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

A Comparison of Drug-Induced Sleep Endoscopy Findings in Infants and Toddlers

OBJECTIVE

To compare patterns of obstruction in infants and toddlers with obstructive sleep apnea (OSA) by analyzing drug-induced sleep endoscopy (DISE) examinations.

STUDY DESIGN

Retrospective chart review.

SETTING

An academic tertiary care pediatric hospital at a single institution.

METHODS

Children aged ≤3 years who underwent DISE with propofol titration from 2020 to 2022 were included in the study. Data extracted included age, body mass index, comorbidities, and polysomnography parameters. The sites of anatomic obstruction during DISE were recorded using a validated 10-site scoring system.

RESULTS

A total of 86 children underwent DISE, including 15 infants (<1 year) and 71 toddlers (>1≤3 years). Sixty-two percent were male and 37% were female. The mean age of the infant group was 9.6 months (95% confidence interval [CI]: 7.92, 11.28 months), and the mean age of the toddler group was 2.3 years (95% CI: 2.06, 2.50 years). The mean total number of sites of obstruction was not significantly different between infants (N = 2.5) and toddlers (N = 3.2, P = .086). The most common subsite of significant obstruction in both infants and toddlers was the aryepiglottic folds (46.7% and 36.8%, respectively; P = .578). The sites of obstruction and frequency of their occurrence were not significantly different between the 2 groups.

CONCLUSION

Multisite airway obstruction is common among children with OSA, especially at the epiglottis, aryepiglottic folds, and tongue base. There is no difference in sites of obstruction and their frequency between toddlers and infants.

Patient positioning and its impact on perioperative outcomes in children: A narrative review

Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer-centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri-procedural anxiety.

Episodic apnea: gastroesophageal reflux associated with gastric organo-axial malrotation: a case report

BACKGROUND

Gastroesophageal reflux is a normal physiologic process occurring several times a day in healthy infants. On the other hand, symptoms such as failure to thrive, feeding or sleeping problems, chronic respiratory distress, persistent forceful vomiting, and choking may indicate reflux associated with underlying anatomic, neurological, or infectious abnormalities. Gastric malrotation is an extremely rare disorder in the pediatric population and one of the anatomic causes associated with severe reflux, which could lead to serious complications. In such cases, life-threatening symptoms overlapping with other diseases cause delayed diagnosis and treatment.

CASE PRESENTATION

We report a 2.5-month-old white girl diagnosed with gastric malrotation-related reflux, which caused inadequate weight gain, feeding difficulties, episodes of apnea with cyanosis, and choking after successive coughing, hence previously misdiagnosed as epilepsy and pertussis.

CONCLUSION

Life-threatening symptoms in an infant with reflux suggest anatomic, neurological, or infectious conditions. Gastric malrotation is more common than generally thought and specifically looked for in young children with severe reflux symptoms, and should be diagnosed and treated as soon as possible.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

The Role of Combined Multichannel Intraluminal Impedance-pH Monitoring in Infants with Brief, Resolved, Unexplained Events

PURPOSE

Data on the relationship between gastroesophageal reflux (GER) and brief resolved unexplained events (BRUE) in infants is scarce. The aim of this study was to identify the characteristics of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in infants who have experienced BRUE.

METHODS

We conducted a prospective study of infants who were hospitalized on account of BRUE and required 24-hour MII-pH monitoring.

RESULTS

Twenty-one infants (mean age, 4.7 months; range, 0.9-8.9 months; male/female, 11/10) participated in this study. BRUE symptoms associated with GER were found in 10 infants (47.6%). Based on the RI on pH-metry alone, only 7 (33.3%) infants were diagnosed with GERD. More than 100 GER episodes detected by MII were found in 10 (47.6%) infants. Nineteen percent of infants were diagnosed with GERD based on both pH and MII.

CONCLUSION

Both acid and non-acid reflux seem to play a significant role in the pathogenesis of GER-related BRUE in infants.

Differentiating esophageal sensitivity phenotypes using pH-impedance in intensive care unit infants referred for gastroesophageal reflux symptoms

BACKGROUND

To identify esophageal sensitivity phenotypes relative to acid (S_Acid), bolus (S_Bolus), acid and bolus (S_Acid+Bolus), and none (S_None) exposures in infants suspected with gastroesophageal reflux disease (GERD).

METHODS

Symptomatic infants (N = 279) were evaluated for GERD at 42 (40-45) weeks postmenstrual age using 24-h pH-impedance. Symptom-associated probability (SAP) for acid and bolus components defined esophageal sensitivity: (1) S_Acid as SAP ≥ 95% for acid (pH < 4), (2) S_Bolus as SAP ≥ 95% for bolus, (3) S_Acid+Bolus as SAP ≥ 95% for acid and bolus, or (4) S_None as SAP < 95% for acid and bolus.

RESULTS

Esophageal sensitivity prevalence (S_Acid, S_Bolus, S_Acid+Bolus, S_None) was 28 (10%), 94 (34%), 65 (23%), and 92 (33%), respectively. Emesis occurred more in S_Bolus and S_Acid+Bolus vs S_None (p < 0.05). Magnitude (#/day) of cough and emesis events increased with S_Bolus and S_Acid+Bolus vs S_None (p < 0.05). S_Acid+Bolus had increased acid exposure vs S_None (p < 0.05). Distributions of feeding and breathing methods were distinct in infants with S_Bolus vs S_None (both, p < 0.05). Multivariate analysis revealed that arching and irritability events/day were lesser at higher PMAs (p < 0.001) and greater for infants on NCPAP (p < 0.01) with S_Bolus and S_Acid+Bolus (p < 0.05). Coughs/day was greater at higher PMAs (p < 0.001) for infants with gavage and transitional feeding methods (p < 0.02) with S_Bolus and S_Acid+Bolus (p < 0.05) but lesser with Trach (p < 0.001). Number of emesis events/day were greater with S_Bolus and S_Acid+Bolus (p < 0.001). Sneezes/day decreased for infants on Trach (p = 0.02).

CONCLUSIONS

Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. We differentiated esophageal sensitivity phenotypes in NICU infants referred for GERD symptoms using pH-impedance. Acid sensitivity alone was rare, which may explain poor response to acid suppressives; aerodigestive symptoms were predominantly linked with bolus spread. Magnitude of esophageal acid exposure and esophageal sensitivity to bolus spread may explain the pathophysiological basis for symptoms.

IMPACT

Objective GERD diagnosis and reasons for symptoms in NICU infants remains unclear. Differentiation of esophageal sensitivities by acid and bolus components of GER reveal distinct symptom profiles, specifically the bolus component of GER significantly contributes to symptom occurrence. Acid only sensitivity to GER is rare, and acid-suppressive therapy alone may not improve symptoms in a majority of NICU infants. Magnitude of esophageal acid exposure and esophageal sensitivity to any bolus spread may explain the pathophysiological basis for symptoms. Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. GERD treatments should be individualized to the patient's GERD phenotype and likely also target the bolus component of GER.

Apnea in preterm neonates: what's the role of gastroesophageal reflux? A systematic review

A causal relationship between gastro-esophageal reflux (GER) and apnea in preterm infants has been frequently hypothesized and is currently debated. The present study aims at reviewing the currently available scientific evidence, in order to clarify the role of GER on the occurrence of apnea and to help improving the clinical management of apneic preterm neonates. We performed a systematic literature search to identify all the clinical studies on preterm neonates that properly assessed the relationship between apnea and GER. Two-hundred and fifty-two papers, including 32 reviews and meta-analysis, were screened. Out of them, only 7 were included in the final analysis according to the selected criteria. Among them, 3 studies reported an increased frequency of apnea after reflux compared to reflux-free period and 4 denied a significant temporal relation. In conclusion, a minority of apneic events occurs soon after GER episodes. Whether this happens by chance or because of a causal relationship is still impossible to define. Based on the available data, empirical treatment with acid inhibitors is not recommended in neonates with apnea unless a proven temporal relation is shown by simultaneous esophageal pH-impedance and polysomnography or cardiorespiratory monitoring and in the absence of a clear clinical benefit.

Correlation between cardiorespiratory events and gastro-esophageal reflux in preterm and term infants: Analysis of predisposing factors

BACKGROUND

The association between cardiorespiratory events (CRE) and gastro-esophageal reflux (GER) among neonates is still controversial.

AIMS

To test such an association in preterm and term infants.

STUDY DESIGN

Prospective observational study.

SUBJECTS

Forty-seven infants with suspected GER and recurrent CRE admitted at a neonatal intensive care unit, who underwent simultaneous and synchronized 24-hour recording of heart rate (HR), peripheral oxygen saturation (SpO2) and pH-impedance monitoring (MII-pH). HR/SpO2 data were filtered to avoid artefactual episodes of hypoxia and hypoperfusion.

OUTCOME MEASURES

The main outcome measure was the symptom association probability (SAP), with a 2-minute time window. Infants with positive (>95%) and negative (≤95%) SAP index tests were compared by univariate and multivariate statistics.

RESULTS

Median gestational age at birth was 29^4/7 weeks, median age at study 36 days. We recorded 3341 GER events and 4936 CRE (4710 desaturations, 226 bradycardias); 609/4936 (12%) CRE were temporally associated with GER episodes: 338 preceded and 271 followed GER events. The SAP index was significant in 5/47 (11%) patients. The SAP index including only CRE following GER events was significant in 3/47 (6%). There was no significant difference in the number of acid, weakly acid, non-acid, pH-only events preceding or following CRE between infants with SAP-positive and SAP-negative tests. Infants with positive SAP-index tests compared to those with SAP-negative tests had lower weight gain in the three days preceding the test and tended to have lower birth weight.

CONCLUSIONS

GER and CRE were associated in <11% of patients. The evaluation of ponderal growth might be helpful in predicting such an association.

Gastro-oesophageal reflux is not a major cause of brief resolved unexplained events in infants

Although it is often stated that gastro-oesophageal reflux is the most common cause of a brief resolved unexplained event or apparent life-threatening event, there are very few data to support the hypothesis of cause and effect http://bit.ly/2FjknUy.

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

BACKGROUND

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

METHODS

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

KEY RESULTS

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

CONCLUSIONS & INFERENCES

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Apparent Life-Threatening Events (ALTE): Italian guidelines

Five years after the first edition, we have revised and updated the guidelines, re-examining the queries and relative recommendations, expanding the issues addressed with the introduction of a new entity, recently proposed by the American Academy of Pediatrics: BRUE, an acronym for Brief Resolved Unexplained Events. In this manuscript we will use the term BRUE only to refer to mild, idiopathic cases rather than simply replace the acronym ALTE per se.In our guidelines the acronym ALTE is used for severe cases that are unexplainable after the first and second level examinations.Although the term ALTE can be used to describe the common symptoms at the onset, whenever the aetiology is ascertained, the final diagnosis may be better specified as seizures, gastroesophageal reflux, infection, arrhythmia, etc. Lastly, we have addressed the emerging problem of the so-called Sudden Unexpected Postnatal Collapse (SUPC), that might be considered as a severe ALTE occurring in the first week of life.

How to Care for Patients with EA-TEF: The Known and the Unknown

PURPOSE OF REVIEW

Guidelines were recently published highlighting why esophageal atresia (EA) patients are prone to complication risks, and the need for long-term follow-up. In this review, we will focus on how to investigate and treat potential complications, as well as the pros and cons of different investigative and treatment modalities, and what areas continue to need further research.

RECENT FINDINGS

EA patients are at high risk for gastroesophageal reflux and esophageal strictures, and the sequela that result. Extraintestinal manifestations of gastroesophageal reflux disease (GERD) can appear similar to other pathologic diagnoses commonly found in EA patients, such as congenital stricture, eosinophilic esophagitis, esophageal dysmotility, tracheomalacia, recurrent fistula, aspiration, etc. Therefore, it is important to have a standardized way to monitor for these issues. pH impedance allows for detection of nonacid reflux and the height of reflux, which are important in correlating symptoms with reflux episodes. A multidisciplinary approach is beneficial in evaluating and monitoring EA patients in the long term.

The comparative analyses of different diagnostic approaches in detection of gastroesophageal reflux disease in children

Objectives

The aim of this study was to compare the different diagnostic approaches in detection of gastroesophageal reflux disease in children presented with symptoms suggesting gastroesophageal reflux disease.

Methods

The study design was cross sectional. The study retrospectively included all children who underwent combined multiple intraluminal impedance and pH (pH-MII) monitoring due to gastrointestinal and/or extraesophageal symptoms suggesting gastroesophageal reflux disease at University Children's Hospital in Belgrade, from July 2012 to July 2016.

Results

A total of 218 (117 boys/101 girls), mean age 6.7 years (range 0.06–18.0 years), met the inclusion criteria. Gastroesophageal reflux disease was found in 128 of 218 children (57.4%) by pH-MII and in 76 (34.1%) children by pH metry alone. Using pH-MII monitoring as gold standard, sensitivity of pH-metry was lowest in infants (22.9%), with tendency to increase in older age groups (reaching 76.4% in children ≥ 9 years). The sensitivity of pH-metry alone in children with extraesophageal symptoms was 38.1%, while the sensitivity of pH-metry in children with gastrointestinal symptoms was 63.8%. Reflux esophagitis was identified in 31 (26.1%) of 119 children who underwent endoscopy. Logistic regression analysis showed that best predictors of endoscopic reflux esophagitis are the longest acid episode (OR = 1.52, p<0.05) and DeMeester reflux composite score (OR = 3.31, p<0.05). The significant cutoff values included DeMeester reflux composite score ≥ 29 (AUC 0.786, CI 0.695–0.877, p<0.01) and duration of longest acid reflux ≥ 18 minutes (AUC 0.784, CI 0.692–0.875, p<0.01).

Conclusions

The results of our study suggested that compared with pH-metry alone, pH-MII had significantly higher detection rate of gastroesophageal reflux disease, especially in infants. Our findings also showed that pH-MII parameters correlated significantly with the endoscopically confirmed erosive esophagitis.

Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) is a normal physiologic process. It is important to distinguish GER from GER disease (GERD) since GER does not require treatment. Although a diagnosis of GERD can largely be based on history and physical alone, endoscopy and pH impedance studies can help make the diagnosis when there in atypical presentation. In children and adolescents, lifestyle changes and acid suppression are first-line treatments for GERD. In infants, acid suppression is not effective, but a trial of hydrolyzed formula can be considered, as milk protein sensitivity can be difficult to differentiate from GER symptoms.

Pepsin as a Marker of Extraesophageal Reflux

Diagnosis of extraesophageal reflux (EER) currently relies on tools designed for diagnosis of gastroesophageal reflux. Such tools lack the sensitivity and reproducibility to detect the less frequent and mildly acidic reflux associated with upper airway disease. Pepsin has been posited to be a reliable biological marker of EER. Our aim was to present a comprehensive literature review of the use of pepsin as a diagnostic marker of EER. Two methods are typically used for detection of pepsin in the airways: enzymatic and immunologic. The limitations, advantages, and examples of use of each are discussed. Pepsin assay has been used to identify refluxate in trachea, lung, sinus, middle ear, combined sputum and saliva, and breath condensate. An immunologic pepsin assay of combined sputum and saliva was determined to be 100% sensitive and 89% specific for detection of EER (based on pH-metry), and an enzymatic test of nasal lavage fluid (100% sensitivity and 92.5% specificity) demonstrated an increased incidence of EER in patients with chronic rhinosinusitis. Pepsin assay identified tracheal pepsin to be an indicator of bronchopulmonary dysplasia and related mortality risk in ventilated preterm infants. Pepsin assay is a useful tool for correlation of reflux with airway disease and is a reliable diagnostic marker of EER.

Impedance Testing in Esophageal Atresia Patients

Esophageal atresia patients are predisposed to gastroesophageal reflux as a result of the altered esophageal anatomy and motility. These patients experience significant morbidity from gastroesophageal reflux. As a result, an effective way to diagnose and monitor for reflux is crucial. pH-metry is able to quantify acid burden, ensure that acid suppression is adequate during long-term follow-up, and correlate acid reflux to symptoms. pH with impedance is additionally able to detect non-acid reflux as well as volume clearance, both of which also correlate with patient symptoms. It is also able to correlate extra-gastrointestinal symptoms to reflux, which may help guide treatment. If complications associated with uncontrolled reflux are identified, aggressive reflux management is necessary, oftentimes requiring surgical intervention.

Morbidity and Mortality in Preterm Infants following Antacid Use: A Retrospective Audit

Background and Objectives. Antacids are often prescribed to preterm infants due to misdiagnosis of gastro-oesophageal reflux. This suppresses gastric acidity, a major defence mechanism against infection. This study aims to determine if ranitidine and omeprazole use in very low birth weight (VLBW) neonates, <1500 grams, is associated with increased risk of late onset sepsis, necrotising enterocolitis (NEC), and mortality. Methods. Retrospective analysis was conducted on neonates, <1500 grams, born and admitted into the Neonatal Intensive Care Unit at The Canberra Hospital during the period from January 2008 to December 2012. Information regarding late onset sepsis, NEC, mortality, ranitidine/omeprazole use, and other neonatal/hospital factors was collected for each neonate. Results. 360 neonates were evaluated, 64 received ranitidine and/or omeprazole, and 296 had not. There were no statistically significant differences in incidence of late onset sepsis (OR = 0.52, CI = 0.24-1.1, and p = 0.117), NEC Stage 2 and above (OR = 0.4, CI = 0.05-3.2, and p = 0.7), or mortality (OR = 0.35, CI = 0.08-1.5, and p = 0.19) between the two groups. After adjusting significant differences in neonatal and hospital factors, risk of late onset sepsis was significantly lower in those that received ranitidine/omeprazole (OR = 0.28, CI = 0.13-0.65, and p = 0.003). Conclusions. Ranitidine and omeprazole use in VLBW preterm infants may not be associated with an increased risk of infection, NEC, and mortality.

Combined Multichannel Intraluminal Impedance and pH Measurement in Detecting Gastroesophageal Reflux Disease in Children

OBJECTIVE

The aim of the study was to evaluate and compare multichannel intraluminal impedance-pH (MII-pH) monitoring with standard investigations including pH testing for detecting gastroesophageal reflux disease (GERD) in children.

METHODS

A retrospective review of all MII-pH studies performed between July 2007 and March 2013 at Sydney Children's Hospital. Results from MII-pH testing, esophagogastroduodenoscopy (EGD), barium meal and pepsin assay, symptoms, underlying comorbidities, age, and medication usage were evaluated.

RESULTS

An additional 47.18% of children had GERD detected by MII-pH testing, which would have been missed by pH testing alone. Based on symptomatology, 50.49% of children with respiratory symptoms as a result of GERD and 47.54% of those with gastrointestinal symptoms would have been missed by pH testing alone. GERD was detected in an additional 39.47% of children with neurological impairment, 44.44% for those with cystic fibrosis, and 52.17% for those with esophageal atresia-tracheoesophageal fistula by MII-pH. In patients with persistent symptoms on anti-reflux medication, GERD would have been missed by pH testing alone in 50.40%. GERD was detected in an additional 62.79% of infants and 42.76% of older children by MII-pH compared with pH testing alone. With reference to MII-pH, the sensitivity of other standard investigations, pH testing (32.35%), barium meal (25.00%), EGD (45.26%), and pepsin assay (48.89%) was significantly lower in the detection of GERD in children. Of all abnormal MII-pH results, 51.1% were abnormal because of symptom association alone.

CONCLUSIONS

Combined MII-pH testing is superior to standard investigations such as 24-hour pH testing, barium meal, EGD, and pepsin assay in detecting GERD in children, particular because of its ability to associate symptoms with acid and non-acid reflux events.

Influence of intrapulmonary percussive ventilation in upright position on gastro-oesophageal reflux in infants

OBJECTIVES

To determine the influence of physiotherapy using intrapulmonary percussive ventilation on gastro-oesophageal reflux (GOR) in infants <1 year.

METHODS

In this controlled trial with intra-subject design, children were studied using multichannel intraluminal impedance pH (pH-MII) monitoring over 24 hr, during which they received one 20-min session of intrapulmonary percussive ventilation in upright position (IPV_R ), 2 hr after their latest feeding. Two hours after each feeding, the number of reflux episodes (RE) over a 20-min period was registered for each infant and a mean per 20 min was calculated in order to obtain a baseline value. The number of RE during IPV_R intervention was compared to baseline.

RESULTS

Fifty infants with a median age of 133 days were recruited of whom 21 were diagnosed with pathological GOR. During IPV_R , the incidence of RE in the entire group was significantly lower compared to baseline; median (inter-quartile range [IQR]) 0 (0-1) versus 0.71 (0-1.33) RE, respectively, P = 0.003. The subgroup with abnormal GOR showed also a significant decrease of RE during IPV_R ; median (IQR) 0 (0-1) versus 1.17 (0.55-2.16) RE, respectively, P = 0.03. No difference was detected in the group with normal reflux; median (IQR) 0.6 (0-1) compared to 0 (0-1) RE, respectively, P = 0.34.

CONCLUSION

IPV_R does not induce, nor aggravate GOR in infants without and with pathological GOR, respectively, but on the contrary decreases the number of RE in patients with pathological reflux. Pediatr Pulmonol. 2016;51:1065-1071. © 2016 Wiley Periodicals, Inc.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Temporal Association Between Reflux-like Behaviors and Gastroesophageal Reflux in Preterm and Term Infants

OBJECTIVES

Multichannel intraluminal impedance studies (MII-pH) have become the criterion standard for the diagnosis of gastroesophageal reflux (GER). Several clinical signs and symptoms that are attributed to GER during infancy may not be related to true reflux. Our objective was to correlate the observed reflux-like behaviors to reflux events on MII-pH studies.

METHODS

This is a retrospective study on infants being evaluated for GER with MII. During the MII-pH study, the infants were observed for clinical behaviors. Symptom Index (SI), symptom sensitivity index (SSI), and symptom association probability were used to correlate symptoms with reflux events.

RESULTS

Of 58 infants (40 preterm, 18 term) included in the study, only 6 infants (10%) had an abnormal MII-pH study. Irritability (32 infants), bradycardia (20), and desaturation (18) were the common signs and symptoms. A total of 2142 (755 acidic and 1386 nonacidic) reflux episodes and 953 clinical reflux behaviors were recorded. The incidence and pattern of GER was similar in preterm and term infants. There was no significant difference in GER episodes and acid exposure in preterm infants fed orally or via nasogastric tube. The symptom association probability was abnormal in only 6 (19%), 1 (5%), and 5 (28%) infants with irritability, bradycardia, and desaturation, respectively.

CONCLUSIONS

The prevalence of GER as detected by MII-pH was low (10%) in symptomatic preterm and term infants. The incidence and pattern of GER was similar in preterm and term infants. The majority of suspected clinical reflux behaviors did not correlate with reflux events.

The feasibility and efficacy of multi-channel intraluminal impedance monitoring in children

INTRODUCTION

The diagnosis of gastro-oesophageal reflux is currently based on clinical presentation and oesophageal pH monitoring. In recent years, the use of multi-channel intraluminal impedance (MII) monitoring has gained increasing attention in the adult population. However, its use in the paediatric population is still in the developing stage with only limited number of publications. This study aims to review our early experience of MII application in children.

METHODS

A retrospective study of all patients who underwent MII monitoring between 2011 and 2014 at a tertiary referral centre was performed. Patients' medical records were reviewed with demographic data extracted. Number of reflux episodes and other MII parameters were analysed.

RESULTS

In total, 34 patients were identified during the study period, with 20 males and 14 females. Indication for study included previous aspiration pneumonia (n = 13), persistent reflux or vomiting symptom (n = 10) and as part of routine assessment before gastrostomy (n = 11). At the time of study the average age was 69 months (range 9-216 months). 28 patients showed significant gastro-oesophageal reflux. On average patient has 36.1 acidic and 22.3 non-acidic reflux episodes during the 24 h monitoring period. Non-acidic reflux accounts for 38.1 % of the overall reflux episodes. The sensitivity of MII monitoring to detect reflux was higher compared to conventional pH study (73 vs 50 %, p = 0.1).

CONCLUSION

MII monitoring is safe and feasible in children. Non-acid reflux should not be underestimated in paediatric population. MII appears to be more sensitive than conventional pH monitoring in our study, but its true significance is yet to be confirmed by larger study in the future.

Combined multichannel intraluminal impedance-pH (MII-pH): multicenter report of normal values from 117 children

Although combined multichannel intraluminal impedance/esophageal pH monitoring (MII-pH) has replaced prolonged pH monitoring alone for assessing gastroesophageal reflux (GER) in the pediatric population, it does so in the absence of reference values for non-acid GER (NAGER). The purpose of this study was to identify a normal range of NAGER impedance values for infants and children. We evaluated EPM/MII tracings for patients referred for GER assessment to Nationwide Children's Hospital (Columbus, OH), Inova Children's Hospital, and Hospital Italiano (Buenos Aires, Argentina). We excluded tracings from patients who had AGER indices greater than 50 % of the upper end of normal (i.e., >3 % for children >12 months and >6 % for infants ≤ 12 months), had a positive temporal association of GER with symptoms, were on anti-reflux medications at the time of the study, and/or had a fundoplication prior to the study. We also excluded studies with durations shorter than 20 h. Values for NAGER percent time, NAGER episode frequency, frequency of proximal NAGER, and mean NAGER duration were calculated for upright position, recumbent, and total. Study population consisted of 46 infants (20 female [F]/26 male [M], median age 4.8 months [range 3 weeks-11.9 months]) with a median AGER index of 2.2 % (range 0.0-5.9 %) and 71 children (22 F/49 M, median age 7.2 years [range 1.3-17 years]) with a median AGER index of 1.1 % (range 0-3.0 %). Data are presented in tables in the text. The results of this study provide a range of values characteristic of infants and children with normal AGER indices and no positive temporal associations of GER with symptoms. These values may be used as references for comparison to identify infants and/or children who may be at risk of developing serious clinical manifestations due to abnormal patterns of GER.

Impacts of endoscopic gastroesophageal flap valve grading on pediatric gastroesophageal reflux disease

BACKGROUND

Gastroesophageal flap valve (GEFV) endoscopic grading is reported to be associated with gastroesophageal reflux disease (GERD) in adults; however its role in pediatric groups remains unknown. This study aimed to investigate the significance of GEFV grading and the associations to multichannel intraluminal impedance and pH monitoring (MII-pH) in children with GERD.

METHODS

A total of 48 children with GERD symptoms who received esophagogastroduodenoscopy and MII-pH monitoring were enrolled. The degree of GEFV was graded from I to IV according to the Hill classification, and classified into two groups: normal GEFV (Hill grades I and II), and abnormal GEFV (Hill grades III and VI). Endoscopic findings and MII-pH monitoring were analyzed among the groups.

RESULTS

Thirty-six patients had normal GEFV while 12 had abnormal GEFV. The presence of erosive esophagitis was significantly more common in the patients with abnormal GEFV (p = 0.037, OR 9.84, 95% CI 1.15-84.42). Pathological acidic gastroesophageal reflux (GER) determined by MII-pH was more prevalent in the patients with loosened GEFV geometry (p = 0.01, OR 7.0, 95% CI 1.67-27.38). There were significant positive correlations between GEFV Hill grading I to IV and the severity of erosive esophagitis (r = 0.49, p<0.001), percentage of supine acid reflux (r = 0.37, p = 0.009), percentage of total acid reflux (r = 0.3284, p = 0.023), and DeMeester score (r = 0.36, p = 0.01) detected by pH monitoring. In the impedance study, GEFV Hill grading also positively correlated to median number of acid reflux events (r = 0.3015, p = 0.037).

CONCLUSIONS

GEFV dysfunction highly associated with acid GER and severe erosive esophagitis. An abnormal GEFV is a sign of acid GER in children.

Esophageal pH and Combined Impedance-pH Monitoring in Children

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

Software for symptom association analysis in pediatric gastroesophageal reflux disease

Gastroesophageal reflux (GER) disease is a serious complication of the upper gastrointestinal tract. Cardiorespiratory symptoms such as apnea, oxygen desaturation and bradycardia may be related to GER. Thus, the recommended diagnostic methodology in pediatric patients requires 24-h synchronized esophageal and cardiorespiratory monitoring. However, there is no computer tool available for this purpose and therefore, researchers and physicians are forced to seek for customized solutions. This paper presents an open source computer program for the analysis of symptom association. It allows a convenient visualization of the biological signals and implements the three main metrics for symptom association, that is, the symptom index, the symptom sensitivity index and the symptom association probability. This software represents a flexible solution and will facilitate caregivers an easy assessment of the existence of temporal association between GER and cardiorespiratory episodes. This would ideally reduce inappropriate medical and surgical treatments and would provide an early diagnosis of the medical condition.

Pharmacological therapy of gastroesophageal reflux in preterm infants

Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.

Diagnostic accuracy of tests in pediatric gastroesophageal reflux disease

OBJECTIVE

To systematically review the literature evaluating the diagnostic accuracy of commonly used diagnostic tests over conventional history taking and physical examination in children ≤ 18 months and >18 months suspected of gastroesophageal reflux disease (GERD).

STUDY DESIGN

We searched Medline, Embase, and the Cochrane database for studies assessing the diagnostic accuracy of pH-metry, pH-impedance, esophagogastroscopy, barium contrast study, scintigraphy, and empirical treatment as diagnostic tools. Quality was assessed according to Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews criteria.

RESULTS

Of the 2178 studies found, 6 studies were included, containing 408 participants (age 1 month-13.6 years) and 145 controls (age 1 month-16.9 years). Studies included children with GERD symptoms; 1 included an atypical presentation. In all the studies, the diagnostic accuracy of pH-metry was investigated, and in 2 studies esophagogastroscopy was investigated as well. Sensitivity and specificity were calculated in 3 studies. The range of reported sensitivity and specificity was broad and unreliable because of poor methodological quality according to Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews criteria and inadequate study design.

CONCLUSION

Diagnostic accuracy of tests in children suspected of GERD remains unclear and implications for practice are hard to give. There is an urgent need of well-designed randomized controlled trials where the effect of treatment according to specific signs and symptoms will be compared with the effect of treatment based on the results of additional diagnostic tests, for patient relevant outcomes.

Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children

BACKGROUND

The effect of proton pump inhibitors on the characteristics of gastroesophageal reflux (GER) in children and adolescents was evaluated.

METHODS

Twenty-one children and adolescents with symptoms suggesting GER disease (GERD) underwent upper endoscopy and a 24-hour multichannel intraluminal impedance/pH (MII-pH) monitoring before and at the end of 2 months of therapy with proton pump inhibitors (PPIs).

RESULTS

Fourteen (67%) patients reported clinically relevant symptom improvement after 2 months of PPIs intake. At the first endoscopy, 8 (38%) patients had macroscopic signs of reflux esophagitis; after two months of therapy, 6/8 (75%) patients had a complete mucosal recovery. There was a significant reduction in the total percentage of mean acid reflux time (from 13.1% to 3.8%), and the De Meester score dropped to normal (from 46.4 to 13.1). The mean number of acid refluxes decreased significantly from 48 to 15 per 24 hours, while inversely, the mean number of weakly acid refluxes increased significantly from 26 to 64 per 24 hours. PPI therapy did not affect the total number of reflux episodes, the number of liquid and mixed refluxes, the duration of esophageal bolus exposure and proximal extent of the reflux.

CONCLUSIONS

In children and adolescents with GERD, PPIs do not affect the total number of reflux episodes. PPIs only decrease the acidity of refluxate. Nevertheless, the majority of patients with typical reflux symptoms may report symptom improvement. Esophagitis can be healed after PPI treatment. The treatment of weakly acid and weakly alkaline reflux remains a challenge for physicians in the future.

Pathophysiology of aerodigestive pulmonary disorders in the neonate

No test can provide a definitive diagnosis of aerodigestive disease. When interpreting tests, one should weigh the benefits and weaknesses of different technologies and methods, scientific appropriateness of the testing conditions, clinicopathologic correlation, and pharmacologic approaches. Gastroesophageal reflux disease (GERD) symptoms and airway symptoms can coexist, and they cannot be distinguished without specific testing and direct observations. Important aerodigestive disorders include dysphagia, GERD, and aggravation of airway injury due to malfunctions of swallowing or airway protection mechanisms. Objective evaluation of aerodigestive reflexes and symptom correlation may provide support for evidence-based personalized management of feeding and airway protection strategies.

Impedance-pH monitoring and conventional pH monitoring are complementary methods to detect association between gastroesophageal reflux and apnea-related symptoms in preterm infants and neonates

OBJECTIVE

To investigate the usefulness of Multichannel intraluminal impedance-pH (MII-pH) monitoring as compared with conventional pH monitoring for detecting Gastroesophageal reflux (GER) episodes and apnea-related symptom association in preterm infants and neonates.

METHODS

Twenty-three infants (16 preterm and 7 term infants) in hospital, who underwent 24-h MII-pH monitoring, were studied retrospectively. GER indices and apnea-related symptom association were measured by both MII-pH and conventional pH based analysis.

RESULTS

Of the total 998 GER episodes assessed by MII-pH monitoring, 407 (40.8%) were acidic and 590 (59.1%) were weakly acidic. A total of 1689 GER episodes were detected by conventional pH based analysis and 270 (16%) were related to retrograde bolus movement. A total of 313 apnea-related symptoms were reported. Five patients had a positive symptom association: 3 by MII-pH, 1 by both MII-pH and conventional pH, 1 only by conventional pH.

CONCLUSIONS

Addition of MII-pH monitoring to conventional pH monitoring improves the diagnostic yield of symptom association analysis in preterm infants and neonates with apnea-related symptoms. Conventional pH monitoring is still important in the era of impedance measurement.

Clinical Perspectives on Esophageal Disorders in Infants

Esophageal pathologies are complex and lend themselves to multivariable analysis before a definitive diagnosis can be considered. It is imperative that the clinician establish a methodology for selecting the appropriate technological assessment within scientific testing parameters to establish optimal clinicopathological presentation and determine best practice for patient care.

US in the diagnosis of gastroesophageal reflux in children

Several techniques have been used to diagnose gastroesophageal reflux (GER) in children, but no single test is sufficiently accurate to completely investigate the problem. Gastroesophageal US has been described as a widely available, noninvasive and sensitive method. It provides morphological and functional information, but its role in the diagnosis of GER in children is still debated. In this paper we review diagnostic approaches to GER in children. We focus on current use of US in the management of children with suspected GER. Reports suggest that US allows exclusion of several non-GER causes of symptoms and that it provides morphological and functional data with high sensitivity and positive predictive value for the diagnosis of GER. Sonographic assessment of findings such as abdominal esophageal length, esophageal diameter, esophageal wall thickness and gastroesophageal angle provide important diagnostic indicators of reflux and related to the degree of GER. There is a need for standardization of the procedure and for defining diagnostic criteria.

Assessment and treatment of gastroesophageal reflux in healthy infants with apneic episodes: a retrospective analysis of 87 consecutive patients

This retrospective study sought to assess whether gastroesophageal reflux (GER) is associated with recurrent infant apneic episodes (AEs) and whether its treatment prevents AEs. Symptoms, diagnostic measures, and treatment of GER in 87 infants admitted for AEs were recorded. The effect of GER on recurrent AEs and survival were assessed. Esophageal pH monitoring was done to 58/87 (67%) patients, of whom 53/58 (91%) had a pathological finding; 48 patients had treatment for GER (medical 43%/49%; surgical 5%/6%) with continuing AEs during hospitalization (25%/29% patients) as the main indication. Follow-up (65 patients) disclosed recurrent AEs in 12 (18%) patients (no treatment 4/21, medical 8/39, surgical 0/5, P = NS). All 87 patients survived. Recurrent AEs after discharge was predicted by AEs during hospitalization but not by pathological GER. AEs observed during hospitalization predicted postdischarge AE recurrence. Of GER treatment modalities, only surgery prevented recurrent AEs.

The efficacy of the upright position on gastro-esophageal reflux and reflux-related respiratory symptoms in infants with chronic respiratory symptoms

Purpose

Gastro-esophageal reflux (GER), particularly non-acid reflux, is common in infants and is a known cause of chronic respiratory symptoms in infancy. Recent guidelines recommended empirical acid suppression therapy and the head-up position in patients with suspected GER. However, the efficacy of the upright position in relieving GER and reflux-related respiratory symptoms in infants is unclear. We conducted this study to investigate the efficacy of the upright position on GER and reflux-related respiratory symptoms in infants with chronic respiratory symptoms.

Methods

Thirty-two infants (21 male; median age, 5 months; range, 0 to 19 months) with unexplained chronic respiratory symptoms underwent multi-channel intraluminal esophageal impedance and pH monitoring. We retrospectively compared the frequencies of GER and reflux-related symptoms according to body position.

Results

A mean of 3.30 episodes of reflux per hour was detected. Overall, refluxes were more frequent during the postprandial period than the emptying period (3.77 vs. 2.79 episodes/hour, respectively; P=0.01). Although there was no significant difference in the total refluxes per hour between the upright and recumbent positions (6.12 vs. 3.77 episodes, P=0.10), reflux-related respiratory symptoms per reflux were significantly fewer in infants kept in an upright position than in a recumbent position during the postprandial period (3.07% vs. 14.75%, P=0.016). Non-acid reflux was the predominant type of reflux in infants, regardless of body position or meal time.

Conclusions

The upright position may reduce reflux-related respiratory symptoms, rather than reflux frequency. Thus, it may be a useful non-pharmacological treatment for infantile GER disease resistant to acid suppressants.

Impact of feeding strategies on the frequency and clearance of acid and nonacid gastroesophageal reflux events in dysphagic neonates

BACKGROUND

Feeding difficulties and gastroesophageal reflux (GER) are common problems in neonates. The authors hypothesize that GER could be influenced by feeding mechanics by evaluating the effects of feeding volumes, feeding durations, feeding flow rates, and caloric density on the chemical composition and clearance of GER in dysphagic neonates.

METHODS

Symptomatic dysphagic neonates (n = 35) underwent evaluation for suspected GER using pH-impedance methods.

RESULTS

The proportions of acid and nonacid GER were different during the first, second, and third postprandial hours (P < .0001). Prolonged feeding duration was significantly associated with decreased total, nonacid GER and BCT (P < .03). Significant positive correlations (P < .05) were detected between feeding flow rate vs frequency of total, nonacid GER and BCT. Significant positive correlation (P = .002) was noted between feeding volume and BCT. BCT decreased with each hourly interval (analysis of variance [ANOVA] P < .05); however, ACT increased with each hourly interval (ANOVA P = .05). Comparison between BCT and ACT at each postprandial hour is remarkable for longer ACT during the second and third hours after the initiation of feed (P ≤ .001). No significant correlation was noted between the milk types (breast milk or formula) or caloric density with regard to the GER characteristics. Oral-fed infants had more GER events than gavage-fed infants.

CONCLUSIONS

Prolonged feeding durations and slower flow rates are associated with decreased frequency of GER. Modification of feeding duration and flow rate can be a useful adjunct to ameliorate GER in dysphagic neonates.

Detection of pepsinogen in the neonatal lung and stomach by immunohistochemistry

OBJECTIVE

Evaluate the hypothesis that the same pepsinogen C molecule produced in the stomach is also produced by the lung.

PATIENTS AND METHODS

Pulmonary and gastric tissues collected postmortem were immunohistochemically stained for pepsinogen C and pepsinogen A.

RESULTS

Sixteen patients with diverse causes of death were evaluated. Gestational age at birth ranged between 21 and 37 weeks. Pepsinogen A was detected in 12 of the 13 stomach sections, mainly in the chief cells, but not in any lung sections. Pepsinogen C was detected in all stomach sections in chief and mucus cells and in 9 of the 16 lung sections, mainly in type II pneumocytes. Pepsinogen C was not detected in the 3 lung cases with a gestational age <23 weeks.

CONCLUSIONS

The same pepsinogen C molecule is produced in the stomach and in the lung. These findings potentially affect previous study results that used an enzymatic pepsin detection assay to evaluate for and associate gastroesophageal reflux disease with other morbidities.

Temporal association of polysomnographic cardiorespiratory events with GER detected by MII-pH probe in the premature infant at term

OBJECTIVES

The aim of the study was to examine temporal association (TA) between polysomnographic cardiorespiratory (CR) events and gastroesophageal reflux (GER) in premature infants with persistent CR events at >39 weeks postmenstrual age and determine whether the use of multichannel intraluminal impedance (MII)-pH probe improves sensitivity of the TA compared with pH probe alone.

PATIENTS AND METHODS

Seven infants born between 24 and 29 weeks' gestational age with persistent CR events at 39 to 48 weeks' postmenstrual age underwent a polysomnography with MII-pH probe. Symptom index (SI) and symptom-associated probability were calculated for diverse types of reflux and CR events. SI and a Fisher exact test with variable association windows were calculated for obstructive apnea (OA). Odds ratios for an OA given a reflux event and for a reflux event given an OA were determined.

RESULTS

With a Fisher exact test, a subject-specific association between MII events and OA was found in the 3 patients who required a fundoplication or had the worse clinical GER. Some level of TA was found with SI and symptom-associated probability in 6 of 7 infants. Association was found for pH > 4 and pH ≤ 4 reflux events. pH-only events with no change of MII had only a limited role in generating CR events.

CONCLUSIONS

TA between CR events and GER was found in a single-subject-level analysis in some infants with persistent CR events at term. This TA suggests a causal relation between CR and reflux events that was further strengthened by the clinical outcomes of each infant.

Does reflux monitoring with multichannel intraluminal impedance change clinical decision making?

OBJECTIVES

Multichannel intraluminal impedance with pH (pH-MII) has become the criterion standard test for the evaluation of gastroesophageal reflux disease, but it is not clear whether the results of this test change clinical decision making. The goal of the present study was to determine the differences in clinical decision making by attending physicians based on the pH probe results versus MII results.

METHODS

We conducted a prospective study in which physicians were initially given pH probe results and asked how they would change the patient's clinical management based on these results. Physicians were then given the MII results and asked how their management would change. Physicians then were asked whether they believed MII affected their clinical decision making overall.

RESULTS

pH probe results changed clinical management 40% of the time and MII results changed clinical management an additional 22% of the time. Clinical decision making was not influenced by the performance of pH-MII on or off acid suppression. The escalation of acid suppression therapy was the main management change that occurred based on the pH-MII results.

CONCLUSIONS

The addition of MII to the standard pH probe resulted in a change in management in approximately 25% of the patients, suggesting that there may be a role for pH-MII in clinical practice.

The frequency of apneas in very preterm infants is increased after non-acid gastro-esophageal reflux

BACKGROUND

To evaluate whether physical and/or chemical features of gastro-esophageal reflux (GER) influence its relationship with apnea of prematurity (AOP).

METHODS

Fifty-eight preterm newborns (GA ≤ 33 weeks) with recurrent apneas were studied by simultaneous polysomnography and combined impedance and pH monitoring, to analyze whether the correlation between GER and AOP varies according to the acidity, duration and height of GERs.

KEY RESULTS

The frequency of apnea (number apnea/min) occurring after-GER [median (range) 0.07 (0-0.25)] was higher than the one detected in GER-free period [0.06 (0.04-0.13), P = 0.015], and also than the one detected before-GER [0 (0-0.8), P = 0.000]. The frequency of apneas detected in the 30'' after pH-GER [median (range), 0 min(-1) (0-1.09)] was higher than the frequency detected in the 30'' before [0 (0-0.91), P = 0.04]; even more, the frequency of apneas detected after non-acid MII-GER episodes [0 (0-2)] was significantly higher than the one detected before [0 (0-1), P = 0.000], whereas the frequency of apneas detected before acid MII-GER episodes [0 (0-0.67)] did not differ from the one detected after [0 (0-2), P = 0.137]. The frequency of pathological apneas detected in the 30'' after-GER (0 min(-1), range 0-0.55) was higher than the frequency detected before (0, range 0-0.09; P = 0.001). No difference in mean height or in mean duration was found between GERs correlated and those non-correlated to apnea.

CONCLUSIONS & INFERENCES

Non-acid GER is responsible for a variable amount of AOP detected after-GER: this novel finding must be taken into consideration when a therapeutic strategy for this common problem is planned.

The relationship between gastroesophageal reflux and cough in children with chronic unexplained cough using combined impedance-pH-manometry recordings

INTRODUCTION

Assessment of the reflux-cough association in children is challenging. Esophageal (impedance) pH recording is sensitive to recognize reflux. However, cough recorded by an event marker, possibly lacks accuracy. We aimed to study the exact time relationship between reflux and cough in children with chronic cough.

METHODS

Twenty-six children (12 boys; 1-10.5 years) with chronic unexplained cough underwent ambulatory impedance-pH-manometry recordings. Manometry was used for precise cough recognition. Reflux was assessed with impedance-pH monitoring and defined as acid (pH <4), weakly acidic (WA) (pH 4-7), weakly alkaline (WALK) (pH ≥7), or acid only (pH <4 for ≥4 sec without impedance pattern). Cough was considered "induced by" reflux, if it started ≤2 min after reflux. The Symptom Association Probability (SAP) was calculated and considered positive if >95%. Cough-induced reflux if it occurred 30 sec before the reflux event.

RESULTS

Impedance-pH detected 30 (21-52) reflux episodes/patient (55.2% acid, 41.5% WA, and 3.3% WALK). Additionally 59 acid only events were identified [1 (0-21)/patient]. Manometry detected 47 (5-203) cough bursts/patient. Reflux-cough was found in 22/26 patients. Ten patients had a +SAP for reflux-cough (one acid, six WA, and three acid + WA gastroesophageal reflux [GER]), of which nine had a normal acid exposure. Six out of 10 patients with +SAP using manometry had a +SAP using the event marker. Cough-reflux was detected in 19 patients [3 (0-7)/patient]. Only a small fraction of the esophageal acid exposure [9.6 (0.4-31.8%)] was secondary to cough.

CONCLUSION

Both acid and WA GER may precede cough in children with unexplained cough, but cough does not induce GER. Objective cough recording improves symptom association analysis.

Esophageal impedance monitoring for gastroesophageal reflux

Dual pH-multichannel intraluminal impedance (pH-MII) is a sensitive tool for evaluating overall gastroesophageal reflux disease, and particularly for permitting detection of nonacid reflux events. pH-MII technology is especially useful in the postprandial period or at other times when gastric contents are nonacidic.pH-MII was recently recognized by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as being superior to pH monitoring alone for evaluation of the temporal relation between symptoms and gastroesophageal reflux. In children, pH-MII is useful to correlate symptoms with reflux (particularly nonacid reflux), to quantify reflux during tube feedings and the postprandial period, and to assess efficacy of antireflux therapy. This clinical review is simply an evidence-based overview addressing the indications, limitations, and recommended protocol for the clinical use of pH-MII in children.

Esophageal impedance in children: symptom-based results

OBJECTIVE

To correlate multiple intraluminal esophageal impedance recording with pH-monitoring with symptoms.

STUDY DESIGN

Symptoms occurring within a 2-minute window of a reflux were considered to be associated with reflux. Analyses were performed in 1- to 6-, 6- to 12-, and >12-months-old patients for crying, pain, cough, and vomiting.

RESULTS

A total of 70 of 225 tracings were discarded. Of 2172 symptoms, 1136 (52%) were reflux-associated (45% acid reflux [AR], 51% weakly AR, 3% alkaline reflux). The strongest reflux-symptom association was found for vomiting. Cough-reflux association was higher in infants than in older children. In older patients, symptom-reflux association was more with AR. Symptoms were associated with proximal reflux in 70% of patients. The symptom index and symptom association probability (SAP) were positive (>50% for symptom index and >95% for SAP) for all refluxes in 83% and 46% of patients and for AR in 49% and 47% of patients, respectively. In 1- to 6-month-old infants, symptom index and SAP were higher for weakly AR than for AR. For crying, SAP was independent of AR or weakly AR. For cough, SAP was positive in one-third of patients, predominantly with AR in 6- to 12-month-old infants and with weakly AR in the other infants.

CONCLUSION

Multiple intraluminal esophageal impedance recording with pH-monitoring doubles the probability of documenting an association between symptoms and reflux compared with pH monitoring. In young infants, symptoms are more frequently associated with weakly AR than with AR.

Characterization of cardiorespiratory events following gastroesophageal reflux in preterm infants

OBJECTIVE

The aim of this study was to characterize cardiorespiratory events in preterm infants after both acid and nonacid gastroesophageal reflux (GER) as detected by pH and multiple intraluminal impedance (MII).

STUDY DESIGN

Twelve hour overnight studies were performed in 71 preterm infants (gestational age 29.4±3.0 weeks, birth weight 1319±496 g). Apnea ≥10 s in duration, bradycardia ≤80 b.p.m. and oxygen desaturation ≤85% that occurred within 30 s after the initiation of GER were classified as associated with GER.

RESULT

A total of 12,957 cardiorespiratory events and 4164 GER episodes were documented. Less than 3% of all cardiorespiratory events were preceded by GER constituting 3.4% of apnea, 2.8% of oxygen desaturation and 2.9% of bradycardia events. GER did not prolong cardiorespiratory event duration or increase severity. In contrast, GER was associated with a shorter duration of oxygen desaturation events (7.8±4.6 vs 6.3±5.6 s, P<0.05).

CONCLUSION

GER is rarely associated with cardiorespiratory events, and has no detrimental effect on cardiorespiratory event duration or severity.

Gastroesophageal reflux disease and eosinophilic esophagitis in infants and children. A study of esophageal pH, multiple intraluminal impedance and endoscopic ultrasound

OBJECTIVE

Eosinophilic esophagitis (EE) and gastroesophageal reflux disease (GERD) in childhood share aspects of symptomatology. In order to characterize EE and GERD in infants and children with symptoms of GERD we performed a prospective investigation including prolonged esophageal pH measurement, multiple intraluminal impedance (MII) and esophageal wall estimation by endoscopic ultrasound (EUS).

MATERIAL AND METHODS

Infants and children (0-15 years) with typical symptoms of GERD persisting after a 14-days proton pump inhibitor trial were included in a prospective study protocol. Upper endoscopy and EUS of the esophageal wall were performed followed by combined esophageal MII and pH measurement for 24 h.

RESULTS

A total of 78 infants and children were investigated: EE patients (n = 6), GERD patients (n = 28) and a group of infants and children with normal investigations (n = 44). The GERD group did not show a significantly higher number of non-acid reflux episodes (p = 0.9) than the patients with normal investigations. In all patients gastroesophageal reflux regularly extended into the proximal esophagus. EUS in four EE patients suggested an increased thickness of the mucosal layers both in the distal and in the proximal part of the esophagus.

CONCLUSIONS

Esophageal MII indicated that neutral non-acid reflux episodes do not occur frequently in pediatric GERD or in EE. MII and pH-metry indicated that the majority of reflux episodes both in patients and controls pass into the proximal esophagus. EUS measurements suggested in EE patients a thickened mucosa both in the proximal and the distal part of the esophagus as compared to children with GERD and disease controls.

Can acid (pH) refluxes predict multichannel intraluminal impedance refluxes? A correlation study

BACKGROUND AND AIM

The present study aims to explore if and when acid (pH) refluxes can predict refluxes detected by multichannel intraluminal impedance (MII) studies. This correlation may indicate whether pH probe-only and MII-pH studies are interchangeable.

METHODS

Prospective observational cross sectional study of symptomatic children (below 18 years) who had MII-pH studies done for gastroesophageal reflux. Clinical data were extracted from patient records. Non-parametric tests, Pearson's rho and receiver operating characteristic (ROC) curves were used for data analysis.

RESULTS

A total of 153 children were included in the study and 62% were on acid suppression. Indices for acid and MII refluxes correlated with each other only in those without acid suppression. This correlation was lost in children on acid suppression. There was no statistically significant difference in acid or MII reflux indices in children with or without acid suppression. Like acid reflux, indices for MII refluxes had good correlation with each other irrespective of acid suppression. Liquid and mixed MII refluxes showed excellent correlation with respective types of proximally migrating refluxes. The values for MII reflux indices derived from our patient population were in broad agreement with available pediatric and adult data.

CONCLUSIONS

A pH probe-only study in patients without acid suppression may reflect both acid and volume (MII) reflux activities adequately and can substitute for MII-pH study. The observed excellent correlation between acid and MII refluxes with proximal migration may justify using pH probe-only studies for extra esophageal symptoms in patients without acid suppression.

Non-acid gastro-oesophageal reflux in children with suspected pulmonary aspiration

BACKGROUND & AIMS

In a group of children with suspected pulmonary aspiration, we aimed to describe the type and physical characteristics of gastro-oesophageal reflux (GOR) episodes, and to determine their correlation with the lipid-laden macrophage (LLM) content in bronchoalveolar lavage (BAL).

PATIENTS AND METHODS

Twenty-one children with a diagnosis of bronchial asthma, recurrent lung consolidations and recurrent laryngotracheitis underwent 24-h multichannel intraluminal impedance and pH (MII-pH) monitoring, fibreoptic bronchoscopy and BAL. The following parameters were evaluated: total number of reflux episodes, number of acid reflux [AR; pH<4] and non-acid reflux [NAR] episodes [pH>4], height of reflux episodes, LLM content and percentage of neutrophils in the BAL.

RESULTS

The number of NAR episodes and the number of those reaching the proximal oesophagus were significantly higher in patients with recurrent lung consolidations than in those with bronchial asthma and laryngotracheitis (p<0.01 and p<0.01). BAL studies showed a significantly higher LLM content in children with recurrent lung consolidations than in those with bronchial asthma and laryngotracheitis (p<0.01). The LLM content correlated significantly with the total number of reflux episodes (r=0.73; p<0.001) and with those reaching the proximal oesophagus (r=0.67; p<0.001). Finally, the LLM content correlated with the number of NAR episodes (r=0.61; p<0.01), with those reaching the proximal oesophagus (r=0.64; p<0.01) and with the percentage of BAL neutrophils (r=0.7; p<0.01).

CONCLUSION

NAR episodes reaching the proximal oesophagus correlate with diagnostic marker for pulmonary micro-aspiration. MII-pH monitoring increases the yield in identifying types and proximal extension of reflux episodes, that discriminate between patients with and without pulmonary aspiration.