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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Milk protein and Oil-Red-O staining of alveolar macrophages in chronic respiratory disease of infancy

Aspiration is a suspected cause of chronic respiratory disease in infants. We assessed the probability of aspiration by immunocytochemical staining of alveolar macrophages for milk proteins (α-lactalbumin and β-lactoglobulin) and compared these findings with the Oil-Red-O staining score. Broncho-alveolar lavage (BAL), 24-hr esophageal pH-measurement and/or gastro-esophageal scintigraphy were performed in 111 children. Seventy-nine patients were enrolled. Ten exclusively soya milk formula fed children served as a control group. Individual scores, expressed as the mean percentage of positive staining macrophages counted by three blinded authors were made. Relying on the control group, a positive score was defined as a value higher than 1%. A positive score was found in 26% (18/69). Forty-four percent (8/18) of them had positive gastro-esophageal reflux (GER) tests. In 61% (11/18) a concomitant diagnosis of laryngo-/tracheomalacia was made. A positive score was found in 48% (11/23) of patients with laryngo-/tracheomalacia, compared to 15% (7/46) in infants with normal laryngeal and tracheal anatomy. No correlation was found between the immunocytochemical staining score for milk proteins and the Oil-Red-O staining score. We conclude that assuming the 1% criterion, persistent respiratory symptoms were associated with a positive immunostaining score, suggestive for aspiration, in 26% of infants, in 48% in case of concomitant laryngo- and/or tracheomalacia and in 15% of infants with normal laryngeal and tracheal anatomy. No correlation was found between the immunocytochemical staining score for cow milk proteins and the Oil-Red-O staining score.

Acid gastroesophageal reflux in convalescent preterm infants: effect of posture and relationship to apnea

Concerns regarding gastroesophageal reflux (GER) and associated apnea episodes result in some practitioners having convalescent, prematurely born infants sleep in the prone position. We have tested the hypothesis that such infants would not suffer from clinically important acid GER or associated apnea episodes more in the supine compared with the prone position. Lower esophageal pH was measured and videopolysomnographic recordings of nasal airflow, chest and abdominal wall movements, electrocardiographic activity, and oxygen saturation were made on two successive days of 21 premature infants (median gestational age 28 wk) at a median postmenstrual age (PMA) of 36 wk. On each day, the infants were studied prone and supine. The acid reflux index was higher in the supine compared with the prone position (median 3% versus 0%, p = 0.002), but was low in both positions. The number of obstructive apnea episodes per hour was higher in the supine position (p = 0.008). There were, however, no statistically significant correlations between the amount of acid GER and the number of either obstructive or total apnea episodes in either the supine or prone position. Supine compared with prone sleeping neither increases clinically important acid GER nor obstructive apnea episodes associated with acid GER in asymptomatic, convalescent, prematurely born infants.

Inlet patch: heterotopic gastric mucosa--another contributor to supraesophageal symptoms?

OBJECTIVE

To determine prospectively the incidence of an inlet patch (IP) in children requiring esophagogastroduodenoscopy (EGD) and assess the prevalence of presenting symptoms between children with and without an IP.

STUDY DESIGN

All patients undergoing EGD in a 2-year period were assessed for the presence of an IP with biopsy confirmation. IP, distal esophagus, and stomach biopsy specimens were blindly reviewed by a pathologist for the presence and degree of inflammation and intestinal metaplasia. Symptoms from children with and without an IP were compared.

RESULTS

From 407 EGDs done by a single endoscopist, 24 patients had confirmed IP (incidence of 5.9%). The presence and degree of inflammation were always relatively greater in the columnar mucosa of the IP than in the antral/body gastric mucosa in the same patient (P = .0027) Inflammation was similar in the squamous epithelium around the IP and in the distal esophagus (P=.46). Two patients had intestinal metaplasia of the IP. The patients with IPs had a higher prevalence of respiratory symptoms than the control group (P = .03).

CONCLUSIONS

Children with IPs may have a higher frequency of respiratory symptoms. Periodic surveillance should be performed in children with intestinal metaplasia of an IP.

Testing the association between gastroesophageal reflux and apnea in infants

BACKGROUND

There is controversy regarding the association between gastroesophageal reflux and apnea. The controversy is further confused by the variety of ways reflux is detected, the varying methods of data analysis and the heterogeneity of subjects studied.

OBJECTIVES

To determine if apnea is associated with reflux and to determine whether the association differs with acid or non acid reflux.

METHODS

We prospectively evaluated infants with apparent life-threatening events or apnea by simultaneous pneumography, esophageal pH and multichannel intraluminal impedance monitoring. Apneic events and reflux frequency, duration, acidity and height were recorded. Apneic events were considered to be temporally linked to gastroesophageal reflux when they occurred during a gastroesophageal reflux episode or within 5 minutes after clearance of the refluxate. Data described with frequency tables, scatterplots and time series graphs were analyzed by regression analysis and chi testing.

RESULTS

Twenty-five infants (10 males) aged 1 to 19 months were studied for up to 24 hours. Of 527 total apneic episodes, only 80 (15.2%) were temporally linked with gastroesophageal reflux: 37 (7.0%) with acid reflux and 43 (8.2%) with non-acid reflux. Scatterplots revealed no significant correlation between apnea and frequency or duration of reflux episodes. Individual chi analyses within subjects found limited associations between reflux and apnea. Regression analyses showed a significant association between apnea and reflux in 4 of 25 subjects.

CONCLUSIONS

We found little evidence for an association between apnea and total reflux, acid reflux or non-acid reflux. There was no difference between acid gastroesophageal reflux and non-acid gastroesophageal reflux in the frequency association with apnea. Either a chi statistic for each subject or R value computed from a lagged regression model for each subject can be used as an index of association in patient evaluation.

Gastroesophageal reflux: a critical review of its role in preterm infants

There is widespread concern about gastroesophageal reflux (GER) in preterm infants. This article reviews the evidence for this concern. GER is common in infants, which is related to their large fluid intake (corresponding to 14 L/day in an adult) and supine body position, resulting in the gastroesophageal junction's being constantly "under water." pH monitoring, the standard for reflux detection, is of limited use in preterm infants whose gastric pH is >4 for 90% of the time. New methods such as the multiple intraluminal impedance technique and micromanometric catheters may be promising alternatives but require careful evaluation before applying them to clinical practice. A critical review of the evidence for potential sequelae of GER in preterm infants shows that 1) apnea is unrelated to GER in most infants, 2) failure to thrive practically does not occur with GER, and 3) a relationship between GER and chronic airway problems has not yet been confirmed in preterm infants. Thus, there is currently insufficient evidence to justify the apparently widespread practice of treating GER in infants with symptoms such as recurrent apnea or regurgitation or of prolonging their hospital stay, unless there is unequivocal evidence of complications, eg, recurrent aspiration or cyanosis during vomiting. Objective criteria that help to identify those presumably few infants who do require treatment for GER disease are urgently needed.

Pediatric otolaryngologic manifestations of gastroesophageal reflux disease

In adults, an estimated 4% to 10% of chronic, nonspecific laryngeal disease seen in otolaryngologic clinics is associated with gastroesophageal reflux disease (GERD). Although no such estimates exist in children, many investigators have reported extraesophageal manifestations of GERD, of which the most common is the association of GERD with asthma and chronic cough. A variety of signs and symptoms of otolaryngologic disease also have been attributed to GERD, including hoarseness, laryngitis, chronic rhinitis, sinusitis, globus pharyngeus, recurrent croup, laryngomalacia, stridor, subglottic stenosis, otalgia, vocal cord granulomas, and oropharyngeal dysphagia. However, proof of the association between these manifestations of otolaryngologic disease and GERD is sparse. Furthermore, the manifestations of otolaryngologic disease often occur in the absence of such classic systems of GERD as heartburn or chest pain. This review explores the role of GERD in otolaryngologic disease in children.

Gastroesophageal reflux disease and dental erosion in children

Recurrent exposure to gastric acid as in children with bulimia and gastroesophageal reflux disease (GERD) may contribute to dental erosion. We performed a prospective study to evaluate the presence of GERD and dental erosions in children with primary and permanent dentition. Children undergoing elective endoscopy for possible GERD (n = 37) underwent evaluation of their teeth for the presence, severity, and pattern of erosion and stage of dentition: 24 patients had GERD. Dental erosions were identified in 20; all had GERD. Erosion patterns showed more involvement of the posterior teeth. Many affected patients had primary dentition.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

[Chronic cough in children: etiology and decision trees]

Recurrent or chronic cough can be the symptom of a worrying condition which must be diagnosed without delay (cystic fibrosis, asthma, bronchial foreign body, bronchiectasis). Investigation of recurrent or chronic cough is based on simple principles: careful history-taking concerning the characteristics of the cough, full clinical examination to look for any associated symptoms, and auxological assessment to detect any interruption in weight increase. Only when this initial evaluation has been carried out can complementary investigations be sought. Ordinary respiratory infections that are part of the building up of immunity are predominant in coughs of children aged under 6 years and are aggravated by deleterious factors such as passive exposure to tobacco, early introduction to communal life, and urban pollution. We describe the most frequent causes of cough and their frequency according to the age of the child.

Association of apnea and nonacid gastroesophageal reflux in infants: Investigations with the intraluminal impedance technique

An association of apnea and gastroesophageal reflux (GER) was proposed previously. However, pH metry as the standard diagnostic tool for GER only measures acid reflux (pH < 4). It is difficult to interpret studies in infants with a presumed association between apnea and GER based on pH metry because the buffering effect of feeding may result in predominantly nonacid GER. The aim of this study was to investigate the temporal association of apnea and GER with the pH-independent intraluminal impedance technique (IMP). Infants with recurrent regurgitation or respiratory symptoms suggestive of apnea were investigated simultaneously with IMP, pH monitoring, and polygraphy. IMP patterns, pH, oronasal flow, and chest wall movement were recorded and analyzed. In 22 infants, 364 GER episodes were recorded by IMP. One hundred and sixty five apneas were documented by visual validation of polygraph records. Forty-nine apneas (29.7%) were associated with GER; 11 (22.4%) of these showed acid reflux (pH < 4). A significant correlation between the time spent apneic and GER was found (P < 0.001). There is marked association between apnea and gastroesophageal reflux in infants. Patients potentially at risk cannot be reliably identified by pH metry. Its exclusive use is therefore not suitable for the detection of all GER-associated apneas in infants. The pH-independent intraluminal impedance technique has proven to be a sensitive diagnostic tool for this approach.

Intraluminal impedance: an ideal technique for evaluation of pediatric gastroesophageal reflux disease

Gastroesophageal reflux (GER) in infants becomes gastroesophageal reflux disease (GERD) through association with distinct clinical symptoms. Monitoring of pH is considered the standard diagnostic tool through which episodes of acidity can be detected. Apparently, however, the major amount of GER occurs in the physiologic esophageal pH range, which is concealed to pHmetry. Intraluminal impedance is a new method for pH-independent detection of esophageal bolus movement. Long-term measurements and combination with other diagnostic methods, e.g., pHmetry or polygraphic recordings, are possible. Intraluminal impedance has proved especially useful in diagnosing GER and GERD in infants. It may develop into the ideal technique for this group of patients.