Gastroesophageal reflux disease in neonates and infants : when and how to treat

Infant gastroesophageal reflux disease management consensus

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preventing and Treating Colic: An Update

Infantile colic (IC) is c is a self-limiting functional gastrointestinal disorder (FGID) with a favorable natural history. Worldwide, IC has a significant impact on many newborns and their families. Although not an indication of an illness, its symptoms are wide and generic and may indicate a potentially serious underlying issue in a tiny percentage of newborns who may require a medical evaluation. The pathogenesis appears to be multifactorial implying a complex relationship between the infant and the environment. One of the most studied theories attributes a key role to the gut microbiota in the pathogenesis of IC. A variety of approaches have been suggested for the clinical management of IC, and several randomized controlled trials have been reported in the literature. Probiotics can change the host's microbiota and positively impact health. They may be able to restore balance and create a better intestinal microbiota landscape since there is mounting evidence that the gut microbial environment of colicky newborns differs from that of healthy infants. In this review, we revise the most commonly studied probiotics and mixtures to treat and prevent IC and the most recent recommendations.

A single-center experience of using milk scintigraphy in 251 pediatric patients: A retrospective study

To report our experience with milk gastroesophageal scintigraphy and the management of gastroesophageal reflux (GER) in children. In 251 pediatric patients we recorded age, underlying disease, central nervous system (CNS) disorders, and GER management. GER management was classified based on treatment plans: grade 0, non-pharmacological treatment; grade 1, non-pharmacological but using a nasogastric tube; grade 2, pharmacological treatment; grade 3, transpyloric feeding; and grade 4, Nissen fundoplication surgery. Patients were included in classified groups with (grades 2, 3, and 4) and without (grades 0 and 1) GER treatment. We evaluated the GER height (classified based on the height of GER, grade 0; no GER, 1; GER in the lower esophagus, 2; GER in the upper esophagus), GER duration in the lower and upper esophagus, presence or absence of massive GER amounts in the lower and upper esophagus, and gastric emptying time. We compared milk scintigraphy results and patient characteristics between groups with (grades 2, 3, and 4) and without (grades 0 and 1) GER treatment. We treated 121 patients for GER. CNS disorders (presence/absence: 46/74 with vs 21/110 without treatment, P < .001). The GER height grade (1.7 ± 0.5 [range, 0-2] with vs 1.5 ± 0.7 [range, 0-2] without treatment, P = .002), massive GER amount (present/absent: 21/99 with vs 9/122 without treatment, P = .011), and duration of GER (seconds) (324.5 ± 508.3 [range, 0-1800] vs 125.0 ± 291.9 [range, 0-1750], P < .001) in the upper esophageal half differed significantly. Similarly massive GER amount (present/absent: 54/66 with vs 34/97 without treatment, P = .002) and GER duration (621.3 ± 601.0 [range, 0-1800] vs 349.8 ± 452.4 [range, 0-1800], P < .001) in the lower esophageal half differed significantly. Additionally, CNS disorders, age, and massive GER in the upper esophageal half differed significantly among grades 2 and 4 in treated patients (P < .05, P < .001, P < .05, respectively). Milk scintigraphy is useful for deciding whether GER treatment is indicated. However, the treatment plan needs to be decided based on each patient's condition.

The natural course of otitis media with effusion in infants who failed universal newborn hearing screening: a retrospective cohort study

OBJECTIVES

To analyse the natural course of infants with otitis media with effusion who failed universal newborn hearing screening and to explore the appropriate observation period.

METHODS

This retrospective cohort analysis included infants with otitis media with effusion who failed universal newborn hearing screening every 3 months for 12 months.

RESULTS

The average recovery time of the 155 infants was 7.08 ± 0.32 months after diagnosis. Multivariate Cox regression analysis confirmed that frequent reflux, maxillofacial deformities and initial hearing status were independent factors affecting recovery. Moreover, the cumulative recovery of most infants with mild hearing loss and infants with moderate hearing loss accompanied by frequent reflux was significantly higher at six months after diagnosis than at three months.

CONCLUSION

For most infants with mild hearing loss, as well as those with moderate hearing loss accompanied by frequent reflux, the observation period can be extended to six months after diagnosis.

Pediatric Laryngopharyngeal Reflux in the Last Decade: What Is New and Where to Next?

BACKGROUND

Laryngopharyngeal reflux may affect people of any age; still, most of the accumulated knowledge concerns adults, and evidence regarding pediatric populations remains relatively restricted. This study aims to review the most recent and emerging aspects of pediatric laryngopharyngeal reflux from the last ten years. It also attempts to identify gaps in knowledge and highlight discrepancies that future research should urgently address.

METHODS

An electronic search of the MEDLINE database was conducted, limited to January 2012 through December 2021. Non-English language articles, case reports, and studies that concerned a purely or predominantly adult population were excluded. The information from the articles with the most relevant contribution was initially categorized by theme and subsequently synthesized into a narrative form.

RESULTS

86 articles were included, of which 27 were review articles, eight were surveys, and 51 were original articles. Our review systematically maps the research done in the last decade and provides an updated overview and the current state-of-the-art in this subject.

CONCLUSIONS

Despite discrepancies and heterogeneity in accumulating research, evidence gathered so far endorses a need for refining an escalating multiparameter diagnostic approach. A step-wise therapeutic plan appears to be the most reasonable management approach, starting with behavioral changes for mild to moderate, uncomplicated cases and escalating to personalized pharmacotherapy options for severe or nonresponsive cases. Surgical options could be considered in the most severe cases when potentially life-threatening symptoms persist despite maximal medical therapy. Over the past decade, the amount of available evidence has been gradually increasing; however, its strength remains low. Several aspects remain markedly under-addressed, and further adequately powered, multicenter, controlled studies with uniformity in diagnostic procedures and criteria are urgently needed.

Limosilactobacillus reuteri DSM 17938-Containing Infant Formulas and the Associations with Gastrointestinal Tolerance: A Cross-Sectional Observational Study

Limosilactobacillus (L.; previously Lactobacillus) reuteri has been shown to influence gastrointestinal (GI) tolerance. This study was a secondary analysis of GI tolerance data from a multi-country, cross-sectional, observational study in healthy infants using the validated Infant Gastrointestinal Symptom Questionnaire (IGSQ) and a gut comfort questionnaire. Breastfed infants (BFI; n = 760) were compared to formula-fed infants receiving either L. reuteri-containing formula (FFI + LR; n = 470) or standard formula without any probiotic or prebiotic (FFI-Std; n = 501). The IGSQ composite scores (adjusted mean ± SE) in FFI + LR (22.17 ± 0.39) was significantly lower than in FFI-Std (23.41 ± 0.37) and similar to BFI (22.34 ± 0.30;), indicating better GI tolerance in FFI + LR than in FFI-Std. Compared with FFI-Std, FFI + LR had lower reports of difficulty in passing stools (11% vs. 22%; adjusted-odds ratio (OR) (95%CI) = 0.46 (0.31-0.68)), fewer hard stools (mean difference = -0.12 (-0.21, -0.02)) and less physician-confirmed colic (OR = 0.61 (0.45-0.82)), and similar to BFI. Parent-reported crying time (mean difference = -0.15 (-0.28, -0.01)), frequency of spitting-up/vomiting (mean difference = -0.18 (-0.34, -0.03)), volume of spit-up (mean difference = -0.20 (-0.32, -0.08)) and fussiness due to spitting-up/vomiting (mean difference = -0.17 (-0.29, -0.05)) were lower in FFI + LR versus FFI-Std and similar to BFI. In this study, L. reuteri-containing formula was associated with improved digestive tolerance and behavioral patterns.

Infant feeding practice and gastrointestinal tolerance: a real-world, multi-country, cross-sectional observational study

BACKGROUND

Signs of feeding intolerance, such as gastrointestinal (GI) symptoms, are frequently observed in otherwise healthy formula-fed infants in the first months of life. The primary objective of this observational study was to examine GI tolerance in formula-fed infants (FFI) vs. breastfed infants (BFI) in a real-world setting with a secondary objective being the comparison of infants fed formula with pre- and/or probiotics (FFI_PP) and those fed formula without any pre- and/or probiotics (FFI_noPP) as well as BFI.

METHODS

A six-country, cross-sectional study in full-term exclusively/predominantly FFI (n = 2036) and BFI (n = 760) aged 6-16 weeks was conducted using the validated Infant Gastrointestinal Symptom Questionnaire (IGSQ) and a Feeding Practice and Gut Comfort Questionnaire.

RESULTS

The IGSQ composite score in FFI was non-inferior compared to BFI (mean difference [95%CI]: 0.17 [-0.34, 0.67]; non-inferiority p-value < 0.0001) and scores for BFI and FFI were below the threshold of 23, indicating no GI discomfort. Adjusted mean IGSQ scores ± SE were similar in FFI_PP (22.1 ± 0.2) and BFI (22.3 ± 0.3) while FFI_noPP (23.4 ± 0.3) was significantly higher and above 23 indicating some GI discomfort (mean differences [95%CI] FFI_noPP minus FFI_PP and FFI_noPP minus BFI were 1.28 [0.57, 1.98] and 1.09 [0.38, 1.80], respectively; both p < 0.01). Hard stools and difficulty in passing stool were more common in FFI compared to BFI (p < 0.01) but were less common in FFI_PP compared to FFI_noPP (p < 0.01). FFI_PP showed significantly less crying than FFI_noPP and was similar to BFI. Significantly fewer physician-confirmed colic episodes (Rome IV criteria) were reported in FFI_PP compared with FFI_noPP or BFI.

CONCLUSIONS

In this real-world observational study, FFI had non-inferior overall GI tolerance compared to BFI. Within FFI, infants receiving formulas with pre- and/or probiotics had a better GI tolerance, improved stooling and less infantile colic compared to those receiving formula without any pre- and/or probiotics and were more similar to BFI.

TRIAL REGISTRATION

NCT03703583, 12/10/2018 ( https://clinicaltrials.gov/ct2/show/NCT03703583 ).

Probiotics and gastrointestinal diseases

During the past decades, scientists have discovered the intimate role of the gut microbiome in human health, and since then, several papers have been published to investigate if the use of biotics (probiotics, prebiotics, synbiotics, and postbiotics) may have a beneficial impact on human health both in treatment and prevention. We now ask ourselves whether we have reached the finish line or just a new starting point, as the evidence supporting the use of biotics in several conditions still needs a lot of work. Many questions remain unanswered today because the evidence differs depending on the indication, used strain, and amount and duration of administration. Herein we will summarize the evidence on probiotics in some gastrointestinal diseases such as infantile colic, functional abdominal pain disorders, celiac disease, acute gastroenteritis, inflammatory bowel disease, and Helicobacter pylori infection.

Efficacy and Safety of Domperidone in Combination with Proton Pump Inhibitors in Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

The aims of gastroesophageal reflux disease (GERD) treatment are symptom relief and healing of oesophagitis. Besides proton pump inhibitors (PPIs), prokinetic agents are also commonly prescribed to treat GERD. Domperidone, a well-known antiemetic, is an example of a prokinetic agent. It is a dopaminergic blocker that increases lower oesophagus sphincter pressure and activates gastric motility. We carried out a systematic review and meta-analysis to explore the benefits of domperidone in addition to PPI therapy for GERD. We searched for publications comparing PPI plus domperidone to PPI monotherapy in terms of symptom improvement in GERD (until 21 April 2022) on PubMed, Scopus, Google Scholar, Web of Science, Cochrane Library, WHO’s International Clinical Studies Registry Platform, and ClinicalTrials.gov without restricting date, language, or study design. The protocol was registered in PROSPERO (CRD42021242076). This meta-analysis incorporated 11 studies with a total of 841 participants (419 in the PPI plus domperidone group and 422 in the PPI monotherapy group). The combination of a PPI and domperidone resulted in a significant reduction in global GERD symptoms. Adverse events associated with PPI plus domperidone treatment were similar to those associated with PPI monotherapy. In conclusion, the combination of domperidone and a PPI is generally safe and effective in treating GERD as compared with that of PPI alone.

Prevalence and risk factors of functional gastrointestinal disorders in Vietnamese infants and young children

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are common early in life. The prevalence of FGIDs varies among countries but is unknown in Vietnam. The aim of this study is to assess the prevalence of FGIDs in healthy Vietnamese infants and young children.

METHODS

This was a cross-sectional, observational study involving healthy infants and young children between 0 - 48 months old in Hanoi, Vietnam. A representative total of 1511 subjects completed the validated questionnaire on paediatric FGIDs. Rome IV criteria were used to define FGIDs.

RESULTS

For Vietnamese infants (0-6 months) and young children (7-48 months), the prevalence of having at least one FGID was 10.0% and only 0.6% was having more than one FGID. Infantile regurgitation (9.3%) was the most prevalent FGID among infants 0-6 months of age while all other FGIDs had a low prevalence between 0-2.5%. For young children between 7 - 48 months old, functional constipation was the most common disorder at the rate of 5.6%. Association analysis revealed that the risk of infant regurgitation was significantly lower among infants with exclusively breastfeeding at 2 - 3 months and 3 - 4 months, formula initiation at 0 - 1 months, and higher paternal education level. The prevalence of functional constipation was significantly higher in male subjects, children in families with annual household income between 273,000,000 - 546,999,999 VND (or estimate around 11,800 - 23,800 USD), families with one child only, and formula feeding initiation at 1 - 2 months.

CONCLUSIONS

The prevalence of FGIDs in Vietnamese infants and young children is relatively low compared to the published literature using Rome IV diagnostic criteria. Infantile regurgitation was the most common FGID in Vietnamese infants while functional constipation was most prevalent among Vietnamese young children.

TRIAL REGISTRATION

Netherlands Trial Registry Identifier: NL7286/NTR7495 .

Anti-reflux surgery in neonates and infants: analysis of indications, outcomes, and link to mortality among primary and secondary gastroesophageal reflux patients

Background

The indications and benefits of anti-reflux surgery (ARS) in neonates and infants are uncertain. Prematurity, operation before 1 year of age, neurological impairment (NI), and chronic lung disease (CLD) are risk factors for surgical failure. We aim to document the indications, management, and outcomes of ARS in this age group and compare them among primary and secondary gastroesophageal reflux (GERD).

Results

Between January 2008 and December 2019, 24 males and 22 females had ARS; 13 (28.3%) for primary while 33 (71.7%) for secondary GERD. The mean gestational age was 34.6 weeks (range 24–41) and mean birth weight was 2000 gm (range 600–3300). The weight at time of referral ranged from 1.4 kg to 4 kg (mean 2.2 kg). There were no significant differences between the two groups regarding the previous data. The group of primary GERD presented mainly with recurrent aspiration (n = 8), recurrent apnea (n = 5), and recurrent desaturations with or shortly after feeds (n = 4). The group of secondary GERD were referred for poor sucking with failure to thrive (FTT) (n = 25), recurrent aspiration (n = 20), and gastrostomy request (n = 14). The risk factors for secondary GERD were neurologically impaired (n = 22), post-esophageal atresia (EA) repair (n = 9), hiatus hernia (n = 4), thoracic stomach (n = 2), N-type tracheoesophageal fistula (TEF, n = 4), and congenital esophageal stenosis (CES, n = 4). The operations included open Nissen’s fundoplication (ONF) (n = 4) and modified open Thal’s fundoplication (MOTF) (n = 42). There were 8 mortalities in the secondary group, unrelated to surgery. Morbidities after Nissen’s fundoplication included wrap migration, gas bloat, and reoperation in one, laparotomy for intestinal obstruction (IO) in one. Following MOTF, there were two cases of transient recurrent GERD which improved with time and laparotomy in one for IO.

Conclusions

Diagnostic tests remain a challenge. Isolated TEF and CES may require fundoplication for staged management. Cases of the primary group did better with MTFO. Prematurity, CLD and age < 2 months were not significant risk factors for fundoplication failure or mortality. Neurological impairment was a risk factor for mortality.

Prevalence, risk factors and parental perceptions of gastroesophageal reflux disease in Asian infants in Singapore

INTRODUCTION

Infant gastroesophageal reflux disease (GERD) is a significant cause of concern to parents. This study seeks to describe GERD prevalence in infants, evaluate possible risk factors and assess common beliefs influencing management of GERD among Asian parents.

METHODS

Mother-infant dyads in the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) cohort were prospectively followed from preconception to 12 months post-delivery. GERD diagnosis was ascertained through the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R) administered at 4 time points during infancy. Data on parental perceptions and lifestyle modifications were also collected.

RESULTS

The prevalence of infant GERD peaked at 26.5% at age 6 weeks, decreasing to 1.1% by 12 months. Infants exclusively breastfed at 3 weeks of life had reduced odds of GERD by 1 year (adjusted odds ratio 0.43, 95% confidence interval 0.19-0.97, P=0.04). Elimination of "cold or heaty food" and "gas producing" vegetables, massaging the infant's abdomen and application of medicated oil to the infant's abdomen were quoted as major lifestyle modifications in response to GERD symptoms.

CONCLUSION

Prevalence of GERD in infants is highest in the first 3 months of life, and the majority outgrow it by 1 year of age. Infants exclusively breastfed at 3 weeks had reduced odds of GERD. Cultural-based changes such as elimination of "heaty or cold" food influence parental perceptions in GERD, which are unique to the Asian population. Understanding the cultural basis for parental perceptions and health-seeking behaviours is crucial in tailoring patient education appropriately for optimal management of infant GERD.

Use of Limosilactobacillus reuteri DSM 17938 in paediatric gastrointestinal disorders: an updated review

Strains of lactobacilli are the most widely used probiotics and can be found in a large variety of food products and food supplements throughout the world. In this study, the evidence on Limosilactobacillus reuteri DSM 17938 (LR DSM 17938) has been reviewed. This species secretes reuterin and other substances singularly or in microvesicles, inhibiting pathogen growth and interacting with the intestinal microbiota and mucosa, restoring homeostasis. The use of LR DSM 17938 has been exploited in several pathological conditions. Preclinical research has shown that this probiotic can ameliorate dysbiosis and, by interacting with intestinal mucosal cells, can raise the pain threshold and promote gastrointestinal motility. These aspects are amongst the significant components in functional gastrointestinal disorders, such as colic and regurgitation in infants, functional abdominal pain and functional constipation in children and adolescents. This strain can decrease the duration of acute diarrhoea and hospitalization for acute gastroenteritis but does not seem to prevent nosocomial diarrhoea and antibiotic-associated diarrhoea. Because of its ability to survive in the gastric environment, it has been tested in Helicobacter pylori infection, showing a significant decrease of antibiotic-associated side effects and a tendency to increase the eradication rate. Finally, all these studies have shown the excellent safety of LR DSM 17938 even at higher dosages. In conclusion data from various clinical trials here reviewed can guide the clinician to find the correct dose, frequency of administration, and therapy duration.

GASTROESOPHAGEAL REFLUX DISEASE IN INFANTS WHO PRESENTED BRIEF RESOLVED UNEXPLAINED EVENT (BRUE)

BACKGROUND

The term brief resolved unexplained events (BRUE) is a description of the acute event occurring in infants less than 1-year-old that includes at least one of the following characteristics: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone or altered level of responsiveness. An investigative proceeding is required to identify the triggering phenomenon in those who are at high risk of complications. Prolonged esophageal pHmetry has been used as a tool in searching for gastroesophageal reflux disease (GERD) as one of the underlying etiologies.

OBJECTIVE

The study aims to verify the frequency of GERD in infants up to 1-year-old, when pHmetry has been performed for investigating high-risk BRUE (HR-BRUE) and to analyze if clinical characteristics or any particular symptom related by caregivers during BRUE could be correlated to GERD.

METHODS

It was performed a cross-sectional study. The data was collected retrospectively of patients less than 1-year-old, who had performed pHmetry in a tertiary hospital for investigating HR-BRUE between October 2008 and January 2018. For the analysis of medical records, a data collection protocol included: gender, age at the first HR-BRUE episode, age at the time of the pHmetry, gestational age, type of delivery (normal or caesarean) and birth weight and symptoms associated to HR-BRUE related by caregivers. Relation between variables were assessed using Fisher's exact test and Mann-Whitney test. The significance level was set at 0.05.

RESULTS

A total of 54 infants were included (preterm 25, term 29), 62.9% males, median age at the HR-BRUE was 36 days, 53.7% HR-BRUE episodes had occurred during or right after feeding. According to pHmetry results: nine pHmetry results were considered inconclusive, physiological reflux (n=30) and GERD (n=15). The frequency of GERD diagnosed by pHmetry was 33%. GERD was not statistically related to gender (P-value=0.757), age at first HR-BRUE episode (P-value=0.960), age at the time of the pHmetry (P-value=0.720), prematurity (P-value=0.120) or type of delivery (P-value=0.738). GERD was statistically related to low birth weight (P-value=0.023). There was no association between symptoms reported by caregivers during HR-BRUE and GERD.

CONCLUSION

GERD diagnosed by the pHmetry was found in one third of infants that experiencing a HR-BRUE, showing the importance of properly investigation. In half of infants BRUE occurred during or right after feeding. Besides low birth weight, it was not possible to select other data from the clinical history that suggest that these patients would be more likely to have GERD.

There is an association between gastro-oesophageal reflux and cow's milk protein intolerance

AIMS

Gastro-oesophageal reflux (GOR) and cow's milk protein intolerance (CMPI) are two frequently occurring conditions found in infancy. The aim of this review is to examine the association between the two.

METHODS

A literature review was conducted via PubMed, Sciencedirect and Google scholar using search terms "gastro-oesophageal reflux" + "cow's milk protein intolerance". The inclusion criteria were studies from 1985 to present, studies involving infants and studies involving both GOR and CMPI. Exclusion criteria were studies not including infants, or studies involving GOR or CMPI independently.

RESULTS

This review revealed varying degrees of co-existence of GOR and CMPI. Iacono et al., Farahmand et al., Kamer et al., and Semeniuk and Kaczmarski, displayed co-occurrence of GOR and CMPI in 41.8%, 33.3%, 46.5%, and 44.9% of infants respectively. In two separate studies by Cavataio et al., concomitance was apparent in 41.6% and 30% of infants. Others suggested a less significant link at 16-20%. Nielsen et al. found 18/42 children to have severe GORD, 10 of whom had CMPI in addition.

CONCLUSION

This review highlights an association between GOR and CMPI. CMPI should be considered, particularly in cases of reflux resistant to pharmacological therapy, as a co-existing or causative entity accounting for symptoms.

The Length of Gomco Clamp Timing and Its Effect on Bleeding

BACKGROUND

Bleeding is the most common complication of circumcisions in newborns. Gomco clamps are used to perform neonatal circumcisions. Although a clamp time of 5 minutes is recommended, there is no evidence to support this recommendation.

METHODS

Circumcisions performed by attending physicians from the Division of Pediatric Hospital Medicine at an academic children's hospital were split into 2 groups. Group 1 had a clamp time of 5 minutes. Group 2 did not have a clamp time minimum. Nursing staff examined for bleeding at intervals of 15- and 30-minutes' postprocedure. Bleeding was determined to be significant if pressure and/or a microfibrillar collagen hemostat agent was applied.

RESULTS

The study sample contained 23 physicians who saw a total of 1252 patients: 13 physicians (647 patients) in group 1 and 10 physicians (605 patients) in group 2. The average clamp time in group 2 was 2 minutes, 5 seconds. The estimated percentage of circumcisions that required microfibrillar collagen hemostat application was 5.1% (95% confidence interval [CI], 3.1-8.1) for group 1 and 5.6% (95% CI: 3.5-8.8]) for group 2. Circumcisions that had pressure applied were estimated to be 0.6% (95% CI: 0.2-1.7) for group 1 and 1.3% (95% CI: 0.5-3.1) for group 2. The difference between groups, in both categories, was not statistically significant.

CONCLUSIONS

In this prospective study we evaluated clamp time duration and bleeding outcomes for neonatal circumcision. Clamp time does not appear to have an association with bleeding risk. Providers need not maintain a 5-minute clamp time to decrease postprocedural bleeding.

A narrative review of gastroesophageal reflux in the pediatric patient

Gastroesophageal reflux (GER) is the retrograde passage of gastric contents into the esophagus. It is a physiologic condition that is common in neonates, typically resolves spontaneously, and does not result in clinically significant complications. When pathologic, gastroesophageal reflux disease (GERD) can cause numerous complications including persistent emesis, failure to thrive, aspiration, and respiratory symptoms. While a diagnosis can often be made from a thorough history and physical, some patients may require further testing. In general, many clinicians will reserve extensive investigation such as multiple intraluminal impedance and pH monitoring for patients with a confounding clinical picture or relative contraindications to medical or surgical management. Whereas most pediatric GER resolves spontaneously, medical management including lifestyle changes, changes to feeds, and the use of H₂-antagonists and/or proton pump inhibitors (PPIs) can be utilized to alleviate symptoms. Surgical treatment is reserved for patients who are refractory to medical management or have suffered significant complications as a consequence of GER. In this article we seek to provide a concise but detailed review of recent updates in the understanding, work up and management of GER in the pediatric patient. A summary of new technologies used in the diagnostic and therapeutic arms of this disease are included.

A Novel In Vitro Model for Determining the Optimum pH and Dose Volume of New Liquid Alginate for Infant Reflux Suppression

BACKGROUND

Gastroesophageal reflux frequently occurs in infants from birth to 2 years and is characterised by reflux and regurgitation often occurring during or immediately after feeds. These reflux events can range in both frequency and severity, and as the reflux events increase, they become increasingly distressing for both the infant and the parent. The study aimed to characterise the properties of a new infant liquid alginate product, determining the optimum gastric pH and dose volume for maximum reflux suppressant activity.

METHODS

An in vitro infant stomach model was designed and developed that allowed products to be assessed for their reflux suppression activity. The validation of the model was completed by three independent operators comparing a milk control with infant Gaviscon to evaluate the models' robustness, reproducibility, and ease of use. The model was used to establish reflux suppression activity of a new liquid alginate infant formulation in comparison with a milk control. Suppression activity was assessed at varying doses and pH within a physiological range.

RESULTS

The validation study demonstrated no significant difference in refluxate volumes for the milk control within each reflux event when comparing across the three individual operators. Similarly, no statistical differences were seen during the infant Gaviscon experiments, confirming the robustness and reproducibility of the model. Significant reflux suppression was seen across the pH range (except at pH 5.75); the pH most advantageous for reflux suppression was pH 5.25. The optimum dose volume for consistently suppressing reflux was shown to be 5 ml. An infant stomach model was designed for evaluating reflux suppression activity of a formulation of liquid alginate. The optimum gastric pH and dose volume for demonstrating significant reflux suppression and the thickening of formula milk by the infant liquid alginate formulation were established.

CONCLUSION

This study confirms the mode of action of the alginate formula, demonstrating a superior reduction in the retrograde movement of in vitro gastric contents and volume of regurgitation. The study also demonstrates that optimal performance occurs in conditions that are in line physiologically with the target patient. Both actions compliment and support the efficacy of the alginate formulation as a reflux therapy agent.

Escaping the Finnegan - Is it time?

Neonatal Abstinence Syndrome (NAS) has significantly increased worldwide secondary to a marked increase in the incidence of opioid use disorders (OUD) in women of childbearing age. Since first described in 1975, the Finnegan Neonatal Abstinence Scoring Tool (FNAST) remains the mainstay of monitoring NAS severity and its clinical management. The complexity of the tool (21 independent variables), the need for external validation, excessive subjectivity, poor inter-rater reliability, and uncertainty regarding the clinical relevance of some items has resulted in the need to develop an alternate scoring tool. A validated, simple, clinically relevant, and universally accepted approach to assessing opioid exposed neonates would facilitate high quality clinical care while assisting in the generation of generalizable data from future research studies conducted in this vulnerable population.

Disruptions in the development of feeding for infants with congenital heart disease

Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.

Understanding gastroesophageal reflux disease in children

ABSTRACT

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

Efficacy and Safety of Esomeprazole for the Treatment of Reflux Symptoms in Patients with Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis

Background:

We investigated the efficacy of esomeprazole for the treatment of gastroesophageal reflux disease (GERD) in a meta-analysis of clinical trials results.

Methods:

Medline, Embase, PubMed and Web of Science databases were systematically searched for suitable studies, and double-blind, randomized controlled trials (RCTs) were involved. A meta-analysis of RCTs was performed to analyze the efficacy of esomeprazole on clinical outcomes that associated with the severity of GERD.

Results:

A total of 8 clinical trials were selected in our meta-analysis (N=4495, patients with GERD). Esomeprazole treatment yielded a significant improvement in clinical signs and symptoms of GERD compared to placebo group. Funnel plot and Egger test showed there was no significant bias in the publication. Cochrane collaboration tool and Jadad scale were used to indicate that all 8 RCTs were of high quality. The results of Galbraith radial plot showed that no study was the major source of heterogeneity. Esomeprazole treatment significantly decreased the relapse rates more than that of placebo group (RR = 0.729; 95% CI: 0.670 to 0.794; P<0.001). It seems to be lower rates of heartburn (RR = 0.747; 95%CI: 0.665–0.839; P <0.001) and epigastric pain (RR = 0.795; 95%CI: 0.679–0.932; P =0.005) in esomeprazole-treated group compared with the placebo group. Moreover, serious adverse events was less likely to happen after esomeprazole therapy (RR = 1.406, 95% CI: 1.030–1.918; P =0.032).

Conclusion:

Compared with the control group, esomeprazole is a promising therapeutic agent that improves the management of patients with GERD.

Upper gastrointestinal series in children: what surgeons need to know

Background

Upper gastrointestinal (UGI) series is the standard imaging tool for diagnosis of structural and functional abnormalities affecting the esophagus, stomach, and proximal small bowel. The aim of this study was to delineate the clinical indications for UGI series in children that are associated with the presence of significant radiological abnormalities aiming for more standardized care for those patients.

Results

UGI series of 118 patients was analyzed with calculation of clinical score. Vomiting was the most frequent primary complaint (63.6%), followed by dysphagia and recurrent chest infection. Forty-nine patients had positive upper GI findings (42%). The most detected abnormality was related to the stomach and duodenum (21.4%). Variable degrees of idiopathic gastroesophageal reflux were detected in 16 patients (13.6%). Patients with clinical score 2 or more had significantly more prevalence of abnormal findings (p = .001). Vomiting (especially when bilious), underweight, aspiration, and recurrent chest infection were strong predictors of abnormal findings on upper GI series (p = 0.007, 0.001, 0.009, and 0.001, respectively) and increased the diagnostic yield of upper GI series for detection of abnormalities by 3.48, 9.6, 4, and 4.12 times, respectively.

Conclusion

Diagnostic yield of UGI series was relatively higher in patients having two or more symptoms (clinical score 2 or more) and in children with bilious vomiting, aspiration and underweight, or repeated chest infection.

Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate

OBJECTIVE

To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P).

DESIGN

This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound.

SETTING

The study population was selected from an academic, tertiary care center between 2003 and 2011.

PATIENTS/PARTICIPANTS

Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size.

RESULTS

There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all).

CONCLUSIONS

Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Use OF NBI for the assessment of clinical signs of rhino-pharyngo-laryngeal reflux in pediatric age: Preliminary results

OBJECTIVES

Laryngopharyngeal reflux (LPR) is a complex problem in pediatric population: diagnosis and clinical presentation are still controversial. Classic white light endoscopy shows some pathognomonic signs of LPR in children, such as thickening of pharyngo-laryngeal mucus, the cobblestoning aspect of pharyngeal mucosa, arytenoid edema/hyperemia, nodular thickening/true vocal cord edema, hypertrophy of the posterior commissure, subglottic edema. The NBI (Narrow Band Imaging) technology, generally used in oncology, allows to study neoangiogenesis and hypervascularization of the mucosa, common aspects in both chronic inflammation and neoplastic transformation. The aim of our study was to evaluate the added value of this technology in identifying the main laryngopharyngeal reflux sign in a pediatric population.

METHODS

We evaluated at the Otolaryngology Unit of the "Fondazione Policlinico A. Gemelli" hospital and the Airway Surgery Unit of the "Bambino Gesù" Children's Hospital 35 patients aged from 2 months to 16 years divided into two groups in the period between November 2017 and May 2018. Group A included patients with clinical suspicion of LPR after gastroenterologist evaluation and Group B included patients who underwent an endoscopic evaluation for the assessment of recurrent respiratory symptoms such as stridor, recurrent croup, wheezing and persistent cough. We performed an endoscopic evaluation by white light and NBI for each patient, comparing the results of both methods to evaluate signs of pharyngo-laryngeal reflux and to calculate the value of reflux finding score (RFS).

RESULTS

The analysis of the data showed: for Group A an average value of RFS with white light of 11,84 (range 8-17, standard deviation 2,52 ± 0,57) and with NBI of 13,63 (range 10-17, standard deviation 2,13 ± 0,49); for Group B the analysis of the data showed an average value of RFS with white light of 10,06 (range 8-14, standard deviation 2,32 ± 0,58) and with NBI of 12,50 (range 9-18, standard deviation 2,63 ± 0,65). The comparison between the two methods resulted significant. Furthermore evaluation by NBI allowed to highlight other signs of pharyngo-laryngeal reflux, characteristic of pediatric age and not included in RFS, in particular cobblestone aspect of the hypopharingeal mucosa, phlogosis of the tonsillar crypts and adenoid surface, hyperemia and hypervascularization of subglottic and tracheal mucosa.

CONCLUSION

Although still preliminary our results represent an interesting starting point for further studies, because they underline the potentiality of NBI endoscopy in LPR evaluation and how this technology could improve the identification of reflux signs.

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties

BACKGROUND

We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty.

METHODS

Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model.

RESULTS

Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ± 3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only.

CONCLUSIONS

Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care.

STUDY AND LEVEL OF EVIDENCE

Cost-effectiveness study, Level II.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

Objectives:

Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting.

Methods:

Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR.

Results:

Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; P < .001). Four patients with laryngomalacia developed symptoms requiring supraglottoplasty. Presence and level of salivary pepsin was not significantly associated with need for surgical management, nor were the levels or presence of IL-1β or IL-8 significantly associated with presence or level of pepsin, diagnosis of laryngomalacia, or need for operative management.

Conclusion:

Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.

Turkish Neonatal Society guideline for the follow-up of high-risk newborn infants

Developments in perinatal and neonatal care have increased the survival rate of high-risk newborns but led to a rise in chronic diseases seen in these infants. A significant number of them attend primary and secondary health care centers after discharge; however, there are very few standard protocols for the long-term follow-up of these babies. Therefore, we aimed to establish a follow-up guideline that emphasizes on universal screening schemes and takes into consideration national data. The guide presented here provides brief recommendations for physicians in light of evidence-based data for the follow-up of high-risk newborn infants. The steps taken to monitor and solve the problems of all high-risk infants may vary. We hope the use of such a standard approach in evaluating each infant in daily routine will improve the life quality of these high-risk infants.

Gastroesophageal reflux in children: an updated review

Background

Gastroesophageal reflux is a common disorder in pediatrics. Clinicians should be familiar with the proper evaluation and management of this condition.

Objective

To provide an update on the current understanding, evaluation, and management of gastroesophageal reflux in children.

Methods

A PubMed search was performed with Clinical Queries using the key term ‘gastroesophageal reflux’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to the English literature and the pediatric age group.

Results

Regurgitation is the most frequent symptom of gastroesophageal reflux and is present in nearly all cases. Gastroesophageal reflux occurs normally in infants, is often physiological, peaks at 4 months of age, and tends to resolve with time. Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce troublesome symptom(s) and/or complication(s). A thorough clinical history and a thorough physical examination are usually adequate for diagnosis. When the diagnosis is ambiguous, diagnostic studies may be warranted. A combined esophageal pH monitoring and multichannel intraluminal esophageal electrical impedance device is the gold standard for the diagnosis of gastroesophageal reflux disease if the diagnosis is in doubt. In the majority of cases, no treatment is necessary for gastroesophageal reflux apart from reassurance of the benign nature of the condition. Treatment options for gastroesophageal reflux disease are discussed.

Conclusion

In most cases, no treatment is necessary for gastroesophageal reflux apart from reassurance because the condition is benign and self-limiting. Thickened feedings, postural therapy, and lifestyle changes should be considered if the regurgitation is frequent and problematic. Pharmacotherapy should be considered in the treatment of more severe gastroesophageal reflux disease for patients who do not respond to conservative measures. Proton pump inhibitors are favored over H₂-receptor antagonists because of their superior efficacy. Antireflux surgery is indicated for patients with significant gastroesophageal reflux disease who are resistant to medical therapy.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Identification of clinical parameters to increase the diagnostic yield of the non-emergent upper gastrointestinal series in pediatric outpatients

BACKGROUND

Outpatient, non-emergent upper gastrointestinal (GI) series are frequently requested in children with no surgical history who have nonspecific symptoms such as abdominal pain, failure to thrive and vomiting. The positive yield of an upper GI series in these patients, and, thus, its utility, has not been studied.

OBJECTIVES

We evaluated the incidence of positive upper GI findings in children without a history of GI pathology or abdominal surgery in order to identify clinical indications associated with a greater diagnostic yield.

MATERIALS AND METHODS

Findings of upper GI series performed between October 2015 and October 2017 in three institutions in children younger than 18 years of age were retrospectively reviewed. The upper GI series protocol for each institution was also reviewed. Children with a medical or surgical GI history, children with insufficient history in the chart and those with an incomplete upper GI series were excluded from the study. Exam indications, patient demographics and clinical history were obtained from the electronic medical records.

RESULTS

Of 1,267 children who underwent outpatient upper GI series, 720 (median age: 2 years) had no GI history and were included in the study. The most common indications were non-bilious vomiting (62%), reflux symptoms (28%) and abdominal pain (20%). Upper GI series were normal in 605/720 cases (84%), including 25/26 children with reported bilious emesis. Of the 115 positive studies, 78 (68%) showed only gastroesophageal reflux (GER) (median age: 11 months). Of the remaining 37 studies, 19 demonstrated esophageal findings. One case of malrotation without midgut volvulus was identified in a patient who presented with dysphagia and reflux symptoms. Using a multinomial logistic regression model and adjusting for other variables, reflux symptoms and younger patient age were independent predictors of GER on upper GI series (relative risk ratios of 2.2 and 0.9, respectively). Dysphagia and/or foreign body sensation and older patient age were independent predictors of the presence of esophageal findings (relative risk ratios of 3.3 and 1.1, respectively).

CONCLUSION

The yield of routine upper GI series in children with nonspecific symptoms, such as abdominal pain and vomiting, and no surgical history is low. Diagnostic yield was improved in older children and in those complaining of dysphagia and/or foreign body sensation. Routine upper GI series should be avoided in clinically well children with symptoms only of uncomplicated GER and no significant GI history. In children with a history of dysphagia and/or foreign body sensation, an esophagram/barium swallow can suffice.

Effect of small-quantity lipid-based nutrient supplements on growth, psychomotor development, iron status, and morbidity among 6- to 12-mo-old infants in South Africa: a randomized controlled trial

Background

Evidence on the effect of small-quantity lipid-based nutrient supplements (SQ-LNSs) on early child growth and development is mixed.

Objective

This study assessed the effect of daily consumption of 2 different SQ-LNS formulations on linear growth (primary outcome), psychomotor development, iron status (secondary outcomes), and morbidity in infants from age 6 to 12 mo within the context of a maize-based complementary diet.

Methods

Infants (n = 750) were randomly assigned to receive SQ-LNS, SQ-LNS-plus, or no supplement. Both SQ-LNS products contained micronutrients and essential fatty acids. SQ-LNS-plus contained, in addition, docosahexaenoic acid, arachidonic acid (important for brain and eye development), lysine (limiting amino acid in maize), phytase (enhances iron absorption), and other nutrients. Infants' weight and length were measured bimonthly. At age 6 and 12 mo, psychomotor development using the Kilifi Developmental Inventory and South African Parent Rating Scale and hemoglobin, plasma ferritin, C-reactive protein, and α1-acid glycoprotein were assessed. WHO Motor Milestone outcomes, adherence, and morbidity were monitored weekly through home visits. Primary analysis was by intention-to-treat, comparing each SQ-LNS group with the control.

Results

SQ-LNS-plus had a positive effect on length-for-age zscore at age 8 mo (mean difference: 0.11; 95% CI: 0.01, 0.22; P = 0.032) and 10 mo (0.16; 95% CI: 0.04, 0.27; P = 0.008) but not at 12 mo (0.09; 95% CI: -0.02, 0.21; P = 0.115), locomotor development score (2.05; 95% CI: 0.72, 3.38; P = 0.003), and Parent Rating Score (1.10; 95% CI: 0.14, 2.07; P = 0.025), but no effect for weight-for-age zscore. Both SQ-LNS (P = 0.027) and SQ-LNS-plus (P = 0.005) improved hemoglobin concentration and reduced the risk of anemia, iron deficiency, and iron-deficiency anemia. Both SQ-LNS products reduced longitudinal prevalence of fever, coughing, and wheezing but increased incidence and longitudinal prevalence of diarrhea, vomiting, and rash/sores.

Conclusions

Point-of-use fortification with SQ-LNS-plus showed an early transient effect on linear growth and improved locomotor development. Both SQ-LNS products had positive impacts on anemia and iron status. This trial was registered at clinicaltrials.gov as NCT01845610.

Optimizing the Use of Medications and Other Therapies in Infant Gastroesophageal Reflux

Gastroesophageal reflux (GER) is the retrograde movement of gastric (and sometimes duodenal) contents into the esophagus. While the majority of GER is physiologic, for patients, it can be associated with symptoms. While some symptoms are merely bothersome (crying), others can be life threatening (cough, gagging, choking). The main driver of GER in infants is the frequent feedings that produce increased intra-abdominal pressure, which is known to trigger transient relaxations of the lower esophageal sphincter. The recent 2018 clinical practice guidelines reported by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN/ESPGHAN) have recommended non-pharmacologic management initially with subsequent consideration of brief trials with acid suppressants. The main target for these acid suppressants is the gastric parietal cells. Our review of the literature has revealed a paucity of data regarding the use of histamine-2 receptor antagonists and proton pump inhibitors in infants. Despite the absence of well-controlled clinical studies, the prescription rate of these medications has increased internationally. Risks to patients of all ages have become increasingly recognized, with new associations being reported all too often. Here we report our review of all pharmacologic modalities as well as some non-surgical options.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Sex-specific airway hyperreactivity and sex-specific transcriptome remodeling in neonatal piglets challenged with intra-airway acid

Acute airway acidification is a potent stimulus of sensory nerves and occurs commonly with gastroesophageal reflux disease, cystic fibrosis, and asthma. In infants and adults, airway acidification can acutely precipitate asthma-like symptoms, and treatment-resistant asthma can be associated with gastroesophageal reflux disease. Airway protective behaviors, such as mucus secretion and airway smooth muscle contraction, are often exaggerated in asthma. These behaviors are manifested through activation of neural circuits. In some populations, the neural response to acid might be particularly important. For example, the immune response in infants is relatively immature compared with adults. Infants also have a high frequency of gastroesophageal reflux. Thus, in the current study, we compared the transcriptomes of an airway-nervous system circuit (e.g., tracheal epithelia, nodose ganglia, and brain stem) in neonatal piglets challenged with intra-airway acid. We hypothesized that the identification of parallel changes in the transcriptomes of two neutrally connected tissues might reveal the circuit response, and, hence, molecules important for the manifestation of asthma-like features. Intra-airway acid induced airway hyperreactivity and airway obstruction in male piglets. In contrast, female piglets displayed airway obstruction without airway hyperreactivity. Pairwise comparisons revealed parallel changes in genes directly implicated in airway hyperreactivity ( scn10a) in male acid-challenged piglets, whereas acid-challenged females exhibited parallel changes in genes associated with mild asthma ( stat 1 and isg15). These findings reveal sex-specific responses to acute airway acidification and highlight distinct molecules within a neural circuit that might be critical for the manifestation of asthma-like symptoms in pediatric populations.

Complex care of individuals with multiple sulfatase deficiency: Clinical cases and consensus statement

Multiple sulfatase deficiency (MSD) is an ultra-rare neurodegenerative disorder that results in defective sulfatase post-translational modification. Sulfatases in the body are activated by a unique protein, formylglycine-generating enzyme (FGE) that is encoded by SUMF1. When FGE is absent or insufficient, all 17 known human sulfatases are affected, including the enzymes associated with metachromatic leukodystrophy (MLD), several mucopolysaccharidoses (MPS II, IIIA, IIID, IVA, VI), chondrodysplasia punctata, and X-linked ichthyosis. As such, individuals demonstrate a complex and severe clinical phenotype that has not been fully characterized to date. In this report, we describe two individuals with distinct clinical presentations of MSD. Also, we detail a comprehensive systems-based approach to the management of individuals with MSD, from the initial diagnostic evaluation to unique multisystem issues and potential management options. As there have been no natural history studies to date, the recommendations within this report are based on published studies and consensus opinion and underscore the need for future research on evidence-based outcomes to improve management of children with MSD.

Infant Feeding Regimens and Gastrointestinal Tolerance: A Multicenter, Prospective, Observational Cohort Study in China

To study feeding tolerance in infants fed formula with increased sn-2 palmitate and oligofructose (sn-2+OF) in a real-world setting, healthy Chinese infants were enrolled in this 48-day observational study on their current feeding regimens: exclusively breastfed (BF; n = 147), exclusively sn-2+OF formula-fed (FF; n = 150), or mixed-fed with breast milk and sn-2+OF formula (MF; n = 163). Throughout the study, incidence (90% confidence interval) of hard stools was ≤2.1% (0.0-5.3) in FF and 0.8% (0.0-3.5) in MF, with no hard stools in BF. Incidence of watery stools was ≤5.0% (1.0-9.2) in FF and ≥5.1% (2.4-9.3) in MF and BF. Gastrointestinal tolerance scores, although low in all groups (lower scores indicating better tolerance), were slightly higher (P ≥ .03) in FF (17.5 ± 4.8) and MF (18.2 ± 5.0) versus BF (16.3 ± 3.2) at mid-study; this difference disappeared at study end. Overall, low incidences of hard and watery stools and good feeding tolerance were observed in infants fed sn-2+OF formula.

Infantile Gastroesophageal Reflux: Adherence to Treatment Guidelines in the Hospital Setting

OBJECTIVES Recent guidelines defined and differentiated the management of gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). The guidelines recommend against using empiric acid suppression therapy for infantile GER. The primary objective of this study was to assess inpatient guideline adherence regarding management of infantile GER through the perspective of pharmacists. Secondary objectives included assessing pharmacist comfort level with differentiation between GER and GERD, observing current trends in practice relating to the primary objective, and determining the availability of institution-specific guidelines that address the management of infantile GER.

METHODS An institutional review board-approved, national, online survey of pharmacists with inpatient pediatric experience was conducted. Pediatric pharmacy membership directories were used to create the listserv of eligible pharmacists. The 2009 NASPGHAN/ESPGHAN (North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) Pediatric Gastroesophageal Reflux Clinical Practice Guideline was used to develop the survey and to define both GER and GERD. Demographic data was also collected regarding the institutional setting and pharmacists responding.

RESULTS The overall response rate was 14.8% (n = 149). Although 29.7% of pharmacists stated empiric acid suppression trials were not used for infantile GER at their institution, 44.6% responded that these trials are initiated 1 to 2 times per week in their hospitals. In addition, 19.6% responded that these empiric trials were initiated 3 to 5 times per week. A smaller percentage of responders reported even higher frequencies per week at their institutions.

CONCLUSIONS From the results of the survey, infants continue to receive empiric acid suppression trials for GER in the inpatient setting, which is not adherent to the current guideline recommendation.

Investigation and management of gastro-oesophageal reflux in United Kingdom neonatal intensive care units

AIM

In 2004, wide variation in the investigation and management of gastro-oesophageal reflux (GOR) of infants on UK major neonatal units was demonstrated. Our aim was to resurvey neonatal practitioners to determine current practice and whether it was now evidence based.

METHODS

A questionnaire was sent to all 207 UK neonatal units.

RESULTS

Responses were obtained from 84% of units. The most frequent 'investigation' was a trial of therapy (83% of units); pH studies were used in 38%, upper GI contrast studies in 19% and multichannel intraluminal impedance (MII)/pH studies in 5%. Only six units suggested a threshold for an abnormal pH study and two units for an abnormal MII study. Infants were commenced on antireflux medication without investigation always in 32% of units, often in 29%, occasionally in 19% and only never in 1%. Gaviscon was used as first line treatment in 60% of units, and other medications included ranitidine in 53%, thickening agents in 27%, proton pump inhibitors in 23%, domperidone in 22% and erythromycin in 6%.

CONCLUSION

There remains a wide variation in diagnostic and treatment strategies for infants with suspected GOR on neonatal intensive care units, emphasising the need for randomised trials to determine appropriate GOR management.

Gastroesophageal Reflux in the Intensive Care Unit Patient

The incidence of gastroesophageal reflux disease (GERD) in the critically ill patient in the intensive care unit is unknown. Interventions used in critically ill patients, such as sedation, tracheal tubes, mechanical ventilation, enteral feedings, positioning, and medications, along with specific patient characteristics and comorbid conditions contribute to an increased risk for gastroesophageal reflux (GER) in this population. Critical care nurses have an integral role in helping identify critically ill patients at risk for GER or with known GERD, in preventing complications associated with these conditions.

Feed thickener for infants up to six months of age with gastro-oesophageal reflux

BACKGROUND

Gastro-oesophageal reflux (GOR) is common in infants, and feed thickeners are often used to manage it in infants as they are simple to use and perceived to be harmless. However, conflicting evidence exists to support the use of feed thickeners.

OBJECTIVES

To evaluate the use of feed thickeners in infants up to six months of age with GOR in terms of reduction in a) signs and symptoms of GOR, b) reflux episodes on pH probe monitoring or intraluminal impedance or a combination of both, or c) histological evidence of oesophagitis.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed (1966 to 22 November 2016), Embase (1980 to 22 November 2016), and CINAHL (1982 to 22 November 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials.

SELECTION CRITERIA

We included randomised controlled trials if they examined the effects of feed thickeners as compared to unthickened feeds (no treatment or placebo) in treating GOR in term infants up to six months of age or six months of corrected gestational age for those born preterm.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified eligible studies from the literature search. Two review authors independently performed data extraction and quality assessments of the eligible studies. Differences in opinion were resolved by discussion with a third review author, and consensus was reached among all three review authors. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

Eight trials recruiting a total of 637 infants met the inclusion criteria for the systematic review. The infants included in the review were mainly formula-fed term infants. The trials were of variable methodological quality. Formula-fed term infants with GOR on feed thickeners had nearly two fewer episodes of regurgitation per day (mean difference -1.97 episodes per day, 95% confidence interval (CI) -2.32 to -1.61; 6 studies, 442 infants, moderate-certainty evidence) and were 2.5 times more likely to be asymptomatic from regurgitation at the end of the intervention period (risk ratio 2.50, 95% CI 1.38 to 4.51; number needed to treat for an additional beneficial outcome 5, 95% CI 4 to 13; 2 studies, 186 infants, low-certainty evidence) when compared to infants with GOR on unthickened feeds. No studies reported failure to thrive as an outcome. We found low-certainty evidence based on 2 studies recruiting 116 infants that use of feed thickeners improved the oesophageal pH probe parameters of reflux index (i.e. percentage of time pH < 4), number of reflux episodes lasting longer than 5 minutes, and duration of longest reflux episode. No major side effects were reported with the use of feed thickeners. Information was insufficient to conclude which type of feed thickener is superior.

AUTHORS' CONCLUSIONS

Gastro-oesophageal reflux is a physiological self resolving phenomenon in infants that does not necessarily require any treatment. However, we found moderate-certainty evidence that feed thickeners should be considered if regurgitation symptoms persist in term bottle-fed infants. The reduction of two episodes of regurgitation per day is likely to be of clinical significance to caregivers. Due to the limited information available, we were unable to assess the use of feed thickeners in infants who are breastfeeding or preterm nor could we conclude which type of feed thickener is superior.

Oral Nutrition in Children With Bronchiolitis on High-Flow Nasal Cannula Is Well Tolerated

OBJECTIVES

To determine the incidence of aspiration-related respiratory failure and nutrition interruptions in children with bronchiolitis on high-flow nasal cannula (HFNC) receiving enteral nutrition.

METHODS

We performed a single-center, prospective, observational cohort study within a 313-bed tertiary medical center from January through December 2015. We included term children 1 month to 2 years of age without comorbid bacterial pneumonia or chronic medical conditions who were diagnosed with bronchiolitis while receiving HFNC and enteral nutrition. Primary outcomes were incidence of aspiration-related respiratory failure and nutrition interruptions. Secondary outcomes were duration of HFNC therapy, length of stay, and nutrition characteristics.

RESULTS

Of the 344 children admitted with bronchiolitis, 132 met the inclusion criteria. Ninety-seven percent received enteral nutrition by mouth and 3% by nasogastric tube. HFNC flow rates at the time of nutrition initiation ranged between 4 and 13 L per minute (0.3-1.9 L/kg per minute) and respiratory rates from 18 to 69 breaths per minute. One (0.8%) subject had aspiration-related respiratory failure and 12 (9.1%) experienced nutrition interruptions. Children with interruptions in nutrition had a longer length of stay by 2.5 days (P < .01) and received an additional day of HFNC therapy (P < .01). By discharge, 55 (42%) children achieved all nutritional goals: caloric, volume, and protein. Children admitted overnight had an increased incidence of delay to nutrition initiation (30% vs 11%; P < .01).

CONCLUSIONS

We observed a low incidence of aspiration-related respiratory failure in term children with bronchiolitis on HFNC receiving enteral nutrition. Oral nutrition was tolerated across a range of HFNC flow and respiratory rates, suggesting the practice of withholding nutrition in this population is unsupported.

Revised consensus statement on the preventive and symptomatic care of patients with leukodystrophies

Leukodystrophies are a broad class of genetic disorders that result in disruption or destruction of central myelination. Although the mechanisms underlying these disorders are heterogeneous, there are many common symptoms that affect patients irrespective of the genetic diagnosis. The comfort and quality of life of these children is a primary goal that can complement efforts directed at curative therapies. Contained within this report is a systems-based approach to management of complications that result from leukodystrophies. We discuss the initial evaluation, identification of common medical issues, and management options to establish a comprehensive, standardized care approach. We will also address clinical topics relevant to select leukodystrophies, such as gallbladder pathology and adrenal insufficiency. The recommendations within this review rely on existing studies and consensus opinions and underscore the need for future research on evidence-based outcomes to better treat the manifestations of this unique set of genetic disorders.

Association Between Infant Feeding Modes and Gastroesophageal Reflux: A Repeated Measurement Analysis of the Infant Feeding Practices Study II

BACKGROUND

Gastroesophageal reflux in neonates is frequently reported by parents, potentially motivating changes in infant feeding mode and/or addition of solid food.

OBJECTIVE

The authors prospectively analyzed associations between repeated measurement of feeding modes and reflux in infancy.

METHODS

The Infant Feeding Practices Study II, conducted between 2005 and 2007 (2,841 infants), provides data on reflux and feeding modes at nine time points from months 1 to 12. Feeding modes were defined based on direct breastfeeding, feeding of bottled human milk, formula feeding, their combinations, and use of solid food. Repeated measurements were investigated using 1-month delayed models to estimate risk ratios (RRs) and their 95% confidence intervals (CIs). Risk ratios of different feeding modes were estimated for reflux; addressing a reverse association, RRs for feeding mode were estimated as responses to prior reflux.

RESULTS

Compared to direct breastfeeding, combinations with formula feeding showed a statistically significant risk for reflux (bottled human milk plus formula feeding: RR = 2.19, 95% CI [1.11, 4.33]; formula feeding: RR = 1.95, 95% CI [1.39, 2.74]; and mixed breastfeeding plus formula feeding: RR = 1.59, 95% CI [1.40, 2.42]). Addition of solid food was not protective (RR = 1.21, 95% CI [0.86, 1.70]). Analyses of reverse association (reflux → feeding) showed fewer breastfed infants among those with reflux in the prior month.

CONCLUSION

Any combination of infant feeding with formula seems to be a risk for reflux. Although breastfeeding was protective, mothers with a child with reflux were more likely to wean their child.