i.e. antisecretory drugs).

CONCLUSION

The results of this pilot study suggest that esophageal mucosal protection is a promising therapeutic avenue for GERD also in children. Provided, these data be confirmed by a large, randomized clinical trial, this medical device can enter our therapeutic armamentarium against this challenging disease.

Pediatric Aspects of Nutrition Interventions for Disorders of Gut-Brain Interaction

Dietary factors may play an important role in the generation of symptoms in children with disorders of gut-brain interaction (DGBIs). Although dietary modification may provide successful treatment, there is a relative paucity of controlled trials that have shown the effectiveness of dietary interventions. This study is a narrative review that explores the existing literature on food and pediatric DGBIs. The following have been shown to be beneficial: (i) in infants with colic, removing cow's milk from the infant's diet or from the maternal diet in those who are breastfed; (ii) in infants with regurgitation, adding thickeners to the formula or removing cow's milk protein from the infant's diet or the maternal diet in those who are breastfed; and (iii) in children with pain-predominant DGBIs, using soluble fiber supplementation or a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. In children with functional constipation, there is no evidence that adding fiber is beneficial. Given that most dietary interventions include restriction of different foods in children, a thoughtful approach and close follow-up are needed.

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.

Continuous versus bolus intermittent intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease is a particularly common condition among preterm and low birth weight infants. These infants are more likely to have excessive regurgitation, as they do not have a fully developed antireflux mechanism. Preterm and low birth weight infants who are unable to suck oral feeds are required to be fed via an intragastric tube for varying lengths of time. Intragastric tube feeding can be delivered by the intermittent bolus method or by the continuous feeding method. Use of continuous or intermittent bolus intragastric feeding may have a positive or negative effect on the incidence or severity of gastro-oesophageal reflux disease.

OBJECTIVES

• To determine whether continuous or intermittent bolus intragastric tube feeding reduces the number of episodes and the duration of gastro-oesophageal reflux disease (GORD) in preterm and low birth weight infants • To perform subgroup analyses for gestational age; birth weight; age in days from birth at full enteral feeding via intragastric tube (breast versus bottle); frequency of intermittent bolus feed; and type of medication for treatment of GORD (only if medication was prescribed and was given similarly to both intervention groups) SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 7), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 8 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

Published and unpublished RCTs and quasi-RCTs were eligible for inclusion in this review, as were cluster-randomised and cross-over randomised trials that compared the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality. We planned to use the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We did not identify any randomised trials that evaluated the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants. Well-designed and adequately powered trials are needed.

Twenty-Four-Hour Esophageal pH Measurement in Mechanically Ventilated Children: A Prospective Cohort Study

OBJECTIVES

To assess the prevalence of gastroesophageal reflux in mechanically ventilated children using 24-hour esophageal pH-metry and its role as a risk factor for ventilator-associated pneumonia.

DESIGN

Prospective cohort study.

SETTING

PICU of a tertiary care hospital from North India.

PATIENTS

Mechanically ventilated children 1-15 years old in PICU from July 2015 to June 2017, excluding those receiving acid suppressants, known cases of gastroesophageal reflux disease, having upper gastrointestinal bleed.

INTERVENTION

Demographic details, baseline investigations, diagnosis, treatment details, and Pediatric Risk of Mortality III score were recorded at enrollment. Gastroesophageal reflux was evaluated using 24-hour esophageal pH-metry. Children were followed up for 7 days or 48 hours after extubation for development of ventilator-associated pneumonia using Centers for Disease Control and Prevention criteria. Pathologic acidic gastroesophageal reflux was defined as fall in esophageal pH less than 4 for more than 4% of total time, whereas pathologic alkaline gastroesophageal reflux as rise in esophageal pH greater than 7 for more than 17% of total time.

MEASUREMENTS AND MAIN RESULTS

Sixty-one children (median [interquartile range], age 73 mo [30-132 mo]; 44 boys [72%]) were enrolled. Median Pediatric Risk of Mortality III score was 10.0 (3-16). Median duration of ventilation was 6 days (3-9 d). Pathologic gastroesophageal reflux (acidic or alkaline) was present in 47 children (77%). Twelve children (19.7%) met criteria for pathologic acidic gastroesophageal reflux, whereas 44 children (72.1%) had pathologic alkaline gastroesophageal reflux; nine children (14.7%) had both pathologic acidic and alkaline gastroesophageal reflux. Of the enrolled children, 17 (27.9 %) developed ventilator-associated pneumonia. No patient had both pathologic acidic gastroesophageal reflux and ventilator-associated pneumonia. Of 17 children who developed ventilator-associated pneumonia, 12 (70.5%) had pathologic alkaline gastroesophageal reflux as compared to 32 children (72.7%) among the 44 children who did not develop ventilator-associated pneumonia (p = 0.87).

CONCLUSIONS

The current study shows high incidence of gastroesophageal reflux on 24-hour esophageal pH-metry in mechanically ventilated children with medical diagnoses. The significance of this finding and its impact on ventilator-associated pneumonia and other ventilator-associated events need to be examined in larger studies.

Understanding gastroesophageal reflux disease in children

ABSTRACT

Gastroesophageal reflux disease (GERD) is a common disorder with increasing prevalence in children. The diagnosis and management of GERD remains a challenge because of its nonspecific symptomatology from infancy through adolescence. Certain presenting alarm symptoms warrant a further, more extensive workup. Treatment of pediatric GERD begins with lifestyle and nonpharmacologic management, including postural adjustments, dietary changes, and weight loss if indicated. Pharmacologic interventions can be prescribed to relieve symptoms for patients whose disease does not respond to lifestyle management. Patients with refractory symptoms can be managed with surgical intervention. Complications may arise if GERD remains untreated, ranging from worsening oral health to failure to thrive.

Cow's Milk Allergy or Gastroesophageal Reflux Disease-Can We Solve the Dilemma in Infants?

Cow's milk allergy (CMA) and gastro-esophageal reflux disease (GERD) may manifest with similar symptoms in infants making the diagnosis challenging. While immediate reaction to cow's milk protein indicate CMA, regurgitation, vomiting, crying, fussiness, poor appetite, sleep disturbances have been reported in both CMA and GERD and in other conditions such as functional gastrointestinal disorders, eosinophilic esophagitis, anatomic abnormalities, metabolic and neurological diseases. Gastrointestinal manifestations of CMA are often non-IgE mediated and clinical response to cow's milk free diet is not a proof of immune system involvement. Neither for non-IgE CMA nor for GERD there is a specific symptom or diagnostic test. Oral food challenge, esophageal pH impedance and endoscopy are recommended investigations for a correct clinical classification but they are not always feasible in all infants. As a consequence of the diagnostic difficulty, both over- and under- diagnosis of CMA or GERD may occur. Quite frequently acid inhibitors are empirically started. The aim of this review is to critically update the current knowledge of both conditions during infancy. A practical stepwise approach is proposed to help health care providers to manage infants presenting with persistent regurgitation, vomiting, crying or distress and to solve the clinical dilemma between GERD or CMA.

Role of feeding strategy bundle with acid-suppressive therapy in infants with esophageal acid reflux exposure: a randomized controlled trial

OBJECTIVE

To test the hypothesis that a feeding bundle concurrent with acid suppression is superior to acid suppression alone in improving gastroesophageal reflux disease (GERD) attributed-symptom scores and feeding outcomes in neonatal ICU infants.

METHODS

Infants (N = 76) between 34 and 60 weeks' postmenstrual age with acid reflux index > 3% were randomly allocated to study (acid-suppressive therapy + feeding bundle) or conventional (acid-suppressive therapy only) arms for 4 weeks. Feeding bundle included: total fluid volume < 140 mL/kg/day, fed over 30 min in right lateral position, and supine postprandial position. Primary outcome was independent oral feeding and/or ≥6-point decrease in symptom score (I-GERQ-R). Secondary outcomes included growth (weight, length, head circumference), length of hospital stay (LOHS, days), airway (oxygen at discharge), and developmental (Bayley scores) milestones.

RESULTS

Of 688 screened: 76 infants were randomized and used for the primary outcome as intent-to-treat, and secondary outcomes analyzed for 72 infants (N = 35 conventional, N = 37 study). For study vs. conventional groups, respectively: (a) 33% (95% CI, 19-49%) vs. 44% (95% CI, 28-62%), P = 0.28 achieved primary outcome success, and (b) secondary outcomes did not significantly differ (P > 0.05).

CONCLUSIONS

Feeding strategy modifications concurrent with acid suppression are not superior to PPI alone in improving GERD symptoms or discharge feeding, short-term and long-term outcomes.

IMPACT

Conservative feeding therapies are thought to modify GERD symptoms and its consequences. However, in this randomized controlled trial in convalescing neonatal ICU infants with GERD symptoms, when controlling for preterm or full-term birth and severity of esophageal acid reflux index, the effectiveness of acid suppression plus a feeding modification bundle (volume restriction, intra- and postprandial body positions, and prolonged feeding periods) vs. acid suppression alone, administered over a 4-week period was not superior in improving symptom scores or feeding outcomes. Restrictive feeding strategies are of no impact in modifying GERD symptoms or clinically meaningful outcomes. Further studies are needed to define true GERD and to identify effective therapies in modifying pathophysiology and outcomes. The improvement in symptoms and feeding outcomes over time irrespective of feeding modifications may suggest a maturational effect. This study justifies the use of placebo-controlled randomized clinical trial among NICU infants with objectively defined GERD.

Impact of Feeding Strategies With Acid Suppression on Esophageal Reflexes in Human Neonates With Gastroesophageal Reflux Disease: A Single-Blinded Randomized Clinical Trial

INTRODUCTION

Aims were to test hypothesis that esophageal provocation-induced reflexes are superior with acid suppression plus feeding modifications vs acid suppression alone among infants treated for gastroesophageal reflux disease (GERD).

METHODS

Infants (N = 49, 41.3 ± 2.6 of postmenstrual age) with acid reflux index >3% underwent longitudinal motility testing (weeks 0 and 5) with graded midesophageal provocation to test randomly allocated therapies (4 weeks' proton pump inhibitor [PPI] ± feeding modifications) on sensory-motor aerodigestive reflexes. Feeding modification included restricted fluid volume <140 mL/kg per day, fed over 30 minutes in right lateral position and supine postprandial position. Primary motility outcome was frequency-occurrence of peristaltic reflex. Secondary outcomes included upper esophageal sphincter contractile reflex, lower esophageal sphincter (LES) relaxation reflex, respiratory change, and symptom characteristics.

RESULTS

Treatment groups did not differ for primary outcome (odds ratio = 0.8, 95% confidence interval 0.4-1.6, P = 0.99) or secondary outcomes (all P > 0.05). For both treatment groups at follow-up, distal esophageal contraction and LES tone decreased, and LES relaxation reflex occurrence is less frequent (all P < 0.05). In a subgroup analysis, comparing infants with PPI washout (N = 40) vs with continued (N = 9) PPI therapy, no differences were noted for aerodigestive reflex response frequency-occurrence (all P > 0.05).

DISCUSSION

In infants with GERD, feeding modification with acid suppression is not superior to acid suppression alone in modifying aerodigestive reflexes (frequency, sensation, or magnitude). Contiguous areas targeted by GER, i.e., LES and distal esophageal functions, worsened at follow-up for both groups despite PPI therapy. Maturation is likely the key factor for GERD resolution in infants, justifying the use of placebo in clinical trials for objectively determined GERD.

Children With Gastroesophageal Reflux Disease Consume More Calories and Fat Compared to Controls of Same Weight and Age

OBJECTIVE

The aim of the study was to compare the rates of nutrients consumption in children and adolescents with gastroesophageal reflux disease (GERD) compared to the control group without the disease.

METHODS

Based on symptom evaluation and esophageal pH-impedance recordings patients were allocated on to GERD and control groups. All patients underwent esophagogastroscopy. Levels of nutrients consumption were assessed with the use of food frequency questionnaire in the regard to the presence of the disease, esophagitis, and z score body mass index (BMI).

RESULTS

Data of 219 children and adolescents were available for the final analysis. Risks to have GERD were higher in groups with obesity (risk ratio 1.2 [95% confidence interval 0.8-1.7]) and excessive weight (1.1 [0.9-1.4]). Energy values of the rations and amount of fat consumption were higher in the GERD group compared to the control when rations were compared according to z score BMI. In contrast to nonerosive form of GERD, patients with erosive esophagitis consumed more protein (percentage deviation from the recommended daily allowance Me [25%;75%]): 14.3 (11.07; 19.1) % versus 8.5 (6.71; 14.1) %, total fat 36.8 (12.5; 75.5) % versus 16.9 (10.1; 17.9) %, and less polyunsaturated fats -54.3 (-73.4; -47.7) % versus -45.6 (-56.2; -33.1) %, P < 0.05.

CONCLUSIONS

The rations of children with GERD are characterized by higher calorie values and larger amounts of fat intake compared to the control group in the regard to z score BMI. Low dietary fiber consumption is additional factor associated with GERD in children with excessive weight and obesity. Compared to nonerosive GERD, higher intake of energy, protein, and total fat and lower of polyunsaturated fats revealed in patients with GERD with erosive esophagitis.

Upper endoscopy for non-acute non-specific symptoms is seldom beneficial for children under the age of seven

AIM

This study estimated the diagnostic yield of oesophagogastroduodenoscopy (OGD) in young children with non-acute, non-specific gastrointestinal or respiratory symptoms who were treated by a Finnish tertiary level referral centre.

METHODS

A retrospective chart analysis was performed on 1850 Finnish children under 7 years of age who underwent their first diagnostic OGDs at Helsinki University Hospital during 2006-2016. We noted the endoscopy indications, macroscopic findings, the histology of the mucosal biopsies and the follow-up data.

RESULTS

After the exclusion criteria were applied, we enrolled 666 patients (57.7% boys) at a median age of 3.5 years. The number of children with non-specific symptoms referred for OGD increased 2.3-fold in 11 years. A routine set of biopsies was obtained in 644/666 (96.7%) of the endoscopies. The OGD was both macroscopically and histologically normal in 519/644 (80.6%) of cases. The most common indication was to rule out gastro-oesophageal reflux disease in 268/666 (40.2%) cases, and the most frequent histological diagnosis was mild to moderate oesophagitis in 57/644 (8.9%) cases. There was no erosive oesophagitis.

CONCLUSION

The diagnostic yield of macroscopic and histological OGD findings was low in our cohort. Unless there are alarming symptoms, younger children do not need OGD.

Weight Gain and Growth After Fundoplication in the Pediatric Patient: A Case Report in the Pediatric Patient With Cystic Fibrosis and Literature Review

Gastroesophageal reflux (GER) is common among infants, but when symptoms become troublesome, that is defined as gastroesophageal reflux disease (GERD). Making a diagnosis of GERD is difficult because there is no gold standard. GERD can be especially problematic for infants with cystic fibrosis (CF). There are signs and symptoms (ie, malnutrition, recurring aspiration pneumonias, refusal to eat, wheezing, coughing, and asthma) in addition to invasive and noninvasive methods used to determine a diagnosis. The treatments for GERD span from nonpharmacological to surgical, with a laparoscopic Nissen fundoplication being the gold standard of surgical intervention. Although surgical interventions have been demonstrated to reduce symptoms associated with GERD, there is little known about the weight/growth-related outcomes. This case report discusses an infant with CF and GERD requiring multiple interventions and ultimately a laparoscopic Nissen fundoplication and the weight changes from presurgery to postsurgery. The case report is expanded upon with a structured literature review of fundoplication and growth studies. There were 4 available studies that assessed changes in weight/growth before and after fundoplication among children with GERD. Because of the heterogeneity of the nutrition outcomes used, the weight/growth benefits after fundoplication are unclear at this time. Further research in needed to assess the nutrition outcomes among patients with GERD requiring fundoplication.

Is the Diagnostic Trial with Proton Pump Inhibitors Reasonable for School Age Children with Gastroesophageal Reflux Symptoms?

PURPOSE

On the basis of evidence, we aimed to reevaluate the necessity of the empirical proton pump inhibitor (PPI) trial for children with suspected gastroesophageal reflux disease (GERD).

METHODS

We analyzed the frequency of GERD in 85 school-age children with gastroesophageal reflux (GER) symptoms, who received 24-hour esophageal pH monitoring and/or upper endoscopy. According to the reflux index (RI), the children were classified into normal (RI <5%), intermediate (5%≤ RI <10%), or abnormal (RI ≥10%) groups.

RESULTS

Fifty six were female and 29 were male. Their mean age was 12.6±0.5 (±standard deviation) years (range: 6.8-18.6). The RI analysis showed that the normal group included 76 patients (89.4%), the intermediate group included 6 patients (7.1%), and the abnormal group included 3 patients (3.5%). The DeMeester score was 5.93±4.65, 14.68±7.86 and 40.37±12.96 for the normal, intermediate and abnormal group, respectively (p=0.001). The longest reflux time was 5.56±6.00 minutes, 9.53±7.84 minutes, and 19.46±8.35 minutes in the normal, intermediate, and abnormal group, respectively (p=0.031). Endoscopic findings showed reflux esophagitis in 7 patients. On the basis of the Los Angeles Classification of Esophagitis, 5 of these patients were included in group A, 1 patient, in group B and 1 patient, in group C.

CONCLUSION

The incidence of GERD was very low in school-age children with GER symptoms. Therefore, injudicious diagnostic PPI trials would be postponed until the actual prevalence of GERD is verified in future prospective studies.