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

[Esophageal pH-metry in children with recurrent respiratory events: diagnosis value of a day time esophageal pH monitoring]

Detection of a gastroesophageal reflux in the aetiology of recurrent respiratory diseases is the main indication of continuous gastroesophageal pH-metry in children. The aim of the study was to measure the diagnostic value of a daytime esophageal pH monitoring in children with recurrent respiratory diseases.

METHODS

One hundred seventeen continuous esophageal pH monitoring of 5 +/- 3 year-old children presenting recurrent respiratory diseases have been reviewed. For each record, an analysis of the total record period, then the diurnal record, then the nocturnal record period was performed. The reflux index, the number of reflux per hour, and the number of long lasting reflux (> 5 min) per hour were compared between different periods (total, diurnal, and nocturnal).

RESULTS

For the reflux index, the sensibility, the specificity, the positive predictive value and the negative predictive value of the awake period in comparison with the continuous 24 h record, considering the same standards for both periods, were 97%, 46%, 72% and 92% respectively. The ROC graph analysis showed that the cut-off adaptation for the reflux index and for the number of reflux per hour, did not allow to improve the day pH-metry performance, since sensibility and specificity moved respectively from 66% to 56% for reflux index, and from 75% to 56% for the number of reflux per hour.

CONCLUSION

In children explored for recurrent respiratory diseases, the night record has a bad diagnostic value and a negative diurnal record is strongly predictive of absence of pathological gastroesophageal reflux in these children. Because of the absence of paediatric specific standards for this disorder, it is not possible to reduce the recording time to the diurnal period.

Clinical response to amino acid-based formula in neurologically impaired children with refractory esophagitis

OBJECTIVE

Chronic gastrointestinal symptoms and histologic changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux disease (GERD) may be improved by the use of elemental formulas. The aim of our study was to evaluate the efficacy of a dietary trial in neurologically impaired children unresponsive to medical and surgical therapy for GERD.

METHODS

Nine children (three boys and six girls; median age, 44 months; range, 13-180 months) affected by cerebral palsy associated with severe mental retardation and with long-standing history of GERD were fed the elemental formula, Neocate, for a minimum of 4 weeks. Before and after the dietary trial, each child underwent endoscopy with esophageal biopsy and a cellobiose/mannitol sugar permeability test. The diagnosis of GERD was based on the microscopic changes of the esophagus.

RESULTS

Before the dietary trial, according to conventional histologic criteria, esophagitis was considered moderate in seven children and mild in two. Five of nine patients also had abnormal sugar permeability test results. During and after the dietary trial, seven of nine patients experienced resolution of their long-term symptom complaints. Furthermore, after the dietary trial, both endoscopic ( < 0.01) and histologic ( < 0.05) findings significantly improved. At 6-month follow-up, progressive reintroduction of individual dietary proteins, except for cow's milk protein, did not cause reappearance of the symptoms.

CONCLUSIONS

In neurologically impaired children unresponsive to conventional antireflux treatments, a course of a highly restricted diet with an amino acid-based formula may bring an immediate and sustained, endoscopically and histologically proven improvement in long-standing gastrointestinal symptoms and esophagitis.

Mechanisms of gastroesophageal reflux and gastroesophageal reflux disease

Gastroesophageal reflux is a physiological phenomenon, occurring with different severity and duration in different individuals. Reflux occurs when this normal event results in the occurrence of symptoms/signs or complications. The pathophysiology of gastroesophageal reflux is complex and diverse, since it is influenced by factors that are genetic, environmental (e.g., diet smoking), anatomic, hormonal, and neurogenic. However, many mechanisms remain incompletely understood. Future research should focus on a better understanding of the physiology of the upper and lower esophageal sphincters, and of gastric motility. The afferent and efferent neural pathways and neuropharmacologic mediators of transient lower esophageal sphincter relaxations and gastric dysmotility require further study. The role of anatomic malformations such as hiatal hernia in children has been underestimated. While therapeutic possibilities are greater in number and largely improved, the outcomes of some treatments are far from satisfactory in many cases. In addition to development of new forms of treatment, research should address better use of currently available medical and surgical treatments.

Assessment of three methods of pH probe positioning in preterm infants

BACKGROUND

In the assessment of gastroesophageal reflux, correct placement of the pH catheter is crucial. This is particularly so in very low birth weight infants where a small error in positioning could give rise to a potentially large error in results. Accepted modes of assessing correct positioning can be problematic in this population of infants and alternative methods were investigated.

METHODS

A total of 26 preterm infants (<35 weeks gestation) were enrolled in this study. All infants were suspected of having GOR and pH monitoring was performed. Probe position was assessed using Strobel's formula, manometry and acid-alkali interface and confirmed by chest x-ray.

RESULTS

There was a highly significant positive correlation between the calculation of the pH probe position using Strobel's formula and the position on x-ray and a significant positive correlation between the acid/alkali interface and x-ray position. There was no correlation between manometry and x-ray position and this method was also shown to be problematic in its' application.

CONCLUSION

The data suggests that it is appropriate to use Strobel's formula as a method of accurate positioning of pH probes in preterm infants, thus avoiding the need for additional x-rays. The acid/alkali interface, when obtainable, is a secondary, satisfactory method to confirm the position calculated by Strobel's formula.

Pediatric orogastric and nasogastric tubes: a new formula evaluated

STUDY OBJECTIVE

We sought to compare the traditional method of determining depth of gastric tube insertion, by measuring from the external landmarks of the nose or mouth, to the earlobe, to the xiphoid process (NEX method), with a graph for determining depth of gastric tube insertion that is based on patient height (graphic method).

METHODS

A prospective, randomized, double-blinded study comparing NEX and graphic methods for gastric tube depth of insertion was undertaken. This study included a convenience sample of pediatric emergency department patients in need of gastric intubation. Patients were block randomized, and their gastric tubes were placed to the depth derived from the particular method employed. Alternate depth of insertion was measured on all patients. Abdominal radiographs were used to determine the distance that the end of the tube was from the center of the stomach.

RESULTS

Forty-four patients each were in the NEX and graphic groups. The mean distance from the center of the stomach was -1.12 cm (SD 1.36) for the graphic group, compared with 1.31 cm (SD 3.39) for the NEX method. The difference between the 2 methods was 2.43 cm (95% confidence interval [CI] 1.33 to 3.54). Using absolute values, the mean distance from the center of the stomach was 1.26 cm (SD 1.23) for the graphic group compared with 2.60 cm (SD 2.51) for the NEX method. Using these values, the difference between the groups is 1.34 cm (95% CI 0.50 to 2.18).

CONCLUSION

When compared with the NEX method, the graphic method demonstrates a significant ability to more consistently and accurately determine the depth of pediatric gastric tube insertion.

Gastroesophageal reflux in the neonate

Physiologic GER may be a maturational phenomenon, because infants outgrow this over time. Many aspects of GERD in neonates and young infants remain incompletely understood, however, particularly the pathophysiology and long-term problems in high-risk neonates. Diagnostic and therapeutic availability is vital in infants with GER and airway compromise, apnea events, or chronic lung disease. Although most infants improve with conservative therapy, there is a dire lack of ideal pharmacologic agents that work on all the mechanisms of GER with the least consequences. Studies that permit diagnosis not only of the disease but also of the causal mechanism, better feeding strategies, and prevention of morbidity from GERD will be beneficial.

Radiologic localization of esophageal level: comparison with distance from incisor at endoscopy

RATIONALE AND OBJECTIVES

The esophageal level on radiography was compared with that at endoscopy by establishing a relationship between the radiologic landmarks, i.e., the vertebral level and the distance from the carina, and the distance from the incisor at endoscopy.

METHODS

Three hundred ninety spot films in 65 patients who underwent endoscopic retrograde cholangiopancreatography were analyzed. Six spot films were obtained for each patient, wherein the distances of the endoscopic tip were located at 20, 25, 30, 35, 40, and 45 cm from the incisors. On each radiogram, the vertebral level scores were measured as 1 to 12, for the location of the endoscopic tip at the levels of T1 through T12, respectively. When the endoscopic tip was located at the lower half of the vertebral body, 0.5 point was added to the vertebral level score and when the tip was noted at the upper half of it, no additional score was given. The distance between the endoscopic tip and the carina was also measured. Correlations of the distance of the endoscopic tip from the incisors on endoscopy with the vertebral body levels and the distance from the carina on radiography, accounting for patient height, were analyzed by multiple linear regression and equations were extracted.

RESULTS

Equation 1 for the vertebral level score (VL) for a given distance of endoscopic tip from incisor (DI) at a given patient height (H) was VL = 0.432DI - 0.048H + 0.099 (r2 = 0.968). Equation 2 for the distance from the carina (DC) for a given DI at a given H was DC = 0.957DI - 0.137H - 5.841 (r2 = 0.983). Two tables denoting radiologic VLs and DCs for given endoscopic DIs and patients' heights were generated using these equations.

CONCLUSIONS

Regressed equations and tables will enable radiologists to better localize the esophageal lesions that are seen at endoscopy, and vice versa.

Esophagitis in distressed infants: poor diagnostic agreement between esophageal pH monitoring and histopathologic findings

OBJECTIVES

Our purpose was to study the relation between gastroesophageal reflux (GER) and esophagitis in infants with persistent distress.

STUDY DESIGN

Infants (n = 125, 79 boys; median age, 4.2 months) with persistent distress and clinical symptoms suggestive of GER and esophagitis were retrospectively studied. All had undergone esophageal 24-hour pH monitoring and had upper gastrointestinal biopsy specimens taken.

RESULTS

There were 65 (48%) infants with inflammatory changes found in at least one upper gastrointestinal biopsy specimen, of whom 32 (25.6%) had esophagitis; 11 infants with esophagitis also had gastritis or duodenitis. Although infants with frequent regurgitation (n = 65) had significantly more frequent GER episodes per 24 hours (P <.03) and greater fractional reflux time (P <.001) than infants without, this was not associated with histologic esophagitis (P =.33). Of the 32 infants with esophagitis, 9 had abnormal pH monitoring and 23 had nonreflux esophagitis. A separate group of 23 infants had abnormal pH monitoring but no esophagitis. Diagnostic agreement between pH monitoring and esophageal histologic features was poor (kappa = 0.07).

CONCLUSION

Esophagitis occurred in one quarter of infants with persistent distress. Abnormal esophageal pH monitoring did not reliably predict esophagitis, suggesting a nonacid peptic cause in some of these infants.

Lansoprazole in children: pharmacokinetics and efficacy in reflux oesophagitis

BACKGROUND

Data on the proton pump inhibitor lansoprazole in paediatric patients are limited.

AIM

To investigate the pharmacokinetics, optimal dosage and efficacy of lansoprazole in paediatric patients.

METHODS

A 24-h gastric pH recording and a pharmacokinetic study were performed after 7 days of lansoprazole, 17 mg/m2, in 23 patients with reflux oesophagitis (median age, 3.5 years). Response was defined as pH > 3 for > 65% of the recording. The dosage was doubled in non-responders. Patients with no response on day 14 were excluded. Responders underwent endoscopy after 4 weeks on the response-inducing dosage; abnormal findings led to a repeat endoscopy after four additional weeks.

RESULTS

Nine patients responded to 17 mg/m2 and six to 30.3 mg/m2. On day 7, time with pH > 3 was significantly correlated with the area under the plasma concentration-time curve (P=0.003). The area under the plasma concentration-time curve was significantly greater in the nine responders to 17 mg/m2 than in the 14 other patients. Pharmacokinetic parameters were similar in responders and non-responders to the higher dose. After 4 weeks, oesophagitis was healed in 80% of responders. Adverse events occurred in three patients and required treatment discontinuation in one.

CONCLUSIONS

Lansoprazole is effective and safe in children. The optimal starting dosage is 30 mg/m2 or 1.4 mg/kg.

Intravenous omeprazole in children: pharmacokinetics and effect on 24-hour intragastric pH

BACKGROUND

Omeprazole is a proton pump inhibitor, acting selectively on the gastric parietal cell H+K+-adenosine triphosphatase. Data on the intravenous route are limited in children and not available in infants.

OBJECTIVE

This study was designed to determine the pharmacokinetics and the optimal dosage of intravenous omeprazole in patients younger than 30 months of age.

METHODS

Nine children (three girls), aged 4.5 to 27 months, with normal liver and renal functions requiring intravenous omeprazole were studied. After enrollment in the study and randomization, omeprazole was administered once daily, at 8 am, as a 1-hour infusion. Group 1, consisting of the first four patients, received 20 mg/1.73 m2, and group 2, consisting of the following five patients, received 40 mg/1.73 m2. At day 3, a 24-hour intragastric pH and a pharmacokinetic study of omeprazole were performed. Plasma concentrations were measured by high-performance liquid chromatography.

RESULTS

Patients in group 2 had a significantly higher median pH (6.99 vs. 3.35; P = 0.01) and percent of monitored time with gastric pH >4 than children given 20 mg/1.73 m2 (90.6% vs. 44.8%; P < 0.01). Four had a pH more than 4 during more than 90% of the time versus none of the patients of group 1. The plasma concentration versus time curves showed rapid elimination of the drug. The median area under the curve of omeprazole was 0.78 microg. mL-1. h-1 (range, 0.55-1.64 microg. mL-1. h-1) and 3.95 microg. mL-1. h-1 (range, 1.9-4.9 microg. mL-1. h-1), respectively, in groups 1 and 2 (P < 0.05). Systemic clearance was not different between the two groups: median values were 0.68 and 0.42 L. kg-1. h-1 (P = 0.22).

CONCLUSIONS

In critical situations, intravenous administration of omeprazole may be required in infants. The authors demonstrate that the dose of 20 mg/1.73 m2 is not effective in maintaining 24-hour gastric pH of more than 4 and that a dose of 40 mg/1.73 m2 is required.

Transabdominal sonography of the normal gastroesophageal junction in children

PURPOSE

Because sonography identifies abnormalities of the gastroesophageal junction, it is essential to understand the normal sonographic anatomy. The aim of this study was to determine the normal sonographic appearance of the gastroesophageal junction and its variations and to provide measurements of the abdominal esophagus in asymptomatic, healthy children.

METHODS

In this prospective study, 124 healthy children (75 boys and 49 girls), aged 2 days-12 years, underwent abdominal sonography. With the patient in a supine position, the transducer was placed under the xiphoid and the ultrasound beam was directed cephalad through the window of the left lobe of the liver. The length of the abdominal esophagus was measured from the point at which it penetrated the diaphragm to the gastroesophageal junction. The thickness was measured on the anterior wall at the midpoint of the abdominal esophagus.

RESULTS

The gastroesophageal junction was identified by sonography in all of the children. The mean length of the abdominal portion of the esophagus ranged from 18 mm in the newborns to 34 mm in children older than 6 years. The wall thickness ranged from 2.4 mm to 5.7 mm.

CONCLUSIONS

Our results indicate that visualization of the gastroesophageal junction and measurement of the abdominal esophagus are readily achievable with real-time sonography in healthy children.

Cisapride decreases gastroesophageal reflux in preterm infants

OBJECTIVE

Gastrointestinal prokinetic agents, such as cisapride, are commonly used in pediatric practice to improve gastric emptying, to decrease emesis, to improve lower esophageal sphincter tone, and to improve irritability and feeding aversion associated with gastroesophageal reflux (GER). Although cisapride seems to be effective in infants from 2 months to 14 years old, data for younger and preterm infants are not available. Whether reflux is a significant cause of reflex apnea or feeding intolerance in the preterm infant is controversial. The objective of this 1-year prospective study, started in 1998, was to determine the efficacy of cisapride for treatment of reflux and reflux-associated apnea (RAAP) in preterm infants. Before this study, the diagnosis of reflux was often made clinically and the effect of therapy on reflux or the decision to increase the dose of cisapride was made empirically. The clinical bias was that persistent apnea, not responding to caffeine, was caused by GER. We reasoned that a systematic approach to the diagnosis and treatment of reflux would improve the care of preterm infants and reduce the risk of toxicity, especially if an increased dose of cisapride showed no improvement in reflux or apnea.

STUDY DESIGN

Twenty-four preterm infants (24-36 weeks' gestational age) had clinical apnea/pH studies when they were referred by the attending neonatologist for suspected GER. These infants were born at 28.8 +/- 3.1 weeks with birth weight of 1169 +/- 387 g (range: 631-2263 g). Each infant was studied before and 8 days after starting cisapride treatment. Cisapride dose was 0.09 to 0.25 mg/kg every 6 hours enterally. Treatment decisions regarding dose of cisapride were the responsibility of the attending neonatologist. The pH was recorded continuously for 24 hours at 0.25 Hz and was analyzed using EsopHogram software. A single sensor pH catheter was inserted to ~2 cm above the esophageal gastric junction. GER was defined as a drop in esophageal pH below 4.0 for a least 5 seconds, or pathologic GER was defined as a reflux index (RI) >2 standard deviation (SD) from the mean based on published norms for term infants. The following parameters were calculated from the pH recording: number of reflux events per 24 hours, duration of the longest episode, number of episodes >5 minutes per 24 hours, and RI, ie, percentage of time with pH <4.0. Each study had a combined time-lapse video recording and multichannel digital recording. Recorded parameters were: continuous pulse oximetry, electrocardiogram, respiratory effort (piezo sensor), and airflow (temperature sensor at nostrils and mouth). The recording was scored for central apneas of 10 to 14 seconds and >/=15 seconds (prolonged) and >/=10 seconds for obstructive and mixed apneas. RAAP was scored when an apnea (irrespective of the type) occurred within 1 minute of a GER event. Baseline, after cisapride, and follow-up electrocardiograms were performed because of concern about prolonged QTc and cardiac arrhythmias. The infants were 35.6 +/- 4.5 weeks postconceptional age when first studied. Twelve infants (mean birth weight: 1821 +/- 749 g; gestational age: 32 +/- 2 weeks; postconceptional age: 35.6 +/- 2.6 weeks) were identified retrospectively as controls because their baseline GER parameters were within the normal range using Vandenplas' criteria.

RESULTS

Overall, cisapride treatment significantly improved the RI from 16.6 +/- 15.2 to 9.1 +/- 8.4 SD. The number of reflux episodes >/=5 minutes was reduced from 7.1 +/- 5.8 to 4.3 +/- 4.4 SD. No significant effect was seen on the total number of refluxes (/24 hours). Eight infants (33%) had no decrease in the RI after a week of treatment. Three of these infants improved after cisapride dose was increased from 0.09 to 0.25 mg/kg/dose every 6 hours. Although 0.09 mg/kg/day is the minimum effective dose, 67% of our infants did respond to this low dose. Cisapride was discontinued in 3 infants because of prolonged QTc >/=0.450 seconds (0.473 in 1 and 0.470 in 2). More data about the effect of cisapride on QTc interval are reported in Pediatrics in a separate article. Only 1 infant showed no improvement with increased dose. Caffeine treatment had no effect on the baseline or follow-up GER values. Although apnea indexes for central and obstructive apnea were similar before and after cisapride, mixed apnea was less during treatment. There was a significant decrease (0.32 +/- 0.40 to 0.12 +/- 0.17/hour) in RAAP when the one infant who had increased reflux on increased dose of cisapride was excluded as an outlier. The statistical difference, before and after cisapride, for the group is significant with the outlier omitted. The clinical significance is unclear because ~50% of the infants had minimal changes in their apnea indexes. Furthermore, ~40% of infants did not have RAAP. (ABSTRACT TRUNCATED)

Delayed gastric emptying and gastroesophageal reflux: a pathophysiologic relationship

BACKGROUND

Delayed gastric emptying (DGE) is frequent in patients with gastroesophageal reflux (GER), but its pathophysiologic role has not yet been established. To identify a relationship between DGE and GER, we assessed whether DGE increases esophageal acid exposure and the related importance of possible mechanisms.

METHODS

Thirty pediatric patients with pathological GER were divided according to gastric emptying scintigraphy into a DGE group (n = 14) and normal-emptying group (n = 16). The esophageal pH-monitoring parameters of the two groups were compared with respect to the individual variation between postprandial and fasting periods.

RESULTS

Patients with DGE had less total acid exposure than did those with normal emptying, but patients in both groups had a pathological fraction of time when pH was below 4 in both the postprandial (median: 18 vs. 27.6; P = 0.49) and fasting (8.5 vs. 23.9; P = 0.01) periods. Patients in the normal-emptying group had similar fraction of time when pH was below 4 in the postprandial and fasting periods. However, patients in the group with DGE had a fraction of time when pH was below 4 in the postprandial period that was almost double that presented in fasting period (postprandial to fasting ratio: 2.11:0.90; P = 0.002). The postprandial to fasting ratio for episodes per hour was similar in the two groups (1.81 vs. 1.79; P = 0.62). Patients with DGE had a significantly higher frequency of long episodes in the postprandial period than did those with normal emptying (62.5% vs. 38.2%; P = 0.04). The occurrence of the longest episode in the postprandial period was also significantly higher for patients with DGE (57.1% vs. 6.2%; P = 0.003).

CONCLUSIONS

DGE seems to accentuate postprandial reflux by increasing the volume of refluxate per episode of reflux through an underlying incompetent lower esophageal sphincter.

Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis

BACKGROUND

Distressed behavior is common in infants and is often attributed to gastroesophageal reflux (GER) or food protein intolerance.

OBJECTIVE

To examine the effect of a hypoallergenic amino acid-based infant formula (AAF) on distressed behavior and GER symptoms in infants who failed to respond to extensively hydrolyzed formula and antireflux medications.

STUDY DESIGN

Nineteen distressed infants (9 boys and 10 girls; median age, 5.0 months) with presumed GER underwent gastroscopy (n = 17) and esophageal 24-hour pH monitoring (n = 14). Double-blind placebo-controlled (DBPC) formula challenges of AAF versus previously besttolerated formula were conducted.

RESULTS

Nine infants had histologic evidence of esophagitis, and 9 had inflammatory changes in the stomach and/or duodenum. Symptoms remitted in all infants within 2 weeks of the start of feeding with AAF. On DBPC challenge after a median period of 3 months of receiving AAF, 12 infants were intolerant to active formula (distress score, 287 vs 580 min/wk,P =. 01; symptom score, 23.1 vs 36.1, P =.03). Seven infants did not relapse and were considered tolerant (distress score, 470 vs 581, P =.77; symptom score, 29.5 vs 20.2; P =.89).

CONCLUSION

Treatment with AAF may reduce distressed behavior and symptoms of GER in infants with food protein intolerance.

Gastroesophageal reflux disease in children

In the pediatric population, gastroesophageal reflux most often presents in infancy as effortless regurgitation, but pathologic GERD is accompanied by signs of malnutrition, respiratory diseases, and esophagitis or its complications. Because of the distinctive pathophysiology predisposing infants to GERD, the diagnostic approach must begin with a thorough history that determines the extent of further diagnostic tests and the course of management. Empiric therapy assumes importance in infants with GERD because of the limited differential diagnoses in consideration. Conservative therapy is of utmost importance because of the unique provocative factors in the pathophysiology of infantile GERD. Prokinetic pharmacotherapy takes precedence over acid suppression because of the more important role of motility factors compared with acid secretion in infantile GERD.

Lower esophageal sphincter position in premature infants cannot be correctly estimated with current formulas

OBJECTIVES

Strobel's formula (Esophageal length = 5 + 0.252 x Height) is frequently used as a guide for determining the distance from the nares to the lower esophageal sphincter (LES) in term infants. The aim of this study was to examine this relationship in premature infants.

STUDY DESIGN

The distance from nares to LES was manometrically determined in 156 premature infants (26-40 weeks' postmenstrual age; body weights of 610-3050 g). The ability of body weight, height (body length), head circumference, and postmenstrual age to predict the manometrically determined LES position was evaluated with linear and non-linear regression analyses.

RESULTS

Body weight and body length were the most predictive of distance from nares to LES (r(2) = 0.848 and 0.802, respectively). These relationships were non-linear and, in the case of body length, deviated substantially from Strobel's model.

CONCLUSIONS

In premature neonates, a different formula is needed for prediction of the distance between nares and LES than that applied to term infants and children.

Reflux in infants with laryngomalacia: results of 24-hour double-probe pH monitoring

Laryngomalacia is the most common cause of stridor in children. Previous studies using barium esophagrams or single-probe esophageal pH testing have indicated that 68% to 80% of infants with laryngomalacia have reflux. A recent study in a large series of pediatric patients has shown that these 2 testing modalities are relatively insensitive in detecting reflux when compared with 24-hour double-probe pH testing. This study was undertaken to determine the incidence and frequency of reflux in children with laryngomalacia by use of 24-hour double-probe pH monitoring. Twenty-four children with endoscopically diagnosed laryngomalacia underwent 24-hour double-probe pH testing. The distal probe was placed in the lower esophagus, and the proximal probe was placed just above the cricopharyngeus immediately posterior to the larynx. All 24 (100%) children had pharyngeal acid exposure as judged by the proximal pH probe. These children had a mean of 15.21 episodes of reflux to the level of the pharynx during the 24-hour study period. In contrast, only 16 (66%) children had abnormal acid exposure as measured by the distal esophageal probe. These results indicate that essentially all children with laryngomalacia have reflux of gastric acid to the pharyngeal level. Multiple authors have documented the detrimental effects of acid and the accompanying pepsin in the larynx and tracheobronchial tree. Persistent laryngeal edema is an almost universal finding in patients with reflux to the pharyngeal level and is a common finding in children with laryngomalacia. In some patients with laryngomalacia, reflux may be the primary cause of their airway compromise, whereas in others it may be a significant cofactor exacerbating a preexisting neurologic or anatomic abnormality.

Lack of significant proximal esophageal acid reflux in infants presenting with respiratory symptoms

The effects of proximal esophageal acid reflux on upper and lower respiratory tract symptoms in infants with gastroesophageal reflux (GER) remain controversial. We studied 116 infants with either respiratory or gastrointestinal symptoms to determine whether acid reflux in the proximal esophagus plays an etiologic role in the elicitation of respiratory symptoms in comparison to causing gastrointestinal (GI) symptoms only. Sixty-two infants (age range, 1-12 months) with respiratory symptoms suggestive of GER and 54 infants with gastrointestinal symptoms only (age range, 1-10 months) were evaluated with dual level esophageal pH monitoring. Mean duration of dual-level pH monitoring in infants with respiratory symptoms was 20.4 h, and in those with GI symptoms was 20.7 h. Seventeen of 54 infants with GI symptoms only and 16 of 63 infants with respiratory symptoms had abnormal distal esophageal acid reflux indices (i.e., pH <4.0 for >5% of the duration of study). In infants with abnormal distal pH monitoring, the median proximal acid reflux index in the GI group was 4.0% in comparison to 0.95% in the respiratory group (P < 0.01 by Wilcoxon rank sum W test). Values for other reflux parameters were also higher in the GI than in the respiratory group. We conclude that reflux-associated respiratory symptoms are more likely due to mechanisms other than the mere presence of refluxed acid in the proximal esophagus.

Cisapride in the control of symptoms in infants with gastroesophageal reflux: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of cisapride in the treatment of uncomplicated gastroesophageal reflux in children younger than 36 months of age.

STUDY DESIGN

A total of 95 patients satisfied the entry criteria and were randomly assigned to double-blind treatment with either cisapride (n = 50), 0.2 mg/kg 4 times daily, or placebo (n = 45) for 2 weeks. At the end of the 2-week treatment period, symptom diary and parental evaluation with repeat 24-hour pH study were performed.

RESULTS

Sixty-eight patients completed the trial (38 in the cisapride group and 30 in the placebo group). There were no significant differences in the symptoms of crying, vomiting, or gagging; the overall symptom intensity score; or parental global evaluations. There was a significant difference (P <.03) in the percent time pH <4, the number of reflux episodes lasting more than 5 minutes, and the duration of the longest episode. No significant difference was demonstrated for the number of episodes with pH <4 or the reflux score.

CONCLUSIONS

Cisapride was no better than placebo for relief of symptoms in children with uncomplicated gastroesophageal reflux. A beneficial effect was demonstrated in the cisapride group in relation to the measured parameters for esophageal acid exposure time.

Gastro-oesophageal reflux in infancy

Gastro-oesophageal reflux (GOR) is a common phenomenon in infants, which may occur with or without accompanying symptoms. Although most infants presenting with regurgitation have a normal physical examination, it is now recognized that infants may also present with a wide variety of symptoms. Oesophagitis is associated with increased oesophageal acid exposure. The determination of cause and effect is difficult, as there are many aspects of reflux disease where cause and effect relationships are cyclic. Reflux disease is present when there is an imbalance between a number of factors that can contribute to a decrease, as well as an increase, of GOR. Oesophageal pH monitoring with a semi-disposable monocrysant antimony pH catheter with three sensors is very good at documenting oesophageal acidification and gastric buffering and, therefore, quantifies acid reflux frequency and duration. However, the interpretation of the data is complex as they are influenced by numerous factors, such as position, activity (sleep, crying), feeding (frequency and composition) or medication. The duration of buffering of gastric acidity during pH monitoring might, in the future, appear to be a relevant factor in the interpretation of oesophageal pH data.

Gastroesophageal reflux in preterm infants: norms for extended distal esophageal pH monitoring

BACKGROUND

Preterm infants are predisposed to gastroesophageal reflux, which may manifest itself in many ways ranging from failure to thrive to vomiting. Extended distal esophageal pH monitoring is the gold standard for diagnosing reflux in the preterm infants and it is our objective to establish extended distal esophageal pH norms (reference values) for well, asymptomatic preterm infants and to compare with norms already established for term infants, children, adolescents, and adults.

METHODS

Twenty-one well, asymptomatic preterm infants consuming at least 70% of required maintenance oral feedings were recruited. The mean +/- standard deviation birth weight was 1549 +/- 439 g (range, 670-2470 g); the mean postconceptional age was 30.7 +/- 2.6 weeks (range, 25-35 weeks) and the mean postnatal age was 14 +/- 9 days (range, 2-40 days). Extended distal esophageal pH monitoring was performed on each of the infants, and the following parameters were calculated: reflux index, number of reflux episodes per day, number of reflux episodes lasting more than 5 minutes per day, and the longest recorded reflux episode.

RESULTS

The mean reflux index was 0.7 +/- 1.1%, the mean number of reflux episodes per day was 7.6 +/- 11.2, the mean number of reflux episodes lasting more than 5 minutes per day was 0.5 +/- 1.1 and the mean longest recorded reflux episode was 4.2 +/- 6.1 minutes. These results were comparable to those seen in term infants, children, adolescents, and adults. The trends for pH norms according to postconceptional age and postnatal age seemed to suggest that lower esophageal sphincter maturation might be related to postconceptional age, but the differences observed were not statistically significant (p > 0.05).

CONCLUSION

The norms (reference values) for well, asymptomatic preterm infants were comparable to those seen in term infants, children, adolescents, and adults. With the establishment of these norms, the search for a causal link between many of the respiratory problems encountered in prematurity and gastroesophageal reflux may be aided and the complications associated with gastroesophageal reflux may consequently be reduced.

Dyspepsia in infants and children

Pathological processes and diseases of the upper gastrointestinal tract have become increasingly recognized over recent years as childhood entities responsible for a variety of upper gastrointestinal symptoms previously labelled as functional or non-organic. The term 'dyspepsia' is an adult one whose definition requires clarification before use in the paediatric context, but it encompasses age-dependent symptoms such as feed-associated irritability in the infant, peri-umbilical pain in the younger child, and heart-burn, nausea, and indigestion in the older child as in adults. The possible organic conditions giving rise to such symptoms are multiple and multiorgan and include: gastro-oesophageal reflux; peptic ulcer disease; upper gastrointestinal Crohn's disease; antroduodenal motility disorders; pancreatitis; cholecystitis; cholelithiasis; biliary dyskinesia; and abdominal migraine. However, Munchausen syndrome by proxy must not be forgotten. Non-ulcer dyspepsia, it is now clear, has a basis in altered gastroduodenal motility and may be amenable to propulsion agents. In many individuals the dyspeptic symptoms of recurrent abdominal pain may be altered by psychotherapeutic intervention. Indeed there remains a proportion of children who undoubtedly have a behavioural or psychological base to their complaint. Nevertheless, with the recent increase in diagnostic yield from improved technical investigative aids available to paediatrics in the last 5-10 years, it is clear that the responsibility of the paediatrician to the child to find a cause of their symptoms is paramount. The variety of presenting features, possible causes of these symptoms, and appropriate investigation and treatment will be discussed, and management algorithms based on published literature and personal practice will be offered.

Reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients

OBJECTIVE

Despite the widespread use of 24-hour intraesophageal pH monitoring for evaluation of gastroesophageal reflux in infants and children, there is little published information regarding the reproducibility of ambulatory pH studies in this patient population. The purpose of our study was to evaluate the reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients.

METHODS

We prospectively investigated 26 patients with symptoms suggestive of gastroesophageal reflux (14 females and 12 males) ranging in age from 1 month to 18 years (mean, 9.2 years). The patients underwent extended intraesophageal pH monitoring over two consecutive 24-hour periods.

RESULTS

Data analysis revealed that the overall reproducibility of ambulatory 24-hour pH monitoring is only 69% (r = 0.32). Eight of 26 patients had conflicting results on day 1 compared with results on day 2. Of the 8 patients with conflicting results on day 1 versus day 2, 5 had normal studies on day 1, but demonstrated pathologic reflux on day 2. Thus, the false-negative rate for day 1 was 19.2%. The kappa statistic calculated for the total time the pH was abnormal was 0.32, with values < 0.4 representing poor correlation. Spearman correlation coefficients indicated that the percentage of time with pH < 4 (r = 0.64) and the number of reflux episodes (r = 0.71) per 24-hour period are the most reproducible pH parameters.

CONCLUSION

The reproducibility of 24-hour intraesophageal pH monitoring in the pediatric population is suboptimal. The investigation should be extended or repeated if the result does not correlate with the patient's clinical history.

Gastro-oesophageal reflux in infants under 6 months with cystic fibrosis

AIM

To establish the incidence of pathological gastro-oesophageal reflux (GOR) in newly diagnosed infants with cystic fibrosis and to identify clinical predictors of increased reflux.

METHODS

26 infants with cystic fibrosis less than 6 months of age (14 male, 12 female; mean (SEM) age 2.1 (0.21) months, range 0.8 to 5.6 months) underwent prolonged oesophageal pH monitoring (mean duration 27.1 (0.49) hours; range 21.3 to 30.2 hours). Reflux symptoms, anthropometric variables, pancreatic status, meconium ileus, genotype, and chest x ray findings were correlated with pH monitoring data.

RESULTS

Five infants (19.2%) had an abnormal fractional reflux time of greater than 10%, seven (26.9%) of 5-10%, and 14 (53.8%) of below 5%. Infants who presented with frequent vomiting had a significantly higher fractional reflux time than infants who had infrequent or no vomiting. There was no significant association between abnormal chest x rays and pathological GOR. Sex, genotype, nutritional status, meconium ileus, and pancreatic enzyme supplementation were not significantly associated with pathological GOR.

CONCLUSIONS

About one in five newly diagnosed infants with cystic fibrosis had pathological GOR. Pathologically increased reflux was present before radiological lung disease was established. Apart from frequent vomiting, no useful clinical predictors of pathological reflux were found.

Disorders of the oesophagus and stomach in infants

Pathological processes and disease entities in the upper gastrointestinal (GI) tract, specifically those of the oesophagus and the stomach in infancy, have received a disproportionately small amount of attention until recently when appreciation of their pathophysiology and concordant importance in terms of symptomatology has been highlighted. This is probably a phenomenon secondary to improved diagnostic yield from the recent technical advances in areas such as infant endoscopy and a shift in opinion regarding the pathophysiological origin of ubiquitous symptoms of infancy such as feeding disorders, colic and irritability. In addition, the apparently complex interactions of various aetiological factors such as pH-independent gastro-oesophageal reflux (GOR), cow's milk protein intolerance (CMPI), Helicobacter pylori gastritis and upper GI motor disorders have in the past 1-2 years become underlined in terms of aetiopathogenesis and have radically changed thinking regarding diagnosis and therapy of infants with apparent upper-GI-associated symptoms. The contribution to comprehension of infant upper GI disorders of inflammatory paradigms and ontogeny of the upper GI tract is also a recent area worthy of mention. The recent advances in all of these areas and their contribution to the understanding, and subsequent diagnosis and therapy, of upper GI symptoms and their explanation by way of aetiopathogenesis will be explored in this chapter.

Treatment of childhood peptic esophagitis: a double-blind placebo-controlled trial of nizatidine

BACKGROUND

Nizatidine is an H2 histaminic receptor blocker, which acts on the oxintic cells in the stomach. The efficacy of nizatidine on acid gastric secretion has been widely studied in adults with erosive and ulcerative esophagitis, but not in children. The aim of the present study was to evaluate the therapeutic efficacy of nizatidine in children with reflux esophagitis.

METHODS

Twenty-six patients were studied; all of them underwent endoscopy with multiple esophageal biopsies and 24-h intraesophageal pH monitoring. The diagnosis of esophagitis was based on histologic features. Patients were randomly assigned to double-blind treatment with either nizatidine or a placebo (10 mg/kg/day in two doses) for 8 weeks. A symptomatic score assessment was evaluated during the study.

RESULTS

Twenty-four patients completed the 8-week protocol. After therapy, 9/13 (69%) patients on nizatidine and 2/13 (15%) patients on the placebo were healed (p < 0.007 by Fisher's exact test). Histological findings were improved in two other (16.7%) patients and unchanged in the last (8.3%) patient on nizatidine. In the placebo group there was histological improvement in three (25%) patients, no variation in six (50%), and worsening in one (8.3%). After therapy, determination of esophageal pH showed a statistically significant decrease of the total acid exposure time (p < 0.01) only in the nizatidine group. The clinical score analysis showed an improvement of symptoms only in the nizatidine group (p < 0.01), except for vomiting, which was reduced in both groups.

CONCLUSIONS

Our results show that nizatidine is effective in treating children with reflux esophagitis. The children included in this study did not have severe esophagitis, and the conclusion must be limited to those with mild to moderate degrees of disease.

Omeprazole for severe reflux esophagitis in children

BACKGROUND

Severe esophagitis is a rare complication of gastroesophageal reflux in children. In adults, omeprazole therapy of severe erosive esophagitis has become the gold standard short-term treatment of the disease. In children, data on its use are limited, and problems about the dosage are unresolved. The aim of this study was to evaluate the efficacy of a simplified, body-weight-based daily dosage of omeprazole in children with severe esophagitis.

METHODS

Ten children (median age 75.6 months; range 25-109 months) with severe esophagitis were prospectively investigated. All patients were evaluated by endoscopy, histology, and 24-h pH-metry study before and after 3 months of omeprazole. The starting dose of omeprazole was 20 mg as a single daily dose in children weighing less than 30 kg, and 40 mg daily for those weighing over 30 kg.

RESULTS

A significant improvement in all the children was demonstrated after 3 months of treatment by clinical, endoscopic, and pH-metry assessment. However, histologic study failed to show significant improvement of both inflammatory and hyperplastic findings. Relapse occurred in six of 10 patients after discontinuation of therapy.

CONCLUSIONS

Omeprazole is effective in the short-term treatment of severe oesophagitis in children. The daily dose of the drug could be easily based on the body weight. The persistence of histologic features of esophagitis in spite of clinical and endoscopic healing could be an indicator of poor outcome.

Posture and gastro-oesophageal reflux: a case for left lateral positioning

AIM

Prone posture is often recommended for symptomatic gastroesophageal reflux in young infants, but prone positioning has been associated with sudden infant death. The aim of this study was thus to establish the optimal alternative posture for reducing reflux.

METHODS

24 infants (< 5 months) with symptomatic gastro-oesophageal reflux were studied prospectively with 48 h pH monitoring. They were randomly assigned to one of the 24 permutations of the four positions (supine, prone, right, left). During the first 24 hours the infant was held horizontally, and then the permutation was repeated at 30 degrees head elevation, giving a total of eight study segments for each infant. Data were edited to remove all time when the infants were not in the prescribed positions. Results were evaluated using analysis of covariance.

RESULTS

Gastro-oesophageal reflux expressed as reflux index (mean % (SEM)) was significantly less in the prone and left lateral positions (6.72 (1.06) and 7.69 (1.03) respectively) than in the supine and right lateral positions (15.33 (2.33) and 12.02 (1.38); p < 0.001). Head elevation did not affect any variables significantly.

CONCLUSIONS

Head elevation may not always be of clinical value. The left lateral position is a suitable alternative to prone for the postural management of infants with symptomatic gastro-oesophageal reflux.

The triangular test to assess the efficacy of metoclopramide in gastroesophageal reflux

BACKGROUND

Sequential methods are particularly interesting when recruitment is difficult because they may allow a study to be stopped early while maintaining type I and II error rates.

METHODS

This placebo-controlled, randomized double-blind study was aimed at assessing the efficacy of metoclopramide (0.2 mg/kg three times daily during 14 days) on gastroesophageal reflux in infancy. The main end point was the relative variation of the percentage of time at pH < 4 between inclusion (day 0) and evaluation (day 14) assessed on two 24-hour esophageal pH recordings. Statistical analysis was performed with use of a sequential method, the triangular test.

RESULTS

The study was stopped after the seventh analysis (39 infants evaluated: 20 placebo and 19 metoclopramide) without showing the expected benefit. Improvement on the main end point was 30% +/- 48% (mean +/- SD). Corresponding unbiased median estimates were 22% for placebo and 39% for metoclopramide (p = 0.28, sequential analysis). On day 14, the percentage of time at pH < 4 was 8.1% +/- 11.7% for placebo and 6.7% +/- 9.2% for metoclopramide (p = 0.68, t test), and the number of reflux episodes > 5 minutes was 3.0 +/- 3.5 for placebo and 1.9 +/- 3.0 for metoclopramide (p = 0.33, t test).

CONCLUSION

If a tendency for a superior improvement with metoclopramide than with placebo was observed on the main end point, it was lower than expected and the difference was not significant. Compared with the corresponding single-stage design, the triangular test allowed to stop the study with a 15% reduction in sample size.

Postural drainage and gastro-oesophageal reflux in infants with cystic fibrosis

Gastro-oesophageal reflux is increased in cystic fibrosis and it is possible that postural drainage techniques may exacerbate reflux, potentially resulting in aspiration and further impairment of pulmonary function.

AIM

To evaluate the effects of physiotherapy with head down tilt (standard physiotherapy, SPT) on gastroesophageal reflux and to compare this with physiotherapy without head down tilt (modified physiotherapy, MPT).

METHOD

Twenty (mean age 2.1 months) infants with cystic fibrosis underwent 30 hour oesophageal pH monitoring during which SPT and MPT were carried out for two sessions each on consecutive days.

RESULTS

The number of reflux episodes per hour, but not their duration, was significantly increased during SPT compared with MPT (SPT 2.5 (0.4) v MPT 1.6 (0.3), p = 0.007) and to background (1.1 (0.)1, p = 0.0005). Fractional reflux time was also increased during SPT (11.7 (2.6)%) compared with background (6.9 (1.3)%) p = 0.03) but not compared with MPT (10.7 (2.7)%). There was no significant difference between MPT and background for number of reflux episodes, their duration, or fractional reflux time.

CONCLUSIONS

SPT, but not MPT, was associated with a significant increase in gastro-oesophageal reflux in infants with cystic fibrosis.

Clinical and pH-metric characteristics of gastro-oesophageal reflux secondary to cows' milk protein allergy

AIMS

The primary aim was to assess whether there were differences in symptoms, laboratory data, and oesophageal pH-metry between infants with primary gastro-oesophageal reflux and those with reflux secondary to cows' milk protein allergy (CMPA).

PATIENTS AND METHODS

96 infants (mean(SD) age 7.8(2.0) months) with either primary gastro-oesophageal reflux, reflux with CMPA, CMPA only, or none of these (controls) were studied. Symptoms, immunochemical data, and oesophageal pH were compared between the four groups and the effect of a cows' milk protein-free diet on the severity of symptoms was also assessed.

RESULTS

14 out of 47(30%) infants with gastro-oesophageal reflux had CMPA. These infants had similar symptoms to those with primary gastro-oesophageal reflux but higher concentrations of total IgE and circulating eosinophils (p < 0.005) and IgG anti-beta lactoglobulin (p < 0.003). A progressive constant reduction in oesophageal pH at the end of a feed, which continued up to the next feed, was seen in 12 out of 14 patients with gastro-oesophageal reflux secondary to CMPA and in 24 of 25 infants with CMPA only. No infants with primary gastro-oesophageal reflux and none of the controls had this pattern. A cows' milk protein-free diet was associated with a significant improvement in symptoms only in infants with gastro-oesophageal reflux with CMPA.

CONCLUSION

A characteristic oesophageal pH pattern is useful in distinguishing infants with gastro-oesophageal reflux associated with CMPA.

Intraepithelial cells with irregular nuclear contours as a marker of esophagitis in children with gastroesophageal reflux disease

The diagnostic usefulness of intraepithelial cells with irregular nuclear contours (CINC) (squiggle cells) in esophageal biopsies was investigated in 76 children (range age: 6 months-12 years) with gastroesophageal reflux disease. A further 20 subjects (range age: 10 months-11 years) served as controls. Based on the microscopic changes of the esophagus, according to traditional histological criteria, four groups of patients were identified; esophagitis was severe in 27, moderate in 20, mild in 21, and 8 patients had no clear-cut evidence of microscopic esophagitis. Data are given as mean +/- SD. Intraepithelial CINC had an immunohistochemical profile consistent with T lymphocytes. Patients with severe esophagitis had a CINC density (number per high-power filed) (9.0 +/- 3.5) significantly higher than patients with mild esophagitis (7.0 +/- 3.0) and those without evidence of microscopic esophagitis (6.5 +/- 1.9) (P < 0.05), but not different from those with moderate esophagitis (8.0 +/- 3.6); in all patients groups the CINC density was higher than in controls (2.2 +/- 0.3) (P < 0.01). The percentage of reflux at 24-hr intraesophageal pH monitoring was higher in severe esophagitis patients (11.4 +/- 6.0) as compared to the other groups (moderate: 7.8 +/- 6.3; mild: 6.5 +/- 3.6; no microscopic esophagitis: 6.3 +/- 2.0; P < 0.05). There was no correlation between CINC density and the amount of intraesophageal acid exposure in all patients. Furthermore, 27 of our patients had a normal intraesophageal acid exposure at the prolonged pH test (24-hr % of reflux < or = 4.5): the CINC density was significantly higher in them than in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of gastro-oesophageal reflux in infant irritability

Gastro-oesophageal reflux (GOR) disease may cause excessive crying in infants. The role of GOR was evaluated in infant irritability and an attempt was made to define clinical predictors of pathological reflux. Seventy consecutively admitted infants with irritability and presumptive GOR were retrospectively reviewed. All had undergone prolonged oesophageal pH monitoring. Pathological GOR was defined as a fractional reflux time of > or = 10% and was significantly less common in infants under 3 months (one of 24; 4.2%) than in older infants (10 of 46; 21.7%). All infants with pathological GOR presented with frequent vomiting, and 'silent' pathological reflux did not occur. Poor weight gain, feeding refusal, backarching, and sleep disturbance were not significantly associated with pathological GOR. The results suggest that pathological GOR is an unlikely cause of infant irritability under the age of 3 months.

Gastro-oesophageal reflux and feeding problems after gastrostomy in children with severe neurological impairment

This study evaluated the effect of percutaneous endoscopic gastrostomy (PEG) on the feeding problems and gastro-oesophageal reflux (GOR) of 30 consecutive children with severe neurological impairment who had PEG between October 1990 and March 1993. Evaluation was by questionnaire, clinical history, examination, 24-hour oesophageal pH monitoring and endoscopy. Gastrostomy placement significantly reduced feeding time, feed-related choking episodes and frequency of chest infections. Family stress was significantly reduced in two-thirds of cases. Significant weight-gain occurred. The clinical severity of GOR was significantly increased in eight patients and fundoplication was required in five. 24-hour oesophageal pH measurements before PEG did not reliably predict subsequently increased GOR. Seven patients died, but their deaths were apparently unrelated to GOR. PEG effectively provides nutrition, improves feed-related stresses, but may exacerbate GOR.

Developmental maturation of gastro-oesophageal reflux in preterm infants

The frequency and duration of gastro-oesophageal reflux were examined in 40 preterm infants and compared with a previously published healthy cohort of 74 term infants. Selection required that the infants were born between 24 and 32 weeks' gestation, had a normal head ultrasound and were studied at term post-menstrual age. Multi-channel pen recordings of sleep state, movement, breathing and acid reflux were made. In term and preterm infants the frequency and duration of reflux were greatest in active sleep, rare in quiet sleep and significantly less in preterm than term infants in wakefulness and active sleep (p < 0.05). The fewer and shorter episodes in preterm infants could not be explained by sleep state movement, gestational or postnatal age, days intubated, days on oxygen or the lowest pH of reflux episodes.

Is cow's milk protein intolerance a cause of gastro-oesophageal reflux in infancy?

To test the hypothesis that cow's milk protein intolerance (CMPI) might cause or contribute to gastro-oesophageal reflux (GOR), 10 of 14 infants with abnormal GOR on prolonged oesophageal pH monitoring who had failed to respond to conventional antireflux therapy were placed on a hypo-allergenic diet for 1 month. In no child was there significant improvement in pH monitoring indices, and only two showed any symptomatic improvement. Therefore, in these children, CMPI did not appear to contribute to GOR. It is probable that CMPI is rare as a cause of passive GOR, although our results do not exclude CMPI as a cause of active vomiting.

Quantitative computer-assisted image analysis of suction biopsy in pediatric gastroesophageal reflux

Gastroesophageal reflux is a disorder with well-characterized histopathological features in the adult, but the incidence and pathogenesis of epithelial injury in children are poorly understood. Esophageal suction biopsies from 80 infants exhibiting symptoms of reflux were studied by computer-assisted image analysis and the results compared to routine histological scoring. The histological features evaluated were the number of intraepithelial lymphocytes and eosinophils, papillary height, interpapillary basal cell height, and a novel measure "integrated basal cell height." We quantitatively evaluated these histological criteria by computer-assisted image analysis and compared these results to four subjective grades of esophagitis: low, mild, moderate and high. In this report we now describe this quantitative histopathologic method for the evaluation of pediatric esophageal biopsies. Utilizing this method we demonstrate that both inter- and intra-observer variability were sufficiently low to stratify the mucosal changes reliably into at least four categories. The reliability of this objective analytic technique will permit studies into the disease progression and regression in pediatric reflux esophagitis.

Domperidone plus magnesium hydroxide and aluminum hydroxide: a valid therapy in children with gastroesophageal reflux. A double-blind randomized study versus placebo

To evaluate the efficacy of different drug combinations in treating severe gastroesophageal reflux (GER), we studied 80 children with GER. The patients were randomly divided into four groups: group A was treated with domperidone plus magnesium hydroxide and aluminum hydroxide, group B with domperidone plus alginate, group C with domperidone alone, and group D received placebo. At the time of diagnosis and 8 weeks after treatment the patients were clinically evaluated and underwent 24-h continuous esophageal pH monitoring. After treatment a complete regression of symptoms was observed in 16 of 20 patients in group A, in 8 of 20 in group B (A versus B, p < 0.018), in 9 of 20 in group C (A versus C, p < 0.034), and in 7 of 20 in group D (A versus D, p < 0.001). Moreover, there was a statistically significant improvement in several pH-metric variables studied in all treatment groups; in addition, a comparison of the pH-metric data of the four groups after treatment indicated that reflux variables were significantly lower in group A than in the other groups. We conclude that the domperidone plus magnesium hydroxide and aluminum hydroxide combination was more effective than the other drugs we used in treating GER and in modifying the objective pH-metric variables in pediatric patients.

Omeprazole and high dose ranitidine in the treatment of refractory reflux oesophagitis

Thirty two consecutive patients (age range 6 months-13.4 years) with severe reflux oesophagitis were randomised to a therapeutic trial for eight weeks during which they received either standard doses of omeprazole (40 mg/day/1.73 m2 surface area) or high doses of ranitidine (20 mg/kg/day). Twenty five patients completed the trial (12 on omeprazole, 13 on ranitidine). At entry and at the end of the trial patients underwent symptomatic score assessment, endoscopic and histological evaluation of the oesophagus, and simultaneous oesophageal and gastric pH measurement; results are given as median (range). Both therapeutic regimens were effective in decreasing clinical score (omeprazole before 24.0 (15-33), after 9.0 (0-18); ranitidine before 19.5 (12-33), after 9.0 (6-12)), in improving the histological degree of oesophagitis (omeprazole before 8.0 (6-10), after 2.0 (0-60); ranitidine before 8.0 (8-10), after 2.0 (2-6), and in reducing oesophageal acid exposure, measured as minutes of reflux at 24 hour pH monitoring (omeprazole before 129.4 (84-217), after 44.6 (0.16-128); ranitidine before 207.3 (66-306), after 58.4 (32-128)) as well as intragastric acidity, measured as median intragastric pH (omeprazole before 2.1 (1.0-3.0), after 5.1 (2.2-7.4); ranitidine before 1.9 (1.6-4), after 3.4 (2.3-5.3)). Serum gastrin concentration was > 150 ng/l in four patients on omeprazole and in three patients on ranitidine. It is concluded that in children with refractory reflux oesophagitis high doses of ranitidine are comparable with omeprazole for the healing of oesophagitis and relief of symptoms; both drugs resulted in efficacious reduction of intragastric acidity and intra-oesophageal acid exposure.

Gastro-oesophageal reflux in children: comparison of different durations, positions and sleep-awake periods of pH monitoring in the same patient

A group of 72 children (mean age: 21.7 months, range: 14 days-19 years) with symptoms of gastro-oesophageal reflux were investigated by 22 h pH monitoring. Using a Proxeda software, we compared, in the same patient, the specificity and sensitivity of pH monitoring during 3 h, 6 h, 12 h, 12 nocturnal hours and 3 postprandial hours, as well as the influence of position and the sleep and alert periods. Results showed that all the short pH monitorings were statistically less sensitive than 22 h pH monitoring (P < 0.025). As regards specificity, only the 12 nocturnal hours pH monitoring was not statistically different from the 22 h pH monitoring. Gastro-oesophageal reflux was more frequent when the patient was awake than during sleep. pH monitoring seemed more reliable in the recumbent than in the upright position. We conclude that long-term pH monitoring (22 h) is the test of choice to diagnose gastro-oesophageal reflux because it included sleep and alert periods as well as different positions.

Simultaneous gastroesophageal pH monitoring and the diagnosis of alkaline reflux

The diagnosis of alkaline gastroesophageal reflux (AGER) by esophageal pH-monitoring is elusive because several other causes may raise esophageal pH above 7. This study approaches the issue by simultaneously recording esophageal and gastric pH with a 2.1 mm assembly of two antimony electrodes in refluxing (n = 69) and nonrefluxing (n = 40) children. On the basis of the information gathered, patients were divided into four groups: acid refluxers (GER, n = 40 or 57%), alkaline refluxers (AGER, n = 8 or 11%), alkalacid refluxers (AAGER, n = 15 or 22%), and silent refluxers or false negatives (SGER, n = 6 or 9%). Children with AGER could not be differentiated from other refluxers nor from controls by esophageal pH information alone. Prolonged gastric buffering or alkalinization could be documented in both AGER and AAGER children, indicating extended duodenogastric reflux (DGR) in them. The incidence of esophagitis was not significantly different between the groups of refluxers: 75% for AGER and AAGER, 73% for GER, and 67% for SGER. AGER, a disorder involving both pyloric and gastroesophageal barriers, is as significant a problem in children as in adults and may lead to severe complications even in the absence of excessive acid exposure. Monitoring esophageal pH alone is insufficient for making the diagnosis of AGER. The diagnosis can be made with little more expense and similar patient discomfort using the two-probe test. We suggest the need for a critical reassessment of the current antacid and prokinetic GER treatments and of antireflux operations which leave DGR intact while correcting GER.

Role of hiatal hernia in delaying acid clearance

The aim of this study was to assess prospectively the relationship of a hiatal hernia to gastro-oesophageal reflux. Ninety five children with symptoms of gastro-oesophageal reflux in whom reflux was demonstrated radiologically were investigated. Oesophageal pH monitoring for 18 hours and endoscopy were performed in all patients. On the basis of radiology, patients were divided into those with hiatal hernia (n = 37) and those without (n = 58). Both groups had the same number of reflux episodes on pH monitoring. However, the median duration of the longest episode was significantly greater in the hiatal hernia group (30 min v 19 min), as was the number of reflux episodes longer than five minutes (5 v 4). The percentage with a pH < 4 just failed to be significantly different (13% v 8%). Hiatal hernia was also found to correlate with the presence of oesophagitis. The presence of a hiatal hernia delays the clearance of acid from the oesophagus and is associated with an increased incidence of oesophagitis.

Dose-response study of metoclopramide in gastroesophageal reflux in infancy

Twenty-four infants, 1 to 18 months-old, who were referred to four centers for suspected gastroesophageal reflux and whose esophageal pH after a standard formula meal given at 9 to 10 am (Ho-day 1) fulfilled the criterion of being < 4 for more than 5% of the time between H1 and H6, entered a double-blind placebo-controlled dose-response trial of metoclopramide (M). Twenty-four hours later (day 2), patients were randomly assigned to receive either placebo or a single 0.1, 0.2, or 0.4 mg/kg dose of metoclopramide, 30 min before the formula meal (n = 6/group) and the procedure was repeated. Metoclopramide plasma concentration was measured 1 h after dosing (C1h). On day 1, the time during which the esophageal pH was < 4 (time pH < 4), and five other parameters, were not significantly different in the treatment groups. On day 2, time pH < 4 (m(SD)) decreased from 33(13) to 30(33), 39(27), to 36(47), 42(15) to 18(13) and 48(25) to 31(46) min in the placebo, 0.1, 0.2, and 0.4 mg/kg metoclopramide groups, respectively. Possibly due to the large interindividual variability, no significant differences in parameters were observed between the different groups. None of the parameters correlated with the metoclopramide dose. Time pH < 4 expressed as the difference between day 1 and day 2, relative to day 1, decreased significantly as a function of C1h. No side effects were observed. A similar study should be performed after repeated dosing regimen.

The esophageal temperature gradient in anesthetized children

OBJECTIVE

Our objective was to study the effect of the temperature of the anesthetic gas mixture (AGM) on esophageal temperature measurements made in children whose tracheas had been intubated for anesthesia. We also sought to establish the optimal site for the temperature sensor in the esophagus and to find a way to accurately place the sensor.

METHODS

Special esophageal temperature probes with thermistors located at 1-cm intervals were used for data collection on a multiplex system. Esophageal temperature measurements were made every 15 minutes for a period of 120 minutes in anesthetized children receiving heated (n = 30) and unheated (n = 30) anesthetic gases.

RESULTS

The temperature of the AGM (p < 0.001), the site of measurement (p < 0.001), and the interaction between AGM temperature and site of measurement (p < 0.007) all had a significant effect on esophageal temperature measurements. This effect was greatest at a point 3 cm distal to the level of the tip of the endotracheal tube when AGMs were not heated.

CONCLUSION

We conclude that best results are obtained when care is taken to place the thermistor in the lower quarter of the esophagus. (We provide a simple formula for calculating this placement in pediatric patients of varying ages.) Placing the probe by acoustic criteria cannot consistently be relied on to provide good thermometry.

Gastrooesophageal reflux in children with cerebral palsy

Feeding difficulties, vomiting and recurrent chest infections associated with poor growth and nutrition are common in children with cerebral palsy (CP). However, the role of gastrooesophageal reflux as a possible cause has been little studied. We therefore investigated 23 children with cerebral palsy (median age 2.3 years, range 0.6-11.8) whose symptoms were consistent with gastrooesophageal reflux (severe feeding difficulties 70%, failure to thrive 52%, anaemia 31% and recurrent chest infections 31%). Using 24-hour ambulatory oesophageal pH monitoring, we determined the relationship between gastrooesophageal reflux and: (a) developmental age (Griffith's scales); (b) feeding behaviour skills score; (c) nutritional status and (d) clinical assessment of cerebral palsy (type and severity). Abnormal gastrooesophageal reflux (i.e. reflux index > 5%) was detected in 16 (70%) patients (median reflux index 11.4%; range 5.4-59%). Reflux was unrelated to chronological or developmental age, but there was a significant, unexplained association with male gender (P < 0.01). No correlation was found with feeding behaviour skills score, malnutrition (which was commonly severe) and type and severity of cerebral palsy. We conclude that gastrooesophageal reflux is common and should be sought in symptomatic, neurologically handicapped children as effective treatment is likely to improve quality of life.