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Sultana Z, O Yildiz V, Jadcherla SR. Characteristics of esophageal refluxate and symptoms in infants compared between pre-treatment and on treatment with proton pump inhibitors. J Perinatol 2024; 44:87-93. [PMID: 37980392 DOI: 10.1038/s41372-023-01825-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To examine longitudinal pH-impedance characteristics from those infants who remained on proton pump inhibitors therapy for gastroesophageal reflux disease (GERD) as parents/providers refused to discontinue therapy after 4 weeks. STUDY DESIGN Eighteen infants with acid reflux index >3% underwent treatment, and pH-impedance data were compared prior to and on proton pump inhibitors at 42 ± 1 and 46 ± 1 weeks' postmenstrual age, respectively. Esophageal acid and bolus exposure, symptoms and swallowing characteristics were examined. RESULTS Proton pump inhibitors reduces the acid-mediated effects of reflux but modifies impedance and clearance mechanisms (P < 0.05). Prolonged therapy did not reduce symptoms (P > 0.05). Infants evaluated while on proton pump inhibitors were 1.8 times more likely to have swallows before and after reflux. CONCLUSIONS Prescription of proton pump inhibitors for objectively determined GERD should have time limits, as prolonged treatment can result in prolonged esophageal bolus clearance time without relieving symptoms.
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Affiliation(s)
- Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vedat O Yildiz
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Njeh M, Sultana Z, Plumb T, Alshaikh E, Jadcherla SR. Comparison of direct effects of rice-thickened formula vs routine feeds on symptoms and gastroesophageal reflux indices: A crossover cohort study. JPEN J Parenter Enteral Nutr 2024; 48:64-73. [PMID: 37850573 DOI: 10.1002/jpen.2566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND We compared the direct effects of routine vs rice-thickened formula on 24-h pH-impedance and symptom characteristics and then examined if dietary effects were modified by acid reflux index severity in infants. METHODS Forty infants under consideration for gastroesophageal reflux disease and therapies were evaluated at 43 ± 1 weeks postmenstrual age. Each infant was equally fed routine diet and thickened formula during evaluations. Postprandial sessions were analyzed for acid reflux index, reflux events, clearance times, distal baseline impedance, and symptoms. RESULTS Thickened formula has no effect (P ≥ 0.05) on acid reflux events' characteristics or overall symptom frequency. However, refluxate height and frequency of weakly acidic events and cough were decreased (P < 0.05). Prolonged bolus clearance and a decrease in distal baseline impedance were noted with thickened feeds (vs routine feeds) when acid reflux index was >7 (P < 0.05). CONCLUSION Our pH-impedance testing protocol identifies direct effects of potential therapies at the point of care. Acutely, thickened formula does not impact acid-specific reflux indices but decreases full-column reflux and cough reflexes. In those with an acid reflux index of >7, thickened formula prolongs the distal esophageal bolus clearance (the mechanisms of which are uncertain). Clinical trials are needed to clarify objective indications and therapeutic use of thickened formulas for infants with gastroesophageal reflux disease, along with short- and long-term side effects.
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Affiliation(s)
- Minna Njeh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Toni Plumb
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Enas Alshaikh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio, USA
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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3
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Njeh M, Helmick R, Alshaikh E, Marcano K, Alexander A, Osborn E, Jadcherla SR. The Irritable Infant in the Neonatal Intensive Care Unit: Risk Factors and Biomarkers of Gastroesophageal Reflux Disease. J Pediatr 2024; 264:113760. [PMID: 37777170 DOI: 10.1016/j.jpeds.2023.113760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/21/2023] [Accepted: 09/23/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVES To determine risk factors for arching/irritability in high-risk infants and examine the significance of comorbidity and gastroesophageal reflux (GER) characteristics. STUDY DESIGN Retrospective analysis of 24-hour pH-impedance studies of symptomatic infants in a neonatal intensive care unit (ICU) (n = 516, 30.1 ± 4.5 weeks of gestation, evaluated at 41.7 ± 3.2 weeks postmenstrual age) was conducted. Comparisons were made between infants with >72 vs ≤72 arching/irritability events per day. We characterized risk factors for arching/irritability along with clinical, pH-impedance, and outcome correlates. RESULTS Of 39 973 arching/irritability events and 42 155 GER events, the averages per day were 77.6 ± 41.0 and 81.7 ± 48.2, respectively. Acid reflux and impedance bolus characteristics were not significantly different between infants with >72 and ≤72 arching/irritability events (P ≥ .05). The odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for postmenstrual age and weight at evaluation were significant for risk factors of preterm birth (2.3 [1.2-4.4]), moderate or severe neuropathology (2.0 [1.1-3.6]), and presence of oral feeding at testing (1.57 [1.07-2.30]). CONCLUSIONS Acid GER disease is unlikely the primary cause of arching/irritability and empiric treatment should not be used when arching/irritability is present. Prematurity and neurologic impairment may be more likely the cause of the arching/irritability. Arching/irritability may not be a concern in orally fed infants.
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Affiliation(s)
- Minna Njeh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Roseanna Helmick
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Enas Alshaikh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Kailyn Marcano
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Alexis Alexander
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Erika Osborn
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH; Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.
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4
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Le Mouellic M. [Supporting families in the management of gastroesophageal reflux disease in children]. SOINS. PEDIATRIE, PUERICULTURE 2023; 44:35-40. [PMID: 37328218 DOI: 10.1016/j.spp.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Gastroesophageal reflux disease (GERD) in children is a frequent reason for medical consultation. It is defined as the involuntary passage of gastric contents into the esophagus, with or without regurgitation and vomiting. It can become pathological if it leads to embarrassing symptoms and complications. Often confronted with this pathology, nursery nurses sometimes find themselves at a loss when it comes to treating the symptoms of pathological GERD in a toddler, as well as in supporting the parents. In order to give them some ideas, a review of the literature on the benefits of non-medicinal strategies on regurgitation in full-term infants with pathological GERD was conducted.
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Affiliation(s)
- Marine Le Mouellic
- Service de néonatalogie, centre hospitalier Bretagne Atlantique, 20 boulevard général Maurice-Guillaudot, 56000 Vannes, France.
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5
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Sultana Z, Hasenstab KA, Moore RK, Osborn EK, Yildiz VO, Wei L, Slaughter JL, Jadcherla SR. Symptom Scores and pH-Impedance: Secondary Analysis of a Randomized Controlled Trial in Infants Treated for Gastroesophageal Reflux. GASTRO HEP ADVANCES 2022; 1:869-881. [PMID: 36310566 PMCID: PMC9615096 DOI: 10.1016/j.gastha.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS To evaluate and compare gastro-esophageal reflux (GER) symptom scores with pH-impedance and test the effects of acid-suppressive medications with or without feeding modifications on pH-impedance in high-risk infants. METHODS Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and 24-hour pH-impedance data were analyzed from 94 infants evaluated in a tertiary care setting for GER disease. Longitudinal data from 40 infants that received randomized GER therapy (proton pump inhibitor [PPI] with or without feeding modifications) for 4 weeks followed by 1-week washout were analyzed. Relationships between I-GERQ-R and pH-impedance metrics (acid reflux index, acid and bolus GER events, distal baseline impedance, and symptoms) were examined and effects of treatments compared. RESULTS (A) Correlations between I-GERQ-R and pH-impedance metrics were weak. (B) I-GERQ-R sensitivity, specificity, and positive predictive values were suboptimal when correlated with pH-impedance metrics. I-GERQ-R negative predictive value (NPV) was high for acid symptom-association probability (NPV = 84%) and distal baseline impedence (NPV = 86%) thresholds. (C) PPI with feeding modifications (vs PPI alone) did not alter pH-impedance metrics or symptom scores (P > .05); however, bolus clearance metrics worsened for both treatment groups (P < .05). CONCLUSIONS In high-risk infants (1) I-GERQ-R may be a helpful clinical screening tool to exclude acid-GER disease diagnosis and minimize unnecessary acid-suppressive treatment, but further testing is needed for diagnosis. (2) Acid-suppressive therapy with feeding modifications has no effect on symptom scores or pH-impedance metrics. Clearance of refluxate worsened despite PPI therapy, which may signal development of pharyngoesophageal dysmotility and persistence of symptoms. (3) Placebo-controlled trials are needed in high-risk infants with objective pH-impedance criteria to determine efficacy, safety, and underlying mechanisms. Clinicaltrials.gov ID: NCT02486263.
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Affiliation(s)
- Zakia Sultana
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Rebecca K. Moore
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Erika K. Osborn
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Vedat O. Yildiz
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lai Wei
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan L. Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, The Ohio State University College of Medicine, Columbus, Ohio
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Duncan DR, DiFilippo C, Kane M, Lurie M, McSweeney ME, Rosen RL. Overlapping Symptoms of Gastroesophageal Reflux and Aspiration Highlight the Limitations of Validated Questionnaires. J Pediatr Gastroenterol Nutr 2021; 72:372-377. [PMID: 33264182 PMCID: PMC9765758 DOI: 10.1097/mpg.0000000000002987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Infants frequently present with feeding difficulties and respiratory symptoms, which are often attributed to gastroesophageal reflux but may be because of oropharyngeal dysphagia with aspiration. The Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) is a clinical measure of gastroesophageal reflux disease but now there is greater understanding of dysphagia as a reflux mimic. We aimed to determine the degree of overlap between I-GERQ-R and evidence of dysphagia, measured by Pediatric Eating Assessment Tool-10 (Pedi-EAT-10) and videofluoroscopic swallow study (VFSS). METHODS We performed a prospective study of subjects <18 months old with feeding difficulties. All parents completed Pedi-EAT-10 and I-GERQ-R as a quality initiative to address parental feeding concerns. I-GERQ-R results were compared with Pedi-EAT-10 and, whenever available, results of prior VFSS. Pearson correlation coefficients were calculated to determine the relationship between scores. Groups were compared with 1-way ANOVA and Fisher exact test. ROC analysis was completed to compare scores with VFSS results. RESULTS One hundred eight subjects with mean age 7.1 ± 0.5 months were included. Pedi-EAT-10 and I-GERQ-R were correlated (r = 0.218, P = 0.023) in all subjects and highly correlated in the 77 subjects who had prior VFSS (r = 0.369, P = 0.001). The blue spell questions on I-GERQ-R had relative risk 1.148 (95% confidence interval [CI] 1.043-1.264, P = 0.142) for predicting aspiration/penetration on VFSS, with 100% specificity. Scores on the question regarding crying during/after feedings were also higher in subjects with abnormal VFSS (1.1 ± 0.15 vs 0.53 ± 0.22, P = 0.04). CONCLUSIONS I-GERQ-R and the Pedi-EAT-10 are highly correlated. I-GERQ-R results may actually reflect oropharyngeal dysphagia and not just gastroesophageal reflux disease in infants.
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Affiliation(s)
- Daniel R. Duncan
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Courtney DiFilippo
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Madeline Kane
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Margot Lurie
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Maireade E. McSweeney
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Rachel L. Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
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Role of feeding strategy bundle with acid-suppressive therapy in infants with esophageal acid reflux exposure: a randomized controlled trial. Pediatr Res 2021; 89:645-652. [PMID: 32380509 PMCID: PMC7647955 DOI: 10.1038/s41390-020-0932-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To test the hypothesis that a feeding bundle concurrent with acid suppression is superior to acid suppression alone in improving gastroesophageal reflux disease (GERD) attributed-symptom scores and feeding outcomes in neonatal ICU infants. METHODS Infants (N = 76) between 34 and 60 weeks' postmenstrual age with acid reflux index > 3% were randomly allocated to study (acid-suppressive therapy + feeding bundle) or conventional (acid-suppressive therapy only) arms for 4 weeks. Feeding bundle included: total fluid volume < 140 mL/kg/day, fed over 30 min in right lateral position, and supine postprandial position. Primary outcome was independent oral feeding and/or ≥6-point decrease in symptom score (I-GERQ-R). Secondary outcomes included growth (weight, length, head circumference), length of hospital stay (LOHS, days), airway (oxygen at discharge), and developmental (Bayley scores) milestones. RESULTS Of 688 screened: 76 infants were randomized and used for the primary outcome as intent-to-treat, and secondary outcomes analyzed for 72 infants (N = 35 conventional, N = 37 study). For study vs. conventional groups, respectively: (a) 33% (95% CI, 19-49%) vs. 44% (95% CI, 28-62%), P = 0.28 achieved primary outcome success, and (b) secondary outcomes did not significantly differ (P > 0.05). CONCLUSIONS Feeding strategy modifications concurrent with acid suppression are not superior to PPI alone in improving GERD symptoms or discharge feeding, short-term and long-term outcomes. IMPACT Conservative feeding therapies are thought to modify GERD symptoms and its consequences. However, in this randomized controlled trial in convalescing neonatal ICU infants with GERD symptoms, when controlling for preterm or full-term birth and severity of esophageal acid reflux index, the effectiveness of acid suppression plus a feeding modification bundle (volume restriction, intra- and postprandial body positions, and prolonged feeding periods) vs. acid suppression alone, administered over a 4-week period was not superior in improving symptom scores or feeding outcomes. Restrictive feeding strategies are of no impact in modifying GERD symptoms or clinically meaningful outcomes. Further studies are needed to define true GERD and to identify effective therapies in modifying pathophysiology and outcomes. The improvement in symptoms and feeding outcomes over time irrespective of feeding modifications may suggest a maturational effect. This study justifies the use of placebo-controlled randomized clinical trial among NICU infants with objectively defined GERD.
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Simon M, Levy EI, Vandenplas Y. Safety considerations when managing gastro-esophageal reflux disease in infants. Expert Opin Drug Saf 2020; 20:37-49. [PMID: 33115255 DOI: 10.1080/14740338.2020.1843630] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Gastro-esophageal reflux disease (GERD) in infants is worldwide diagnosed with increasing frequency, resulting in an increasing number of infants exposed to treatment. In this review, we focus on the safety of therapeutic options. Areas covered: English articles were searched from 1990 until May 2020 in PubMed and Google Scholar. Evidence suggests that non-pharmacological treatment is often effective and safe. Guidelines restrict pharmacological treatment to acid-suppressive medication, which is associated with adverse effects, often related to gastro-intestinal dysbiosis and consequences of the latter. Aluminum-free alginates have some efficacy and are not associated with relevant adverse effects. Especially in infants, GERD is often nonacid related. Prokinetics are not recommended because of lack of efficacy and numerous adverse effects. Expert opinion: Pediatric trials are underpowered regarding adverse effects. The number of infants exposed to anti-secretory agents is increasing worldwide, often without indication. Informing healthcare providers about adverse effects of acid-secretory medication may contribute to a more rational use. Acid inhibiting agents such as alginates are a drug class associated with limited efficacy and devoid of serious adverse effects. Regarding prokinetics, the risk of adverse effects outweighs the benefit. Reassurance of parents and nutritional management of GERD in infants is effective and safe.
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Affiliation(s)
- Melina Simon
- KidZ Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel , Brussels, Belgium
| | - Elvira Ingrid Levy
- KidZ Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel , Brussels, Belgium
| | - Yvan Vandenplas
- KidZ Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel , Brussels, Belgium
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Pados BF, Yamasaki JT. Symptoms of Gastroesophageal Reflux in Healthy, Full-Term Infants Younger Than 7 Months Old. Nurs Womens Health 2020; 24:84-90. [PMID: 32109440 DOI: 10.1016/j.nwh.2020.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/05/2019] [Accepted: 01/01/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To describe the range of symptoms of gastroesophageal reflux in healthy, full-term infants in the first 7 months of life. DESIGN Cross-sectional, descriptive study. Median and percentile scores for the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) were calculated for each of the following age groups of infants: 0 to 2, 2 to 4, 4 to 6, and 6 to 7 months. Psychometric properties, including internal consistency reliability and concurrent validity of the I-GERQ-R, were also tested. SETTING Online. PARTICIPANTS Primary caregivers of 559 healthy, full-term (≥37 weeks gestational age) infants younger than 7 months. MEASUREMENTS Participants were asked to answer questions about themselves, their family, and their infant and to complete the I-GERQ-R, the Infant Gastrointestinal Symptoms Questionnaire, and the Neonatal Eating Assessment Tool. RESULTS Symptoms of gastroesophageal reflux decreased over the first 7 months of life. Scores in the 95th percentile decreased from 19 in infants 0 to 2 months old to 16.7 in infants 6 to 7 months old. Internal consistency reliability of the I-GERQ-R was acceptable (Cronbach's α = .71). The I-GERQ-R had evidence of concurrent validity with the Infant Gastrointestinal Symptoms Questionnaire (rs = .69, p < .001) and Neonatal Eating Assessment Tool-Breastfeeding Gastroesophageal Function subscale (rs = .52, p < .001). CONCLUSIONS Authors of prior studies used a cutoff score of 16 for the diagnosis of gastroesophageal reflux disease in infants younger than 18 months. Our results indicate that symptoms of reflux change with age over the first 7 months of life and that using more age-specific reference values may be more appropriate. Health care providers can use these age-specific percentile scores, together with clinical assessment, to identify significant symptomatology related to gastroesophageal reflux disease.
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10
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Smith AB, Fawkes N, Kotze H, Hodgkinson V, Coyle C. Clinically Meaningful Difference for the Infant Gastroesophageal Questionnaire Revised version (I-GERQ-R): A Quantitative Synthesis. PATIENT-RELATED OUTCOME MEASURES 2020; 11:87-93. [PMID: 32189972 PMCID: PMC7068037 DOI: 10.2147/prom.s238673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/06/2020] [Indexed: 11/23/2022]
Abstract
Background Gastroesophageal reflux disease (GORD) is a common condition affecting 30% of infants aged 0–23 months. The Infant Gastroesophageal Questionnaire Revised version (I-GERQ-R) is an observer-reported outcome measures (ObsRO) developed to evaluate the impact of GORD on young infants. However, evidence regarding the clinically important difference (CID) for the I-GERQ-R is limited. The aim of this study was to determine a CID for the I-GERQ-R. Methods A literature review was undertaken (PsycInfo, Embase, MedLine and EconLit databases) for longitudinal studies involving the I-GERQ-R. Articles were not limited by language or publication date. A random effects model was applied to calculate an overall CID, along with I2 and Q statistics. Publication bias was also assessed. Results The search identified 42 articles; 11 were selected for full-text review and 7 articles were identified for full data extraction. The studies included a total of 661 infants (range: 30 to 313); 424 infants had been diagnosed with GORD (64%). The age range of the infants across the studies was from birth to 7 months. The overall CID was −6.54 (95% confidence interval: −4.35 to −8.74), Q = 17.96, p=0.08 and I2=22.04. Conclusion This study derived a CID for the I-GERQ-R and indicated a threshold around 6 could signify a clinically important difference for this instrument. The lower limit of the 95% confidence interval suggested a threshold of 3 to 4 could represent a minimally important difference. These results may help inform clinical decisions in evaluating meaningful change in symptom severity in children affected by GORD.
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Affiliation(s)
- Adam B Smith
- Health Outcomes, Medical Affairs & Evidence Generation, Reckitt Benckiser, Hull, UK
| | - Neil Fawkes
- Medical Excellence, Medical Affairs & Evidence Generation, Reckitt Benckiser, Hull, UK
| | - Helen Kotze
- Global Medical Affairs, Medical Affairs & Evidence Generation, Reckitt Benckiser, Hull, UK
| | - Victoria Hodgkinson
- Clinical Operations, Medical Affairs & Evidence Generation, Reckitt Benckiser, Hull, UK
| | - Cathal Coyle
- Global Medical Affairs, Medical Affairs & Evidence Generation, Reckitt Benckiser, Slough, UK
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Bardou M, Fortinsky KJ, Chapelle N, Luu M, Barkun A. An update on the latest chemical therapies for reflux esophagitis in children. Expert Opin Pharmacother 2018; 20:231-239. [DOI: 10.1080/14656566.2018.1549224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Marc Bardou
- Centre d’Investigations Cliniques CIC1432, CHU de Dijon, Dijon Cedex, France
- Gastroenterology Department, CHU de Dijon, Dijon Cedex, France
| | - Kyle J. Fortinsky
- Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Maxime Luu
- Centre d’Investigations Cliniques CIC1432, CHU de Dijon, Dijon Cedex, France
| | - Alan Barkun
- Gastroenterology department, McGill University Health Centre, Montréal, Québec, Canada
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12
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Salvatore S, Savino F, Singendonk M, Tabbers M, Benninga MA, Staiano A, Vandenplas Y. Thickened infant formula: What to know. Nutrition 2018; 49:51-56. [PMID: 29495000 DOI: 10.1016/j.nut.2017.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 09/21/2017] [Accepted: 10/05/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVES This study aimed to provide an overview of the characteristics of thickened formulas to aid health care providers manage infants with regurgitations. METHODS The indications, properties, and efficacy of different thickening agents and thickened formulas on regurgitation and gastroesophageal reflux in infants were reviewed. PubMed and the Cochrane database were searched up to December 2016. RESULTS Based on the literature review, thickened formulas reduce regurgitation, may improve reflux-associated symptoms, and increase weight gain. However, clinical efficacy is related to the characteristics of the formula and of the infant. Commercial thickened formulas are preferred over the supplementation of standard formulas with thickener because of the better viscosity, digestibility, and nutritional balance. Rice and corn starch, carob bean gum, and soy bean polysaccharides are available as thickening agents. Hydrolyzed formulas have recently shown promising additional benefit. CONCLUSIONS Thickened formulas reduce the frequency and severity of regurgitation and are indicated in formula-fed infants with persisting symptoms despite reassurance and appropriate feeding volume intake.
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Affiliation(s)
- Silvia Salvatore
- Clinical Pediatrica di Varese, Universita dell'Insubria, Varese, Italy
| | - Francesco Savino
- Ospedale Infantile Regina Margherita, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maartje Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Merit Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Annamaria Staiano
- Department of Translation Medical Science, Section of Pediatrics, University of Naples, Federico II, Italy
| | - Yvan Vandenplas
- Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
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14
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Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:516-554. [PMID: 29470322 PMCID: PMC5958910 DOI: 10.1097/mpg.0000000000001889] [Citation(s) in RCA: 436] [Impact Index Per Article: 72.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.
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Affiliation(s)
- Rachel Rosen
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Children's Hospital Boston, Boston, MA
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Michael Cabana
- Division of General Pediatrics, University of California, San Francisco, CA
| | - Carlo DiLorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Frederic Gottrand
- CHU Lille, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lille, France
| | - Sandeep Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois, Peoria, IL
| | - Miranda Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples ‘‘Federico II,’’ Naples, Italy
| | - Nikhil Thapar
- Great Ormond Street Hospital for Children, London, UK
| | - Neelesh Tipnis
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Merit Tabbers
- Emma Children's Hospital/AMC, Amsterdam, The Netherlands
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Rostas SE, McPherson C. Acid Suppression for Gastroesophageal Reflux Disease in Infants. Neonatal Netw 2018; 37:33-41. [PMID: 29436357 DOI: 10.1891/0730-0832.37.1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gastroesophageal reflux is a normal physiologic occurrence that is common throughout infancy and usually resolves on its own. Infrequently, reflux causes complications and turns into gastroesophageal reflux disease (GERD), which may warrant intervention. Available interventions vary in invasiveness and supporting data may be lacking for efficacy and safety. Nonpharmacologic interventions are first-line therapy for GERD in infants, whereas pharmacologic and surgical approaches are controversial. Efficacy data are limited for pharmacologic strategies for infantile GERD and safety data have demonstrated serious risks, especially in younger infants. Utilization of these medications should be approached cautiously in this population, if appropriate diagnostic techniques determine acid suppression could be beneficial. A robust monitoring plan with frequent reassessment of need for therapy may optimize benefit and minimize risk.
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Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-Esophageal Reflux in Children. Int J Mol Sci 2017; 18:E1671. [PMID: 28763023 PMCID: PMC5578061 DOI: 10.3390/ijms18081671] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/06/2017] [Accepted: 07/14/2017] [Indexed: 12/20/2022] Open
Abstract
Gastro-esophageal reflux (GER) is common in infants and children and has a varied clinical presentation: from infants with innocent regurgitation to infants and children with severe esophageal and extra-esophageal complications that define pathological gastro-esophageal reflux disease (GERD). Although the pathophysiology is similar to that of adults, symptoms of GERD in infants and children are often distinct from classic ones such as heartburn. The passage of gastric contents into the esophagus is a normal phenomenon occurring many times a day both in adults and children, but, in infants, several factors contribute to exacerbate this phenomenon, including a liquid milk-based diet, recumbent position and both structural and functional immaturity of the gastro-esophageal junction. This article focuses on the presentation, diagnosis and treatment of GERD that occurs in infants and children, based on available and current guidelines.
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Affiliation(s)
- Anna Rybak
- Department of Gastroenterology, Division of Neurogastroenterology and Motility, Great Ormond Street Hospital, London WC1N 3JH, UK.
| | - Marcella Pesce
- Department of Gastroenterology, Division of Neurogastroenterology and Motility, Great Ormond Street Hospital, London WC1N 3JH, UK.
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80138 Napoli, Italy.
| | - Nikhil Thapar
- Department of Gastroenterology, Division of Neurogastroenterology and Motility, Great Ormond Street Hospital, London WC1N 3JH, UK.
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | - Osvaldo Borrelli
- Department of Gastroenterology, Division of Neurogastroenterology and Motility, Great Ormond Street Hospital, London WC1N 3JH, UK.
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Abstract
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.
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Affiliation(s)
- Hayat Mousa
- University of California, San Diego, 3020 Children's Way, MOB 211, MC 5030, San Diego, CA 92123, USA; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Rady Children's Hospital, 7960 Birmingham Way, Room 2110, MC 5030, San Diego, CA 92123, USA.
| | - Maheen Hassan
- University of California, San Diego, 3020 Children’s Way, MOB 211,
MC 5030, San Diego, CA 92123,
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18
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Acid Suppressant Medications in the Neonatal Intensive Care Unit: Strategies for Appropriate Use. J Perinat Neonatal Nurs 2017; 31:299-302. [PMID: 29068849 DOI: 10.1097/jpn.0000000000000290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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D’Agostino JA, Passarella M, Martin AE, Lorch SA. Use of Gastroesophageal Reflux Medications in Premature Infants After NICU Discharge. Pediatrics 2016; 138:peds.2016-1977. [PMID: 27940703 PMCID: PMC5127072 DOI: 10.1542/peds.2016-1977] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To describe the epidemiology and management of gastroesophageal reflux (GER) medications started in the first year of life for premature infants. METHODS Retrospective review of a cohort of infants ≤35 weeks' gestation presenting for care by 168 days of age to a 30-site network between 2005 and 2009 (n = 2217) and followed to 3 years of age. Medication frequency, types, and duration of use were assessed. Logistic regression identified factors associated with treatment. RESULTS Thirty-seven percent (812) were prescribed GER medications with 77% begun after NICU discharge. Ninety percent (727) received histamine-2 receptor antagonists, 33% (269) proton pump inhibitors, 22% (182) prokinetics; 40% (325) received >1 medication. Outpatient medication was initiated at 95 ± 69 days of life for total of 294 ± 249 days (interquartile ratio: 117-359). Feeding issues (adjusted odds ratio [aOR] 2.05, 95% confidence interval [CI]: 1.24-3.39) were associated with outpatient initiation. Forty-three percent (322) of infants started before 6 months were still on at 1 year of age associated with gestational age <32 weeks (aOR 1.76, 95% CI: 1.16-2.67), chronic lung disease (aOR 2.59, 95% CI: 1.29-5.22), and reactive airways disease (aOR 1.67, 95% CI: 1.05-2.65). CONCLUSIONS Of the 37% of the cohort on GER medications, 77% were started after NICU discharge with prolonged use of medications. Feeding difficulties were associated with starting medication and markers of chronic lung disease with continuation of treatment. With uncertain evidence of efficacy, use of these medications in a high-risk population should be carefully evaluated.
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Affiliation(s)
- Jo Ann D’Agostino
- Department of Pediatrics,,Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Molly Passarella
- Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Ashley E. Martin
- Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Scott A. Lorch
- Department of Pediatrics,,Center for Outcomes Research, and,Center for Perinatal and Pediatric Health Disparities Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,The University of Pennsylvania School of Medicine and,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MBH. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics 2016; 137:peds.2016-0590. [PMID: 27244835 DOI: 10.1542/peds.2016-0590] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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21
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Bardou M, Fortinsky KJ. Safety of medication options for treating pediatric esophagitis. Expert Opin Drug Saf 2015; 14:1087-96. [DOI: 10.1517/14740338.2015.1040389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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22
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Esposito C, Roberti A, Turrà F, Escolino M, Cerulo M, Settimi A, Farina A, Vecchio P, Di Mezza A. Management of gastroesophageal reflux disease in pediatric patients: a literature review. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2015; 6:1-8. [PMID: 29388573 PMCID: PMC5683257 DOI: 10.2147/phmt.s46250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.
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Affiliation(s)
- Ciro Esposito
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Agnese Roberti
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Francesco Turrà
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Maria Escolino
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Mariapina Cerulo
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Alessandro Settimi
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Alessandra Farina
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Pietro Vecchio
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
| | - Antonio Di Mezza
- Department of Translational Medical Sciences, Pediatric Surgery, "Federico II" University of Naples, Naples, Italy
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Visscher MO, Lacina L, Casper T, Dixon M, Harmeyer J, Haberman B, Alberts J, Simakajornboon N. Conformational positioning improves sleep in premature infants with feeding difficulties. J Pediatr 2015; 166:44-8. [PMID: 25311708 DOI: 10.1016/j.jpeds.2014.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 08/27/2014] [Accepted: 09/08/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether premature infants' sleep organization, total sleep time, and arousals may be modulated while on a conformational positioner that provides boundaries, customized positioning, and containment compared with standard positioning (standard crib mattress). STUDY DESIGN A proof of concept trial using a within subject crossover design was conducted among 25 premature infants with feeding difficulties. Infants of 31.5 weeks gestational age served as their own control during overnight polysomnography at postconceptual age 38.4 weeks. Each baby received both interventions (order randomized), 1 for each one-half of the 10.5-hour study. RESULTS Use of the conformational positioner resulted in higher sleep efficiency of 61% vs 54% for the standard mattress (P < .05). The interventions did not differ for percent active sleep, percent quiet sleep, percent indeterminate sleep, or spontaneous arousals. Sleep efficiency was higher on the conformational positioner than standard positioning for surgical subjects and for subjects with necrotizing enterocolitis or gastroschisis (n = 10). The surgical subjects (n = 9) had lower sleep efficiency, lower percentage of active sleep, and more spontaneous arousals compared with the nonsurgical group. CONCLUSIONS The use of the conformational positioner improved sleep efficiency vs the standard mattress in premature infants with feeding difficulties. Infants requiring surgery or with gastrointestinal diagnoses may be more susceptible to environmental stress.
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Affiliation(s)
- Marty O Visscher
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Linda Lacina
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tammy Casper
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Melodie Dixon
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Joann Harmeyer
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Beth Haberman
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Alberts
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN
| | - Narong Simakajornboon
- Newborn Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Managing gastroesophageal reflux symptoms in the very low-birth-weight infant postdischarge. Adv Neonatal Care 2014; 14:381-91; quiz E1-2. [PMID: 25422924 DOI: 10.1097/anc.0000000000000141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroesophageal reflux and gastroesophageal reflux disease symptoms are common challenges for very low-birth-weight infants (<1500 g). These symptoms frequently result in feeding difficulties and family stress. Management of symptoms across healthcare disciplines may not be based on current evidence, and inconsistency can result in confusion for families and delayed interventions. The feeding relationship between infant and caregivers may be impaired when symptoms are persistent and poorly managed. An algorithm for managing gastroesophageal reflux-like symptoms in very low-birth-weight infants (from hospital discharge to 12 months corrected age) was developed through the formation of a multidisciplinary community of practice and critical appraisal of the literature. A case study demonstrates how the algorithm results in a consistent approach for identifying symptoms, applying appropriate management strategies, and facilitating appropriate timing of medical consultation. Application to managing gastroesophageal reflux symptoms in the neonatal intensive care unit will be briefly addressed.
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Orenstein SR. Infant GERD: symptoms, reflux episodes & reflux disease, acid & non-acid refllux--implications for treatment with PPIs. Curr Gastroenterol Rep 2014; 15:353. [PMID: 24197743 DOI: 10.1007/s11894-013-0353-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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26
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Ferreira CT, Carvalho ED, Sdepanian VL, Morais MBD, Vieira MC, Silva LR. Gastroesophageal reflux disease: exaggerations, evidence and clinical practice. J Pediatr (Rio J) 2014; 90:105-18. [PMID: 24184302 DOI: 10.1016/j.jped.2013.05.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 05/23/2013] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. DATA SOURCE a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. DATA SYNTHESIS abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. CONCLUSIONS there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected.
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Affiliation(s)
- Cristina Targa Ferreira
- Pediatric Gastroenterology Service, Hospital da Criança Santo Antônio, Complexo Hospitalar Santa Casa, Porto Alegre, RS, Brazil; Pediatrics Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil; Gastroenterology Department, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brazil.
| | - Elisa de Carvalho
- Pediatrics Unit, Hospital de Base do Distrito Federal, DF, Brazil; Hospital da Criança de Brasília, DF, Brazil; Centro Universitário de Brasília, DF, Brazil; Pediatric Gastroenterology Department, Sociedade Brasileira de Pediatria, Brasília, DF, Brazil
| | - Vera Lucia Sdepanian
- Gastroenterology Department, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brazil; Pediatrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Mauro Batista de Morais
- Gastroenterology Department, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brazil; Pediatrics Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil; Clínica de Especialidades Pediátricas, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Mário César Vieira
- Gastroenterology Department, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brazil; Pediatrics Department, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil; Pediatric Gastroenterology Service, Hospital Pequeno Príncipe, Curitiba, PR, Brazil; Hospital da Criança de Brasília, DF, Brazil
| | - Luciana Rodrigues Silva
- Gastroenterology Department, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brazil; Pediatrics Gastroenterology and Hepatology Service, Universidade Federal da Bahia, Salvador, BA, Brazil; Academia Brasileira de Pediatria, Rio de Janeiro, RJ, Brazil
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27
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Gastroesophageal reflux disease: exaggerations, evidence and clinical practice. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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28
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Extensively hydrolyzed protein formula reduces acid gastro-esophageal reflux in symptomatic preterm infants. Early Hum Dev 2013; 89:453-5. [PMID: 23642476 DOI: 10.1016/j.earlhumdev.2013.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/03/2013] [Accepted: 04/09/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Gastro-esophageal reflux (GER) is diagnosed frequently in preterm infants. Pharmacological treatment of GER has some potential side effects. Conservative treatment of GER should be the first-line approach and should include body positioning and diet modifications. Formula-fed preterm infants experience frequently symptoms of feeding intolerance. Hydrolyzed protein formula (HPF) is often used in these infants due to their effects on gastrointestinal motility. AIMS To investigate the role of an extensively HPF (eHPF) on GER indexes in formula-fed preterm infants with symptoms of both GER and feeding intolerance. STUDY DESIGN Randomized crossover trial. SUBJECTS Preterm infants (gestational age ≤33 weeks) with symptoms of feeding intolerance (large gastric residuals, abdominal distension and constipation) and GER (frequent regurgitations and/or postprandial desaturations). OUTCOME MEASURES GER indexes detected by 24-h combined multichannel intraluminal impedance and pH monitoring. GER indexes detected after 4 feeds of an eHPF were compared to those detected after 4 feeds of a standard preterm formula (SPF) by Wilcoxon signed ranks test. A p<0.05 was considered statistically significant. RESULTS eHPF significantly reduced the number of GERs detected by pH monitoring (p=0.036) and also the reflux index (p=0.044) compared to SPF. No differences in impedance bolus exposure indexes nor in GER height were detected. CONCLUSIONS The use of an eHPF should be evaluated for reducing esophageal acid exposure in preterm infants with feeding intolerance and symptoms of GER. Future research should focus on the evaluation of an eHPF adequate for preterm infants in improving clinical symptoms of GER.
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Abstract
Recent comprehensive guidelines developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition define the common entities of gastroesophageal reflux (GER) as the physiologic passage of gastric contents into the esophagus and gastroesophageal reflux disease (GERD) as reflux associated with troublesome symptoms or complications. The ability to distinguish between GER and GERD is increasingly important to implement best practices in the management of acid reflux in patients across all pediatric age groups, as children with GERD may benefit from further evaluation and treatment, whereas conservative recommendations are the only indicated therapy in those with uncomplicated physiologic reflux. This clinical report endorses the rigorously developed, well-referenced North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines and likewise emphasizes important concepts for the general pediatrician. A key issue is distinguishing between clinical manifestations of GER and GERD in term infants, children, and adolescents to identify patients who can be managed with conservative treatment by the pediatrician and to refer patients who require consultation with the gastroenterologist. Accordingly, the evidence basis presented by the guidelines for diagnostic approaches as well as treatments is discussed. Lifestyle changes are emphasized as first-line therapy in both GER and GERD, whereas medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. Recent black box warnings from the US Food and Drug Administration are discussed, and caution is underlined when using promoters of gastric emptying and motility. Finally, attention is paid to increasing evidence of inappropriate prescriptions for proton pump inhibitors in the pediatric population.
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Neu M, Corwin E, Lareau SC, Marcheggiani-Howard C. A review of nonsurgical treatment for the symptom of irritability in infants with GERD. J SPEC PEDIATR NURS 2012; 17:177-92. [PMID: 22734872 PMCID: PMC3385001 DOI: 10.1111/j.1744-6155.2011.00310.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this review was to assess effectiveness of nonsurgical treatment on irritable behavior of infants with gastroesophageal reflux disease. DESIGN AND METHODS A systematic literature review was conducted. RESULTS Research targeted treatment for irritability in infants with gastroesophageal reflux disease. All interventions including placebo were similar in reducing irritability. Which specific intervention is best for which infant is not yet known. Minor adverse effects that could increase discomfort in infants were found with pharmacologic treatments. PRACTICE IMPLICATIONS Knowledge of the effects of treatment on irritability and regurgitation can assist the nurse to work with other care providers in deciding how best to treat an individual infant.
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Affiliation(s)
- Madalynn Neu
- University of Colorado College of Nursing, Aurora, Colorado, USA.
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Hassall E. Over-prescription of acid-suppressing medications in infants: how it came about, why it's wrong, and what to do about it. J Pediatr 2012; 160:193-8. [PMID: 22018908 DOI: 10.1016/j.jpeds.2011.08.067] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/21/2011] [Accepted: 08/30/2011] [Indexed: 12/12/2022]
Affiliation(s)
- Eric Hassall
- Sutter Pacific Medical Foundation, San Francisco, CA 94118, USA.
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Indrio F, Riezzo G, Raimondi F, Bisceglia M, Filannino A, Cavallo L, Francavilla R. Lactobacillus reuteri accelerates gastric emptying and improves regurgitation in infants. Eur J Clin Invest 2011; 41:417-22. [PMID: 21114493 DOI: 10.1111/j.1365-2362.2010.02425.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Young infants are frequently affected by uncomplicated regurgitation that may persist despite dietetic and conservative interventions. On this basis, we studied the putative effects of probiotics on the frequency of regurgitation and gastric emptying time in infants with functional gastroesophageal reflux (GER). PATIENTS AND METHODS Forty-two infants with regurgitation were randomized to assume Lactobacillus reuteri DSM 17938 at a dose of 1 × 10(8) CFU per day and placebo for 30 days. The episodes of regurgitation were recorded by the parents each day. Gastric emptying time was recorded using real-time ultrasound at baseline and at the end of the study. Twenty-one infants without regurgitation were enroled to compare anthropometric and physiological parameters before the intervention diet. RESULTS Thirty-four infants completed the study (19 infants receiving probiotics and 15 placebo).At baseline, the whole group of infants was similar to the control group as regards anthropometric and physiological data. The median fasting antral area was significantly reduced, (P = 0·01) the delta in gastric emptying rate was significantly increased (P = 0·01) and the median episodes per day of regurgitation was reduced (, P < 0·001) in the probiotic group compared to the placebo group. In the whole group, the frequency of regurgitation and the basal antral area showed a positive correlation (r = 0·53, P = 0·004). CONCLUSIONS In infants with functional GER, L. reuteri DSM 17938 reduce gastric distension and accelerate gastric emptying. In addition, this probiotic strain seems to diminish the frequency of regurgitation.
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Affiliation(s)
- Flavia Indrio
- Department of Pediatrics, University of Bari Policlinico Piazza G.Cesare, Bari, Italy.
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Chipps BE. Evaluation of infants and children with refractory lower respiratory tract symptoms. Ann Allergy Asthma Immunol 2010; 104:279-83; quiz 283-5, 298. [PMID: 20408336 DOI: 10.1016/j.anai.2009.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To define the diagnostic possibilities for young children who present with recurrent wheeze. DATA SOURCES Review of medical literature and 30 years of practice experience. STUDY SELECTION Relevant medical literature. RESULTS When evaluating an infant or child presenting with recurrent respiratory symptoms, several diagnoses must be considered. The workup should include assessment of the risk factors for asthma and careful investigation into the specific symptoms. Recurrent or persistent wheezing and/or coughing often result in a diagnosis of asthma with therapeutic trials of asthma treatment. When the therapy is ineffective, other diagnoses should be considered, including gastroesophageal reflux, protracted bacterial bronchitis, tracheobronchomalacia, and cystic fibrosis. Appropriate testing should be performed in these pediatric patients. CONCLUSION In young children with recurrent lower airway symptoms who have a negative modified Asthma Predictive Index result, the described diagnostic possibilities should be considered.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Center, Sacramento, California 95819, USA.
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Van Howe RS, Storms MR. Gastroesophageal reflux symptoms in infants in a rural population: longitudinal data over the first six months. BMC Pediatr 2010; 10:7. [PMID: 20149255 PMCID: PMC2831886 DOI: 10.1186/1471-2431-10-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 02/11/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing numbers of infants are receiving prescription medications for symptoms associated with gastroesophageal reflux. Our aim was to prospectively measure reported gastroesophageal reflux symptoms in healthy term infants for the first six months of life. METHODS In a prospective cohort study in the rural Upper Peninsula of Michigan, 128 consecutive maternal-infant pairs were followed for six months and administered the Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) at the one-month, two-month, four-month, and six-month well-child visits. RESULTS The I-GERQ-R scores decreased with age. Average scores were 11.74 (SE = 5.97) at one-month, 9.97(4.92) at two-months, 8.44(4.39) at four-months, and 6.97(4.05) at six months. Symptoms associated with colic were greatest at one month of age. CONCLUSION Symptoms of gastroesophageal reflux as measured by the I-GERQ-R decrease with age in the first six months of life in otherwise healthy infants; however the I-GERQ-R may have difficulty differentiating gastroesophageal reflux disease from colic in those under 3 months of age.
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Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, Marquette, Michigan, USA.
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Cross-over trial of treatment for bradycardia attributed to gastroesophageal reflux in preterm infants. J Pediatr 2009; 155:516-21. [PMID: 19540518 PMCID: PMC2891243 DOI: 10.1016/j.jpeds.2009.03.044] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 02/02/2009] [Accepted: 03/23/2009] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine whether anti-reflux medications reduce bradycardia episodes attributed to clinically suspected gastroesophageal reflux (GER). STUDY DESIGN We conducted a masked trial comparing metoclopramide, 0.2 mg/kg/dose q 6 hours, and ranitidine, 2 mg/kg/dose q 8 hours, with saline placebo. Each infant served as his own control. Preterm infants having >3 bradycardia episodes per 2 days were eligible if the clinician intended to begin anti-reflux medications for bradycardia attributed to GER. RESULTS The mean (SD) birth weight was 1238 (394) g and gestational age was 29 (3) weeks. Eighteen infants were enrolled at 35 (22) days of age. There were 4.6 (3.1) and 3.6 (2.7) bradycardia episodes per day in the drug and placebo periods, respectively. The mean difference (drug minus placebo) was 0.94 (95% CI, 0.04 to 1.95) (P = .04 by t test). There was a decrease in bradycardia episodes over time (P < .001 by nonparametric repeated-measures analysis of variance). CONCLUSIONS Anti-reflux medications did not reduce, and may have increased, bradycardia episodes in preterm infants with GER. Because there was an improvement of bradycardia episodes over time, unrelated to treatment, unmasked therapeutic trials of medications are likely to lead to misleading conclusions.
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Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547. [PMID: 19745761 DOI: 10.1097/mpg.0b013e3181b7f563] [Citation(s) in RCA: 479] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.
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Calidad de las recomendaciones farmacoterapéuticas de los procesos asistenciales integrados en Andalucía. FARMACIA HOSPITALARIA 2009. [DOI: 10.1016/s1130-6343(09)72466-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Omari T, Lundborg P, Sandström M, Bondarov P, Fjellman M, Haslam R, Davidson G. Pharmacodynamics and systemic exposure of esomeprazole in preterm infants and term neonates with gastroesophageal reflux disease. J Pediatr 2009; 155:222-8. [PMID: 19394048 DOI: 10.1016/j.jpeds.2009.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 12/22/2008] [Accepted: 02/11/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize the pharmacodynamics and systemic exposure of esomeprazole in 26 preterm infants and term neonates with symptoms of gastroesophageal reflux and pathologic acid exposure. STUDY DESIGN Enrolled patients received oral esomeprazole 0.5 mg/kg once daily for 7 days. Twenty-four-hour esophagogastric pH-impedance monitoring was performed at baseline and on day 7. Pharmacokinetic analysis was performed on day 7. Symptoms occurring during the baseline and day 7 studies were recorded on a symptom chart. RESULTS There were no significant differences from baseline to day 7 of therapy in the frequency of bolus reflux, consistency of bolus reflux (liquid, mixed, or gas), extent of bolus reflux, or bolus clearance time. Acid bolus reflux episodes were reduced on therapy (median 30 vs 8, P < .001), as was the reflux index (mean % time esophageal pH < 4, 15.7% vs 7.1%, P < .001). The estimated geometric mean of area under the plasma concentration time curve during the dosing interval and observed maximum plasma concentration was 2.5 micromol x h/L and 0.74 micromol/L, respectively. The number of gastroesophageal reflux symptoms recorded over 24 hours was lower on therapy (median 22 vs 12, P < .05). CONCLUSIONS In preterm infants and term neonates esomeprazole produces no change in bolus reflux characteristics despite significant acid suppression.
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Affiliation(s)
- Taher Omari
- Gastroenterology Unit, Children, Youth and Women's Health Services, North Adelaide, SA, Australia.
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Sherman PM, Hassall E, Fagundes-Neto U, Gold BD, Kato S, Koletzko S, Orenstein S, Rudolph C, Vakil N, Vandenplas Y. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol 2009; 104:1278-95; quiz 1296. [PMID: 19352345 DOI: 10.1038/ajg.2009.129] [Citation(s) in RCA: 299] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population. METHODS Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system. RESULTS There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established. CONCLUSIONS The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.
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Affiliation(s)
- Philip M Sherman
- Gastroenterology-Pediatric, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Orenstein SR, Hassall E, Furmaga-Jablonska W, Atkinson S, Raanan M. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr 2009; 154:514-520.e4. [PMID: 19054529 DOI: 10.1016/j.jpeds.2008.09.054] [Citation(s) in RCA: 216] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/28/2008] [Accepted: 09/30/2008] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of lansoprazole in treating infants with symptoms attributed to gastroesophageal reflux disease (GERD) that have persisted despite a >or= 1-week course of nonpharmacologic management. STUDY DESIGN This multicenter, double-blind, parallel-group study randomized infants with persisting symptoms attributed to GERD to treatment with lansoprazole or placebo for 4 weeks. Symptoms were tracked through daily diaries and weekly visits. Efficacy was defined primarily by a >or= 50% reduction in measures of feeding-related crying and secondarily by changes in other symptoms and global assessments. Safety was assessed based on the occurrence of adverse events (AEs) and clinical/laboratory data. RESULTS Of the 216 infants screened, 162 met the inclusion/exclusion criteria and were randomized. Of those, 44/81 infants (54%) in each group were responders--identical for lansoprazole and placebo. No significant lansoprazole-placebo differences were detected in any secondary measures or analyses of efficacy. During double-blind treatment, 62% of lansoprazole-treated subjects experienced 1 or more treatment-emergent AEs, versus 46% of placebo recipients (P= .058). Serious AEs (SAEs), particularly lower respiratory tract infections, occurred in 12 infants, significantly more frequently in the lansoprazole group compared with the placebo group (10 vs 2; P= .032). CONCLUSIONS This study detected no difference in efficacy between lansoprazole and placebo for symptoms attributed to GERD in infants age 1 to 12 months. SAEs, particularly lower respiratory tract infections, occurred more frequently with lansoprazole than with placebo.
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Hassall E. Step-up and step-down approaches to treatment of gastroesophageal reflux disease in children. Curr Gastroenterol Rep 2008; 10:324-331. [PMID: 18625145 DOI: 10.1007/s11894-008-0063-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The single biggest change in the approach to treating pediatric gastroesophageal reflux disease (GERD) in recent years has been the empiric use of proton pump inhibitors (PPIs) for symptoms suspected to be those of GERD. In other words, PPIs have been used increasingly as a first-line concurrent diagnostic test and treatment before any investigation. Although this approach is useful for some patients, there are a number of caveats about its application to children. In general, these caveats are related to age per se (eg, infancy) and to age-related symptoms and severity of GERD itself. The most important caveats relate to the prescription of empiric PPI therapy in infants--which generally is to be avoided--and to how PPIs are used in older children--specifically, the advisability of empiric trials being of limited duration. Even in children with proven reflux esophagitis, GERD is not chronic and relapsing in all; thus, trials of therapy withdrawal are warranted. In light of many factors, including the burgeoning literature on potential risks of infections in acid-suppressed children and adults, caution with dose and duration of acid-suppressive drugs in children is urged. The role of antireflux surgery is also mentioned.
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Affiliation(s)
- Eric Hassall
- Division of Gastroenterology, British Columbia Children's Hospital, 4480 Oak Street, Vancouver, British Columbia V6H3V4, Canada.
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Hassall E. Talk is cheap, often effective: symptoms in infants often respond to non-pharmacologic measures. J Pediatr 2008; 152:301-3. [PMID: 18280829 DOI: 10.1016/j.jpeds.2007.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/16/2007] [Indexed: 01/05/2023]
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