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Mouzan ME, Naqeeb AA, Otaibi NA, Askar JA, Joseph T, Sarkhy AA, Asmi MA, Assiri A. Multichannel intraesophageal impedance with pH metry in Saudi children. Saudi J Gastroenterol 2024; 30:103-107. [PMID: 37997390 PMCID: PMC10980298 DOI: 10.4103/sjg.sjg_249_23] [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: 07/08/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Multichannel Intraesophageal Impedance with pH (MII-pH) provides complete characterization of gastroesophageal reflux (GER). The aim of this study was to report our experience in this relatively new technique, emphasizing the challenges in the performance and interpretation of the results. METHODS The study was conducted at King Khalid University Hospital at King Saud University in Riyadh. A retrospective review of the medical records of children who underwent MII-pH was performed. The procedure was performed and interpreted according to the recommended methodology. The impedance catheter was introduced nasally. The use of event markers and diary were explained to the accompanying person. At the end of the recording, the data were downloaded to the software analysis system. RESULTS MII-pH was performed on 98 children, and 16 studies were excluded from analysis for technical reasons. The median age was 32 (range 2-168) months and 44 (54%) were male. The prevalence of nonacid gastroesophageal reflux (NAGER), proximal extent of GER, and postprandial NAGER were 55%, 50%, and 70%, respectively. One hundred and fifty-three symptoms were reported during the study, but only two were significant. CONCLUSION The MII-pH was well-tolerated but the performance and interpretation were technically demanding. The main advantage was the detection of NAGER. However, the lack of normal values and the reliance on symptom association make the interpretation of the results challenging.
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Affiliation(s)
- Mohammad El Mouzan
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ahlam Al Naqeeb
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Najla Al Otaibi
- Department of Pediatrics (Gastroenterology Unit), College of Medicine, Majmaah University, Majmaah, Kingdom of Saudi Arabia
| | - Jawaher Al Askar
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Teema Joseph
- Department of Nursing, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed Al Sarkhy
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mona Al Asmi
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Asaad Assiri
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Hron B, Ng T, Voss S, Rosen R. Effect of blenderized tube feeds on gastric emptying: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:654-661. [PMID: 37165611 PMCID: PMC11223061 DOI: 10.1002/jpen.2513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/12/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Blenderized tube feeds (blends) are associated with lower hospital admissions and reduced gastroesophageal symptoms, but their high viscosity may theoretically prolong gastric emptying. Our objective was to compare differences in gastric emptying with blends vs with formula. METHODS We retrospectively identified individuals 6 months to 20 years with enteral tubes who underwent 1-h liquid gastric emptying scintigraphy from 1998 to 2020 at Boston Children's Hospital. Examinations were excluded if a postpyloric tube was present, tracer was administered orally or with diet differing from habitual, habitual diet was indeterminable, imaging was terminated early, or >50% of input counts emptied during bolus administration. Emptying was classified as delayed if gastric residual at 1 h was ≥60% of ingested dose. RESULTS Eighteen examinations (15 individuals) were performed with blends and 35 examinations (32 individuals) with formula. Although percentage of residual at 1 h was significantly higher in patients receiving blends compared with formula (54 ± 17 vs 40 ± 25, P = 0.04), the number of patients with delayed gastric emptying did not differ (39% vs 29%, respectively, P = 0.54). Type of diet, feed volume or concurrent medications did not predict delayed gastric emptying. Children with blends received higher bolus volumes (106 ± 55 vs 66 ± 59 ml; P = 0.02), and this significantly predicted percentage of residual (β = 0.14; P = 0.01). CONCLUSION The proportion of patients with delayed gastric emptying was similar in children receiving blends and formula. Although the mean percentage of gastric residual was higher with blends, this may be explained by higher bolus volumes administered. This preliminary work suggests that blends compare favorably to formula.
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Affiliation(s)
- Bridget Hron
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA
| | - Thomas Ng
- Department of Radiology, Massachusetts General Hospital, Boston, MA
- Joint Program in Nuclear Medicine, Harvard Medical School, Boston, MA
| | - Stephan Voss
- Joint Program in Nuclear Medicine, Harvard Medical School, Boston, MA
- Department of Radiology, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA
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Khlevner J, Patel D, Rodriguez L. Pediatric Neurogastroenterology and Motility Disorders: What Role Does Endoscopy Play? Gastrointest Endosc Clin N Am 2023; 33:379-399. [PMID: 36948752 DOI: 10.1016/j.giec.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Although pediatric neurogastroenterology and motility (PNGM) disorders are prevalent, often debilitating, and remain challenging to diagnose and treat, this field has made remarkable progress in the last decade. Diagnostic and therapeutic gastrointestinal endoscopy emerged as a valuable tool in the management of PNGM disorders. Novel modalities such as functional lumen imaging probe, per-oral endoscopic myotomy, gastric-POEM, and electrocautery incisional therapy have changed the diagnostic and therapeutic landscape of PNGM. In this review, the authors highlight the emerging role of therapeutic and diagnostic endoscopy in esophageal, gastric, small bowel, colonic, and anorectal disorders and disorders of gut and brain axis interaction.
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Affiliation(s)
- Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, Gastrointestinal Motility Center, NewYork Presbyterian Morgan Stanley Children's Hospital, 622 West 168th Street, PH 17, New York, NY 11032, USA.
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children's Medical Center, 1465 South Grand Boulevard, St Louis, MO 63104, USA
| | - Leonel Rodriguez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Yale New Haven Children's Hospital, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
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Lewit RA, Camp L, Dietrich C, Hammond R, Paton E, Lucas DJ, Gosain A. Upper Gastrointestinal Series in the Workup for Pediatric Gastrostomy Placement: Does it Delay Care? J Surg Res 2023; 283:992-998. [PMID: 36915028 DOI: 10.1016/j.jss.2022.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Upper gastrointestinal (UGI) series is often part of the workup prior to the placement of gastrostomy tubes in children. Prior studies have suggested UGI to be limited in utility and an extra financial burden. The goal of this study was to investigate the utility and cost of UGI studies. METHODS A retrospective, case control study of patients aged < 18 y receiving gastrostomy tubes at a free-standing children's hospital between 2012 and 2017. Total costs were obtained from the Pediatric Health Information System. RESULTS Six hundred eighty five patients underwent gastrostomy placement during the study period. UGI was obtained in 90.8% of patients; 23.6% of studies were abnormal. The most common abnormal findings were reflux (13.8%) and abnormal anatomy (5.8%). The median time to obtain a UGI was 0.82 d (interquartile range 0.22-1.05). Obtaining a UGI was associated with delayed care in 104 patients (15.2%). If a delay was encountered, median time was 2.47 d (interquartile range 1.86-2.99). Ladd's procedures were performed in 12 patients (1.7%) found to have malrotation on UGI. None of the 63 patients who did not undergo UGI required a Ladd's procedure. Patients that had a UGI did not experience an increase in overall length of stay (14.3 versus 15.6 d, excluding intensive care unit patients), operative time (34 versus 39 min), or a change in rate of operative complications (11.5% versus 14.3%). In addition, UGI did not have a significant impact on total adjusted costs ($49,844 versus $83,438 without UGI, P = 0.12) but did slightly increase total adjusted costs per day ($2212 versus $1999 without UGI, P = 0.01). CONCLUSIONS UGI prior to gastrostomy placement in children rarely identified abnormal findings that changed the operative plan, was associated with delayed care in 15% of patients, and was associated with slightly increased costs per day. Further analyses to identify subsets of children that may benefit from routine UGI are warranted.
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Affiliation(s)
- Ruth A Lewit
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Lauren Camp
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee; Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Collin Dietrich
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ryan Hammond
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Elizabeth Paton
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee; College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Donald J Lucas
- Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, San Diego, California; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee; Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.
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Lopez RN, Lemberg DA. Gastro-oesophageal reflux disease in infancy: a review based on international guidelines. Med J Aust 2019; 212:40-44. [PMID: 31834639 DOI: 10.5694/mja2.50447] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastro-oesophageal reflux (GOR) in infancy is common, physiological and self-limiting; it is distinguished from gastro-oesophageal reflux disease (GORD) by the presence of organic complications and/or troublesome symptomatology. GORD is more common in infants with certain comorbidities, including history of prematurity, neurological impairment, repaired oesophageal atresia, repaired diaphragmatic hernia, and cystic fibrosis. The diagnosis of GORD in infants relies almost exclusively on clinical history and examination findings; the role of invasive testing and empirical trials of therapy remains unclear. The assessment of infants with vomiting and regurgitation should seek out red flags and not be attributed to GOR or GORD without considered evaluation. Investigations should be considered to exclude other pathology in infants referred with suspected GORD, and occasionally to confirm the diagnosis. Management of GORD should follow a step-wise approach that uses non-pharmacological options where possible and pharmacological interventions only where necessary.
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Leung AK, Hon KL. Gastroesophageal reflux in children: an updated review. Drugs Context 2019; 8:212591. [PMID: 31258618 PMCID: PMC6586172 DOI: 10.7573/dic.212591] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong.,PICU, The Hong Kong Children's Hospital, Kowloon, Hong Kong
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Gonzalez Ayerbe JI, Hauser B, Salvatore S, Vandenplas Y. Diagnosis and Management of Gastroesophageal Reflux Disease in Infants and Children: from Guidelines to Clinical Practice. Pediatr Gastroenterol Hepatol Nutr 2019; 22:107-121. [PMID: 30899687 PMCID: PMC6416385 DOI: 10.5223/pghn.2019.22.2.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/02/2019] [Accepted: 01/09/2019] [Indexed: 12/13/2022] Open
Abstract
The diagnosis and management of gastro-esophageal reflux (GER) and GER disease (GERD) in infants and children remains a challenge. Published guidelines and position papers, along with Embase, MEDLINE, and the Cochrane Database were reviewed and summarized with the intent to propose a practical approach and management of GER and GERD for healthcare providers and to standardize and improve the quality of care for infants and children. For this purpose, 2 algorithms were developed, 1 for infants <12 months of age and the other for older children. None of the signs and symptoms of GER and GERD are specific and there is no gold standard diagnostic test or tool. Nutritional management is recommended as a first-line approach in infants, while in children, a therapeutic trial with antacid medication is advised for early management. The practical recommendations from this review are intended to optimize the management of GER in infants and older children and reduce the number of investigations and inappropriate use of medication.
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Affiliation(s)
| | - Bruno Hauser
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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8
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Abstract
OBJECTIVE The purpose of this article is to describe the clinical utility of state-of-theart gastrointestinal transit scintigraphy, including the standardized esophageal transit, solid and liquid gastric emptying, small-bowel transit, colon transit, and whole-gut transit scintigraphy, with an emphasis on procedure performance. CONCLUSION Radionuclide gastrointestinal motility studies are noninvasive, quantitative, and physiologic diagnostic tools for evaluating patients with gastrointestinal complaints.
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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: 456] [Impact Index Per Article: 76.0] [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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Ren CL, Esther CR, Debley JS, Sockrider M, Yilmaz O, Amin N, Bazzy-Asaad A, Davis SD, Durand M, Ewig JM, Yuksel H, Lombardi E, Noah TL, Radford P, Ranganathan S, Teper A, Weinberger M, Brozek J, Wilson KC. Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing. Am J Respir Crit Care Med 2017; 194:356-73. [PMID: 27479061 DOI: 10.1164/rccm.201604-0694st] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies. METHODS An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations. RESULTS The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing. CONCLUSIONS Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.
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Bar-Sever Z. Scintigraphic Evaluation of Gastroesophageal Reflux and Pulmonary Aspiration in Children. Semin Nucl Med 2017; 47:275-285. [PMID: 28417856 DOI: 10.1053/j.semnuclmed.2016.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Gastroesophageal reflux (GER) and pulmonary aspiration are encountered in children of all ages. Signs, symptoms, and complications vary from mild and transient to severe life-threatening conditions. This review will present relevant clinical information on these conditions as well as common diagnostic procedures. The role of scintigraphic techniques used in the evaluation of these conditions will be discussed in detail including protocols and performance in comparison to other diagnostic methods.
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Affiliation(s)
- Zvi Bar-Sever
- Department of nuclear medicine, Schneider Children's Medical Center, Petah Tikva, Israel.
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12
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Macharia EW. Comparison of upper gastrointestinal contrast studies and pH/impedance tests for the diagnosis of childhood gastro-oesophageal reflux. Pediatr Radiol 2012; 42:946-51. [PMID: 22864731 DOI: 10.1007/s00247-012-2405-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 01/09/2012] [Accepted: 02/12/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The upper gastrointestinal (UGI) contrast study is used in the assessment of children with gastro-oesophageal reflux (GOR) and for detection of structural anomalies. The pH study is more sensitive than the UGI study for the diagnosis of GOR. The pH study has been replaced by the pH/impedance test, which detects both acid and nonacid reflux. OBJECTIVE To compare the UGI contrast study with the pH/impedance test for the diagnosis of GOR in children. MATERIALS AND METHODS We retrospectively reviewed consecutive records of children investigated for GOR from October 2008 to February 2010, and compared the findings of UGI studies with those of pH/impedance tests. RESULTS The UGI studies revealed GOR in 116 of 579 children (20%). Of the children undergoing a UGI study, 66 also underwent a pH/impedance test. Using the pH/impedance tests as the reference for GOR, UGI had a sensitivity of 42.8% and a negative predictive value of 24%. There was no significant correlation (P > 0.05) between the reflux index and the number of reflux episodes in the pH/impedance tests and height of reflux in the UGI study. There were low incidences of malrotation (0.9%), hiatus hernia (1%) and delayed gastric emptying (0.4%). CONCLUSION The UGI study had low sensitivity for the diagnosis of GOR and low yield for the diagnosis of structural anomalies.
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Affiliation(s)
- Eva W Macharia
- Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Ozmen S, Demirceken F, Barut Y, Dibek Misirlioglu E. Role of laryngoscopy in children with respiratory complaints and suspected reflux. Allergol Immunopathol (Madr) 2012; 40:204-9. [PMID: 21978888 DOI: 10.1016/j.aller.2011.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/04/2011] [Accepted: 06/14/2011] [Indexed: 01/21/2023]
Abstract
BACKGROUND In recent years, laryngopharyngeal reflux (LPR) in children has been taken into consideration. OBJECTIVE The aim of this study was to assess the laryngoscopic findings in children diagnosed LPR and/or gastro-oesophageal reflux (GERD). METHODS The findings of 49 patients with at least one or more respiratory complaint such as chronic cough, wheezing, hoarseness, recurrent laryngitis, and throat clearing/postnasal discharge suggesting LPR were evaluated retrospectively. The diagnosis of LPR+GERD or GERD was done by the clinical history and 24 h double-probe pH monitoring and/or scintigraphy. RESULTS Thirty eight out of 49 patients examined by laryngoscopy underwent 24 h double-probe pH monitoring and/or scintigraphy. Thirty of them were diagnosed as LPR+GERD or GERD by any test positivity. Twelve of 30 patients diagnosed with LPR+GERD or GERD had a positive laryngeal finding on the examination of fibre optic laryngoscopy. The most common finding with eight cases was arytenoid erythema A sensitivity of 40% and specificity of 50% for the laryngoscopy in the diagnosis of LPR/GERD were found. CONCLUSION In children with unexplained respiratory symptoms, laryngopharyngeal reflux should be suspected. Therefore, until enough data on this issue in the literature accumulates, the history and the laboratory findings of the patients obtained from various techniques to document paediatric LPR should be evaluated together.
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Tuncel M, Kıratlı PO, Aksoy T, Bozkurt MF. Gastroesophageal reflux scintigraphy: interpretation methods and inter-reader agreement. World J Pediatr 2011; 7:245-9. [PMID: 21822991 DOI: 10.1007/s12519-011-0322-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 03/17/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Scintigraphic imaging is a useful screening tool for patients with suspected gastroesophageal reflux. New scintigraphic interpretation methods have recently been introduced. This study was undertaken to evaluate the efficiency of various scintigraphic interpretation methods in the detection of gastroesophageal reflux and to measure their influence on inter-reader agreement. METHODS Scintigraphic images of 49 children with suspected gastroesophageal reflux were interpreted by three different methods: visual interpretation, time activity curves, and condensed images. The readings were performed by three specialists and a resident. The discordant results were resolved by a consensus reading done together by all interpreters based on the three different methods. The gastroesophageal refluxes were grouped according to their number, location and intensity. RESULTS Gastroesophageal reflux scintigraphy revealed 22 patients with negative results and 27 with positive results. The sensitivity, positive predictive value and specificity for each of the three specialists vs. the resident were 96%, 96% and 81% vs. 96%; 93%, 90% and 96% vs. 81%; and 90%, 86%, and 95% vs. 73%, respectively. The mean inter-observer reproducibility (κ value) was 0.910 for visual interpretation, 0.652 for time activity curves and 0.789 for condensed images. Twenty-seven percent of the results were discordant and most of these refluxes were of low grade (92%), low intensity (77%) and localization in the distal esophagus (54%). CONCLUSION Gastroesophageal scintigraphy is a useful tool for detecting patients with suspected reflux, and visual interpretation is better than the other two methods in terms of accuracy and inter-observer reproducibility.
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Affiliation(s)
- Murat Tuncel
- Department of Nuclear Medicine, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, 06110, Turkey.
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Patra S, Singh V, Chandra J, Kumar P, Tripathi M. Diagnostic modalities for gastro-esophageal reflux in infantile wheezers. J Trop Pediatr 2011; 57:99-103. [PMID: 20595328 DOI: 10.1093/tropej/fmq056] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the diagnostic value of Gastro-intestinal (GI) scintiscan with 24-h pH study in detecting gastro-esophageal reflux (GER) among infantile wheezers. SUBJECTS Fifty-two children < 2 years of age. METHODS All patients, irrespective of symptom underwent study to evaluate for GER. RESULTS GER studies were positive in almost 45% of cases. The agreement between positivity of these two tests is best among children between 7 and 12 months of age (κ = 0.591, p = 0.002). Overall GI scintiscan was a better test with higher sensitivity and specificity as compared to 24-h pH study when compared with the history suggestive of reflux and clinical response with anti-reflux treatment as standard (p ≤ .001). CONCLUSION Both GER scan and 24-h pH study are complimentary to each other, however, if both the tests are available then GI scintiscan is better as a single test for GER in these early wheezers.
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Affiliation(s)
- Soumya Patra
- Department of Pediatrics, Lady Hardinge Medical College & Kalawati Saran Children's Hospital, New Delhi, India.
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16
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The usefulness of the upper gastrointestinal series in the pediatric patient before anti-reflux procedure or gastrostomy tube placement. J Surg Res 2011; 170:247-52. [PMID: 21550057 DOI: 10.1016/j.jss.2011.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 02/17/2011] [Accepted: 03/03/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Most children undergo an upper gastrointestinal study (UGI) before an anti-reflux (AR) procedure or gastrostomy tube placement (GT). Anatomic abnormalities detected by UGI are uncommon and we hypothesize that the value of routine preoperative use of this test is limited. METHODS Five hundred and seventy-two patients who underwent either an AR or GT over a 10-y period at our institution were reviewed. Data including patient demographics, indications for surgery, preoperative testing, and type of operation were collected. RESULTS Of the 572 cases, an UGI was performed in approximately 71%. The results were interpreted as normal in 63%, and abnormal in 37%. The most common abnormality noted was gastroesophageal reflux in approximately 80%, followed by an anatomic abnormality in 6%, most of which were expected. Of 36 anatomic abnormalities noted, only four were unexpected in the total cohort. In addition to an UGI, half of the subjects received additional evaluations that included pH probes and gastric emptying studies (GES). In these studies, 56% of pH probes and 45% of GES had findings in which reflux was noted. Compared with UGIs, these tests were significantly more likely to identify reflux in patients. CONCLUSION These results suggest that the utility of an UGI before AR or GT procedures is low. Anatomic abnormalities were rare and changed clinical management in a total of four cases. A prospective trial would help to further validate these findings and help identify patients who would benefit from an UGI.
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Patra S, Singh V, Chandra J, Kumar P, Tripathi M. Gastro-esophageal reflux in early childhood wheezers. Pediatr Pulmonol 2011; 46:272-7. [PMID: 20967836 DOI: 10.1002/ppul.21363] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 06/11/2010] [Accepted: 07/29/2010] [Indexed: 12/23/2022]
Abstract
Wheezing is common among infants and young children due to peculiar anatomical and physiological properties of their lungs. Gastro-oesophageal reflux (GER) has been incriminated as one of the cause of non-asthmatic wheezing in this age group. The present study evaluates the magnitude of GER and its causal relationship with wheezing in early childhood. All recurrent and persistent wheezers (under two years) were investigated for GER and treated medically where tests were positive. The subjects were further profiled to identify any predictors for GER. Sixty-seven children of less than 2 years age with recurrent or persistent wheezing were evaluated for GER. Mean age of the study subjects at enrolment was 10.8 months and at onset of wheezing was 7.1 (± 3.8 S.D) months. Asthma and wheeze associated lower respiratory tract infection (WALRI) was diagnosed in about 1/3 each of the patients studied. GER studies were positive in over one-third (25/67) of cases. Forty-two percent of children who wheezed by 1 year of age had a positive GER study. Interestingly, nearly half (12/25) of the patients with an abnormal study did not have any clinical suggestion of regurgitation ("silent" GERs). The severity of wheezing was higher among those who had GER versus those who did not (p ≤ 0.048; OR: 3.2). However, only 32% patients showed significant response to anti reflux treatment alone while others had partial response. GER, therefore, is an important cause for recurrent wheezing among children less than 2 years of age, either singularly or as a co-morbidity. The study findings justify investigations for GER among early wheezers; particularly for those who have onset of symptoms by 12 months of age or those who have severe disease.
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Affiliation(s)
- Soumya Patra
- Department of Pediatrics, Lady Hardinge Medical College & Kalawati Saran Children's Hospital, New Delhi, India
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18
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Valusek PA, St Peter SD, Keckler SJ, Laituri CA, Snyder CL, Ostlie DJ, Holcomb GW. Does an upper gastrointestinal study change operative management for gastroesophageal reflux? J Pediatr Surg 2010; 45:1169-72. [PMID: 20620314 DOI: 10.1016/j.jpedsurg.2010.02.083] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 02/22/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND In patients with gastroesophageal reflux disease, an upper gastrointestinal (UGI) contrast study is often the initial study performed for those patients being considered for fundoplication. The accuracy of UGI for diagnosing reflux is known to be poor, but there are no data on how often this study influences management. Therefore, we reviewed our experience in patients undergoing fundoplication to quantify the impact of the UGI. METHODS A retrospective analysis of our most recent 7-year experience with patients undergoing fundoplication was performed. Results of the diagnostic tests and operative course were recorded. RESULTS From January 2000 to June 2007, 843 patients underwent fundoplication. An UGI study was obtained in 656 patients. A pH study was also performed in 379 of these patients who had an UGI. The sensitivity of the UGI for reflux compared with pH study was 30.8%. An abnormality besides gastroesophageal reflux disease or hiatal hernia that impacted the operative plan was found on the UGI in 30 patients (4.5%). The most common anomaly was malrotation, which was found in 26 patients (4.0%). Malrotation was confirmed in 16 patients and ruled out in 6 patients during fundoplication, and 4 patients had undergone a previous Ladd procedure. Esophageal dilation was performed in 5 patients with the fundoplication for a stricture found on the UGI. Pyloroplasty was performed with the fundoplication in 2 patients, and 1 patient underwent exploration of the duodenum for possible obstruction. CONCLUSIONS The UGI study is a poor study for accurately delineating which patients have pathologic reflux. However, it reveals a finding that may influence management in approximately 4% of cases.
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Affiliation(s)
- Patricia A Valusek
- Department of Surgery, the Children's Mercy Hospital, Kansas City, MO 64108, USA
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19
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Indrio F, Riezzo G, Raimondi F, Cavallo L, Francavilla R. Regurgitation in healthy and non healthy infants. Ital J Pediatr 2009; 35:39. [PMID: 20003194 PMCID: PMC2796655 DOI: 10.1186/1824-7288-35-39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 12/09/2009] [Indexed: 12/15/2022] Open
Abstract
Uncomplicate regurgitation in otherwise healthy infants is not a disease. It consists of milk flow from mouth during or after feeding. Common causes include overfeeding, air swallowed during feeding, crying or coughing; physical exam is normal and weight gain is adequate. History and physical exam are diagnostic, and conservative therapy is recommended. Pathologic gastroesophageal reflux or gastroesophageal reflux disease refers to infants with regurgitation and vomiting associated with poor weight gain, respiratory symptoms, esophagitis. Reflux episodes occur most often during transient relaxations of the lower esophageal sphincter unaccompanied by swallowing, which permit gastric content to flow into the esophagus. A minor proportion of reflux episodes occurs when the lower esophageal sphincter fails to increase pressure during a sudden increase in intraabdominal pressure or when lower esophageal sphincter resting pressure is chronically reduced. Alterations in several protective mechanisms allow physiologic reflux to become gastroesophageal reflux disease; diagnostic approach is both clinical and instrumental: radiological series are useful to exclude anatomic abnormalities; pH-testing evaluates the quantity, frequency and duration of the acid reflux episodes; endoscopy and biopsy are performed in the case of esophagitis. Therapy with H2 receptor antagonists and proton pump inhibitors are suggested.
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Affiliation(s)
- Flavia Indrio
- Department of Pediatrics, University of Bari Policlinico Piazza G.Cesare, 70124 Bari, Italy
| | - Giuseppe Riezzo
- Laboratory of Experimental Pathophysiology, National Institute for Digestive Diseases, I.R.C.C.S. "Saverio de Bellis" Via Turi, 14, 70013 Castellana Grotte (Bari), Italy
| | - Francesco Raimondi
- Department of Pediatrics, University Federico II Policlinico Via S Pansini, 12, 80100 Naples, Italy
| | - Luciano Cavallo
- Department of Pediatrics, University of Bari Policlinico Piazza G.Cesare, 70124 Bari, Italy
| | - Ruggiero Francavilla
- Department of Pediatrics, University of Bari Policlinico Piazza G.Cesare, 70124 Bari, Italy
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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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Abstract
Allergic eosinophilic esophagitis is an increasingly recognized disease in various parts of the world. The clinical presentation mimics other gastrointestinal diseases, especially gastroesophageal reflux disease, making endoscopic examination and histological evaluation of esophageal mucosal biopsies crucial to accurate diagnosis. The pathogenesis likely involves allergen-initiated, TH2-dependent, IL-5 mediated infiltration of eosinophilis into the esophageal mucosa. Therapies currently favored include dietary modifications and use of corticosteroids.
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Affiliation(s)
- Kevin C Bax
- Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indianapolis, Indiana 46202-5225, USA
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22
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Abstract
An association between asthma and gastroesophageal reflux disease (GERD) has long been recognized both mechanistically and epidemiologically. The clinical relevance of this interplay continues to be explored, with special interest given to the role of GERD in the worsening of asthma. The effect of GERD is most frequently contemplated in patients with asthma that is difficult to control. Medical and surgical anti-reflux trials attempting to alter asthma symptoms have reported mixed but generally underwhelming results, although asthma symptom scores are generally improved following effective treatment of GERD. Many of the pharmaceutical studies can be criticised for having too short a duration or for likely incomplete acid suppression. Few trials have specifically studied pediatric populations. Because GERD is a common condition, particularly in young children, the role reflux plays in the worsening of asthma symptoms and the potential benefit on asthma of anti-reflux therapy warrants further exploration. Whether or not treating symptomatic GERD reduces the symptoms and severity of asthma in children, GERD coexisting with asthma should be aggressively treated. GERD symptoms in most patients with or without asthma can be controlled medically with continuous use of proton pump inhibitors such as omeprazole and lansoprazole and to a lesser extent by histamine H(2) receptor antagonists such as famotidine and cimetidine.
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Affiliation(s)
- Mark D Scarupa
- Maryland Institute for Asthma and Allergy, Wheaton, Maryland, USA
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23
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Nazer D, Thomas R, Tolia V. Ethnicity and gender related differences in extended intraesophageal pH monitoring parameters in infants: a retrospective study. BMC Pediatr 2005; 5:24. [PMID: 16026617 PMCID: PMC1188060 DOI: 10.1186/1471-2431-5-24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Accepted: 07/18/2005] [Indexed: 11/28/2022] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is believed to be more common in adult males as compared to females. It also has been shown in adults to be more common in Caucasians. We wanted to determine ethnicity and gender related differences for extended pH monitoring parameters in infancy. Methods Extended pH monitoring data (EPM) from infants <1 year of age were reviewed. Results were classified in two groups, as control and Gastroesophageal reflux disease (GERD) group based on the reflux index (RI). The GERD group had RI of equal to or more than 5% of total monitoring period. The parameters of RI, total number of episodes of pH < 4, and the number of episodes with pH < 4 lasting more than 5 minutes were compared by genders and by ethnic groups, Caucasians and African American (AA). Results There were 569 infants, 388 controls, 181 with GERD (320 males, 249 females; 165 Caucasians, 375 AA). No statistical difference in EPM parameters was detected between genders in both groups. However, Caucasian infants had a significantly higher incidence of GERD than AA infants (p = 0.036). On stratifying by gender, Caucasian females had a significantly higher number of reflux episodes >5 minutes as compared to AA females in the control group (p = 0.05). Furthermore, Caucasian females with GERD showed an overall higher trend for all parameters. Caucasian males had a trend for higher mean number of reflux episodes as compared to AA males in the control group (p = 0.09). Conclusion Although gender specific control data do not appear warranted in infants undergoing EPM, ethnic differences related to an overall increased incidence of pathologic GERD in Caucasian infants should be noted.
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Affiliation(s)
- Dena Nazer
- Children's Hospital of Michigan, Carman and Ann Adams Department of Pediatrics, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Ronald Thomas
- Children's Research Center of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Vasundhara Tolia
- Children's Hospital of Michigan, Carman and Ann Adams Department of Pediatrics, 3901 Beaubien Street, Detroit, MI 48201, USA
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24
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Abstract
Our aims were to compare the specificity and sensitivity of the reflux index (RI), Euler and Byrne score (EBS), and area under the curve (AUC) at pH < 4.0 in infants 1 year old for identifying pathologic gastroesophageal reflux (GER) and to identify new cutoffs on formula feedings. We undertook a prospective investigation of extended pH monitoring (EPM) in 117 infants with symptoms of GER. Infants were categorized as having pathologic reflux by three measures: RI > or = 5%, EBS > or = 50, or AUC pH < 4.0 or < or = 21.3, as determined by receiver operating characteristic (ROC) curve analysis. Using the RI as a criterion, 27 infants (23%) had pathologic reflux. When EBS and AUC were used, 65 (56%), and 67 (57%) respectively, were classified as having pathologic reflux. The specificities of RI, EBS, and AUC were 97.8, 100.0, and 100.0%, respectively, and the sensitivities were 93.0, 91.5, and 94.4, respectively. A new cutoff value for RI of 2.1% was determined using ROC curve analysis to improve the specificity and sensitivity of RI to the above values. The number of infants with pathologic GER is likely to be significantly less using the traditional RI alone on formula feedings, however, the revised RI cutoff value and AUC analysis by computerized pH tracings can enhance the accuracy on formula feedings.
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Affiliation(s)
- Vasundhara Tolia
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA.
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25
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Thomas EJ, Kumar R, Dasan JB, Kabra SK, Bal CS, Menon S, Malhothra A. Gastroesophageal reflux in asthmatic children not responding to asthma medication: a scintigraphic study in 126 patients with correlation between scintigraphic and clinical findings of reflux. Clin Imaging 2003; 27:333-6. [PMID: 12932685 DOI: 10.1016/s0899-7071(02)00555-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I (n = 100) consisted of children with asthma but no clinical symptoms of GER. Group II (n = 26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100-200 microCi (3.7-7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.
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Affiliation(s)
- E J Thomas
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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26
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Rudolph CD. Supraesophageal complications of gastroesophageal reflux in children: challenges in diagnosis and treatment. Am J Med 2003; 115 Suppl 3A:150S-156S. [PMID: 12928092 DOI: 10.1016/s0002-9343(03)00214-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gastroesophageal reflux (GER) occurs throughout the day in healthy infants, children, and adolescents, as well as in adults. However, regurgitation into the pharynx and vomiting are more common in infants than in adults. This places the infant at particular risk for supraesophageal complications of GER. Despite recognition of this risk, a lack of good control data in children and an absence of placebo-controlled treatment trials provide only marginal evidence to support GER as a cause of any supraesophageal disorder in infants or children. An association of GER with "awake apnea," reactive airway disease, and recurrent pneumonia has been demonstrated. Although there is no good evidence to support the efficacy of medical therapy, surgical therapy for GER has been demonstrated to improve symptoms in selected cases with each of these symptom presentations. Although clinical experience and case series suggest that GER may possibly contribute to laryngeal disorders, sinusitis, and otitis media, convincing data are lacking. No studies have definitively demonstrated symptom improvement with medical or surgical therapy for the latter symptom presentations.
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Caglar M, Volkan B, Alpar R. Reliability of radionuclide gastroesophageal reflux studies using visual and time-activity curve analysis: inter-observer and intra-observer variation and description of minimum detectable reflux. Nucl Med Commun 2003; 24:421-8. [PMID: 12673171 DOI: 10.1097/00006231-200304000-00012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radionuclide studies have gained wide acceptance in the evaluation of infants and children with gastroesophageal reflux (GER). For correct interpretation of scan results, knowledge of inter-observer and intra-observer variability and minimum detectable reflux volume is essential. In this study, we evaluated the methodological issues underlying the visual assessment of GER and time activity curve analysis. An in vitro model of stomach and oesophagus was established to determine the minimum detectable reflux by placing various volumes and concentrations representing the diluted activity in the stomach. In the clinical part 99 patients were imaged for 1 h after oral administration of 99mTc sulfur colloid. Eleven patients were excluded from the study either due to incomplete clinical data or suboptimal image quality. Frames of 16 s each, and time-activity curves which were generated after drawing regions of interest from the oesophagus, were read three times by an experienced nuclear medicine physician and a resident in training. On the phantom study, the concentration, volume and duration were the determining factor for the visualization of reflux. In the clinical part, the overall incidence of GER in 88 patients was 69%. The mean intra- and inter-observer reproducibility (kappa values) was 0.76 and 0.7065, respectively. Agreement was slightly higher in the analysis of time-activity curves (0.767 and 0.731). Our results indicate that GER may be reproducibly analysed on scintigraphy by the same and different observers with varying levels of training. Its visualization is associated with reflux duration, volume and dilution factor of radioactivity.
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Affiliation(s)
- M Caglar
- Department of Nuclear Medicine, Hacettepe University Medical Faculty, Ankara, Turkey.
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28
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Thomas EJ, Kumar R, Dasan JB, Chandrashekar N, Agarwala S, Tripathi M, Bal CS. Radionuclide scintigraphy in the evaluation of gastro-oesophageal reflux in post-operative oesophageal atresia and tracheo-oesophageal fistula patients. Nucl Med Commun 2003; 24:317-20. [PMID: 12612473 DOI: 10.1097/00006231-200303000-00012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Gastro-oesophageal reflux (GOR) is a major cause of morbidity in children who undergo surgical repair for oesophageal atresia with tracheo-oesophageal fistula (OA/TOF). We performed a retrospective analysis to determine the incidence of GOR on radionuclide scintigraphy in symptomatic and asymptomatic OA/TOF patients in the first post-operative year. A total of 124 patients (74 males, 50 females), with a mean age of 3.5 months (range, 20 days to 12 months), were studied. Of these 124 patients, 67 were symptomatic and 57 were asymptomatic. On radionuclide scintigraphy, 73 patients (48 symptomatic and 25 asymptomatic) had reflux. Of the 48 symptomatic patients with scintigraphic studies positive for reflux, 79.2% (38) had proximal reflux and 20.8% (10) had distal reflux, whereas, of the 57 asymptomatic patients, 48% (12) had proximal reflux and 52% (13) had distal reflux. There was a significantly higher incidence of GOR in symptomatic children than in asymptomatic children (P<0.01). In particular, there was a significantly higher incidence of proximal GOR in symptomatic children than in asymptomatic children (P<0.001). In conclusion, the severity and incidence of GOR were significantly higher in symptomatic than asymptomatic OA/TOF patients in their first post-operative year. Scintigraphic evidence of proximal reflux correlates with the presence of symptomatic GOR.
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Affiliation(s)
- E J Thomas
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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29
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Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, Gerson WT, Werlin SL. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2002; 32 Suppl 2:S1-31. [PMID: 11525610 DOI: 10.1097/00005176-200100002-00001] [Citation(s) in RCA: 387] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.
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30
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Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is common in newborn infants. A common first line management is the use of feed thickeners. OBJECTIVES In newborn infants with GOR, to evaluate the use of feed thickeners in reducing signs and symptoms of GOR, acid episodes on pH monitoring and histological evidence of oesophagitis. SEARCH STRATEGY We searched MEDLINE from 1966 to December 2001, the Cochrane Controlled Trials Register, The Cochrane Library, Issue 1, 2002. CINAHL from 1982 to December 2001, and conference and symposia proceedings published in Pediatric Research 1990 to 1994. We also searched conference proceedings for the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN) and the North American Society for Pediatric Gastroenterology and Nutrition (NASPGAN) from 1994 to December 2001. We did not restrict the searches to the English language. SELECTION CRITERIA All randomised controlled trials that examine the effects of thickening formulas on treating gastro-oesophageal reflux in neonates. The eligible studies were to compare thickened feeds to no intervention (unthickened feeds). DATA COLLECTION AND ANALYSIS Two independent reviewers identified potential studies from the literature search. Quality was independently assessed by two independent reviewers. MAIN RESULTS No studies fulfilled the requirements for inclusion in the systematic review. REVIEWER'S CONCLUSIONS There is no evidence from randomised controlled trials to support or refute the efficacy of feed thickeners in newborn infants with GOR. Given the absence of evidence, we cannot recommend using thickening agents for management of GOR in newborn infants.
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Affiliation(s)
- R C Huang
- Gastroenterology, Princess Margaret Hospital, Perth, WA, Australia, Roberts Road, GPO D184, Perth, Western Australia, Australia.
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31
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Jang HS, Lee JS, Lim GY, Choi BG, Choi GH, Park SH. Correlation of color Doppler sonographic findings with pH measurements in gastroesophageal reflux in children. JOURNAL OF CLINICAL ULTRASOUND : JCU 2001; 29:212-217. [PMID: 11323775 DOI: 10.1002/jcu.1022] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
PURPOSE We conducted a prospective study of color Doppler sonography in children with suspected gastroesophageal reflux (GER). The purpose of this study was to compare the accuracy of color Doppler sonography with that of continuous 24-hour pH monitoring of the esophagus in diagnosing GER and to determine how to interpret the reflux episodes detected on color Doppler sonography in children at high risk for reflux. METHODS Color Doppler sonography and 24-hour esophageal pH monitoring were performed in 54 children ranging in age from 2 months to 10 years (mean, 3 years). The stomach of each patient was filled for adequate gastric distention just before the color Doppler sonographic examination. We counted the number of reflux episodes over a period of 15 minutes. One day after the sonographic examination, the reflux was evaluated with esophageal pH monitoring, and the resultant reflux index (ReI) was obtained. The ReI was considered to be pathologic when it was equal to or greater than 11.99%. The number of refluxes on color Doppler sonography and the ReI were correlated for each patient. RESULTS The 2 tests showed an 81.5% agreement in the detection of GER. When pH monitoring was taken as the reference test, color Doppler sonography had a high sensitivity (95.5%) for diagnosing GER but a very low specificity (11.0%), with a positive predictive value of 84.3% and a negative predictive value of 33.3%. There was no statistically significant correlation between the frequencies of GER detected on color Doppler sonography and the ReIs on pH monitoring (p = 0.1103). There was no correlation between the reflux grades on sonography and the ReI grades on pH monitoring (p = 0.422). CONCLUSIONS Color Doppler sonography is highly sensitive and easier to use than pH monitoring. Although there are no definite criteria for evaluating the severity of GER on color Doppler imaging, this modality may be useful in screening children for GER.
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Affiliation(s)
- H S Jang
- Department of Radiology, Kangnam St. Mary's Hospital, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, 137-040 Seoul, South Korea
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32
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Abstract
Gastro-oesophageal reflux (GOR) is an extremely common paediatric problem that often runs a harmless and self-limited course. Physiological GOR however can lead to marked parental anxiety, many unnecessary investigations and often unwarranted and potentially harmful therapeutic interventions. Our ability to better define GOR and gastro-oesophageal reflux disease (GORD) has improved in the past 15 years with a better understanding of the pathophysiology in infants and children due to the development and wider use of flexible endoscopy, 24-hour oesophageal pH monitoring and, more recently, the use of micromanometric methods for studying oesophageal motility. This will be further enhanced in the future with the development of non-invasive breath testing to study gastrointestinal motility and the use of electrical impedance to study fluid movement. Our therapeutic interventions have also improved particularly in the areas of acid suppression, improved surgical techniques and most recently laparoscopic fundoplication. This chapter reviews these advances in the paediatric area especially with regard to pathophysiology, diagnostic testing and therapeutic intervention.
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Affiliation(s)
- G P Davidson
- Gastroenterology Unit, Women's and Children's Hospital, 72 King William Road, North Adelaide, Adelaide, SA, 5006, Australia
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33
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Abstract
Gastro-oesophageal reflux (GOR) has been identified as a possible cause of SIDS. Several features of GOR unique to infants presenting with apparent life-threatening events (ALTEs) have led to its 'pathogenic' definition. One is that the life-threatening apnoea itself is initiated by GOR, another is that the ALTE relates to prolonged reflux during sleep, in a vulnerable sleep-state, and finally that the ALTE relates to excessive quantities of GOR. The presumption of GOR 'pathology' as a cause of SIDS however, is questionable in these susceptible infants for three reasons: firstly, GOR is physiological and occurs in most infants; secondly, there is no general consensus on what constitutes normal physiological reflux, and thirdly, variation in the recording technique and methods of data analysis and interpretation may account for the differences between study groups. It seems likely therefore if GOR is implicated in SIDS, additional factors are involved. Under certain circumstances, physiological GOR may trigger life-threatening apnoea in apparently healthy infants, that leads to SIDS. One mechanism that could explain such a death is reflex apnoea by stimulation of laryngeal chemoreceptors (LCR) during sleep. The conditions under which this could be fatal are the occurrence of gastric contents refluxed to the level of the pharynx during sleep, in the young infant who has depressed swallowing and arousal. That is, the occurrence of GOR to the level of the pharynx during sleep, an infrequent event that is usually innocuous, could be converted to a fatal event if swallowing is impaired and arousal depressed, by a variety of mediating factors such as prone sleeping, prematurity, sedatives, seizures or upper respiratory tract infections. The identification of LCR responses, particularly in prone sleeping and premature infants provide further evidence that this mechanism may be implicated in the aetiology of SIDS in apparently healthy infants.
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Affiliation(s)
- M Page
- Department of Neonatal Medicine, Royal Prince Alfred Hospital, Missenden Rd., NSW 2050, Camperdown, Australia
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34
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Abstract
The relation between silent gastroesophageal reflux (GER) and respiratory problems such as persistent wheezing in infants is not well-established. Between January 1994 and June 1997, we evaluated the incidence of GER in 84 otherwise healthy infants referred to the Pediatric Pulmonary Medicine Division at Kosair Children's Hospital for evaluation of daily wheezing, and we followed their clinical course for 18 months. All underwent 24-hr esophageal pH studies to evaluate GER. The pH probe study was performed at a mean age of 8.74 +/- 4.6 months. Infants with a positive GER study were treated with an H2 receptor antagonist (H2RA) and a prokinetic agent for a mean of 5.6 +/- 2.4 months. At first follow-up visit 3 weeks after esophageal pH studies infants treated with an H2RA and those who did not have GER but continued with daily wheezing were started on flunisolide nasal solution (0.025%) delivered by nebulizer (125 mcg t.i.d.). Infants in both groups were followed every 1-2 months for a mean of 18 months and if clinically improved, attempts to decrease their daily asthma medications were made. Fifty-four of 84 (64%) had positive esophageal pH studies (GER-positive group), and 24 of them (44%) had no gastrointestinal symptoms suggestive of GER. Thirty patients had normal esophageal pH studies (GER-negative group). Twenty-two of these 30 (73%) infants without GER required nebulized flunisolide, compared to 13 of 54 (24%) infants with GER (P < 0.0005). Thirty-five of 54 (64.8%) infants with GER were able to discontinue all daily asthma medications within 3 months of starting antireflux therapy, while none of the infants without GER were able to discontinue daily asthma medications during the follow-up period (P < 0.0005). We conclude that silent GER is common in infants with daily wheezing, and controlling GER improves morbidity and decreases the need for daily asthma medications.
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Affiliation(s)
- S Sheikh
- Department of Pediatrics, University of Louisville, Kentucky, USA.
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35
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Abstract
Gastroesophageal reflux is a common pediatric complaint and a frequent reason for pediatric patients to be referred to a gastroenterologist. The pathophysiology and clinical manifestations of this disorder differ according to patient age. The diagnosis is suggested by the history and can be confirmed by a pH probe. In the appropriate clinical setting, anatomic obstruction may need to be ruled out by contrast study. Endoscopy is used to assess associated complications, including esophagitis, esophageal strictures, Barrett's transformation, and failure to thrive. Other complications are controversial, including pulmonary disease, apnea, and sudden infant death syndrome. Treatment depends on the severity of disease. Conservative therapy includes behavorial modifications, prokinetic agents, and H2 antagonists. Proton pump inhibitors are generally reserved for refractory esophagitis. Surgical treatment may be necessary for gastroesophageal reflux resistant to medical management or for severe complications. Gastroesophageal reflux beyond infancy tends to be chronic; therefore, lifelong behavioral modifications or repeated courses of medical therapy may be necessary. An algorithm for the suggested diagnostic approach to gastroesophageal reflux is presented herein.
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Affiliation(s)
- W A Faubion
- Section of Pediatric Gastroenterology, Mayo Clinic Rochester, Minnesota 55905, USA
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36
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Dunn JC, Lai EC, Webber MM, Ament ME, Fonkalsrud EW. Long-term quantitative results following fundoplication and antroplasty for gastroesophageal reflux and delayed gastric emptying in children. Am J Surg 1998; 175:27-9. [PMID: 9445234 DOI: 10.1016/s0002-9610(97)00241-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The operative management of children with combined gastroesophageal reflux and delayed gastric emptying is controversial. This study measures the long-term follow-up of gastric emptying in children who have undergone gastroesophageal fundoplication combined with antroplasty. METHODS Fifteen randomly selected children with gastroesophageal reflux and scintigraphically demonstrated delayed gastric emptying underwent fundoplication and antroplasty. Each patient had another gastric emptying scintigraphic study performed an average of 3.6 years postoperation. RESULTS All patients reported improvement of their symptoms compared with before the operation, and none required further medical therapy for gastroesophageal reflux or experienced dumping syndrome. Eleven of the 15 patients had significant long-term improvement of their gastric emptying postoperatively. The mean percent of isotope meal remaining in the stomach at 90 minutes improved from 72% preoperatively to 40% postoperatively (P = 0.0005). CONCLUSIONS Gastric emptying in children with gastroesophageal reflux and delayed gastric emptying is significantly improved for several years in three-fourths of patients after fundoplication and antroplasty. Fundoplication and concomitant antroplasty are recommended for symptomatic children with documented gastroesophageal reflux and delayed gastric emptying.
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Affiliation(s)
- J C Dunn
- Department of Nuclear Medicine, UCLA School of Medicine, Los Angeles, California 90095, USA
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37
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Abstract
Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.
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38
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Abstract
Radionuclide studies for evaluating gastrointestinal transit in adults have been adapted for use in infants and children for assessing esophageal transit, gastroesophageal reflux, and gastric emptying. However, the measurement of small- and large-bowel transit times in these patients has been limited.
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Affiliation(s)
- S Heyman
- Department of Radiology, Children's Hospital of Philadelphia, PA 19104, USA
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39
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Abstract
Gastroesophageal reflux is often overlooked as both a cause and a complication of respiratory disease in children. The manifestations may be protean and may bear little clinical relationship to the gastrointestinal tract. However, a high index of suspicion for its potential role in unexplained respiratory symptoms may yield large benefits for the physician and patient alike.
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Affiliation(s)
- M F Guill
- Medical College of Georgia Augusta 30912, USA
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40
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Freed GE, Steinschneider A, Glassman M, Winn K. Sudden infant death syndrome prevention and an understanding of selected clinical issues. Pediatr Clin North Am 1994; 41:967-90. [PMID: 7936783 DOI: 10.1016/s0031-3955(16)38841-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The etiology and prevention of sudden infant death syndrome (SIDS) are among the more frustrating topics in pediatrics. This article addresses several clinically relevant issues, including the relationships between apnea and SIDS, the nature of the "terminal event," effectiveness of home monitoring, the role of gastroesophageal reflux in apparent life-threatening events, and the association between the prone sleeping position and SIDS. This article is intended to provide the clinician with an awareness of the issues and the scientific basis needed to understand their contribution to SIDS.
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Affiliation(s)
- G E Freed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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41
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MacFadyen UM. Regurgitation and sudden infant death syndrome. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1993; 82 Suppl 389:98-101. [PMID: 8374206 DOI: 10.1111/j.1651-2227.1993.tb12891.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- U M MacFadyen
- Child Health Department, Leicester Royal Infirmary, UK
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42
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Martinez DA, Ginn-Pease ME, Caniano DA. Recognition of recurrent gastroesophageal reflux following antireflux surgery in the neurologically disabled child: high index of suspicion and definitive evaluation. J Pediatr Surg 1992; 27:983-8; discussion 988-90. [PMID: 1403562 DOI: 10.1016/0022-3468(92)90544-h] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Multiple symptoms suggestive of gastroesophageal reflux (GER) developed in 181 of 240 children (75%) with profound neurological impairment (NI) following operative management of GER. Diagnostic testing was performed in 102 children, 56% of patients with symptoms. Recurrent GER was evident on one or more diagnostic studies in 46% of children evaluated. Significant differences (P less than .05) were found in the testing protocols of children with studies positive for GER and those individuals with negative tests. Children with study-documented recurrent GER: (1) had testing conducted at a more remote time postoperatively; (2) received a greater number of total tests; (3) were evaluated by more than one type of diagnostic test; and (4) underwent upper endoscopy and pH monitoring more frequently. No single clinical symptom was predictive of study-documented recurrent GER. These results suggest that recognition of recurrent GER after an antireflux operation in a child with profound NI requires a high index of suspicion. Definitive evaluation of children with postoperative symptoms demands repeated testing over time and the use of more than one type of diagnostic test. A contrast study should be used to evaluate the mechanical properties of the fundoplication and esophagoscopy and/or esophageal pH monitoring to assess the physiological control of GER.
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Affiliation(s)
- D A Martinez
- Department of Surgery, Ohio State University College of Medicine, Columbus
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43
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Gustafsson PM, Kjellman NI, Tibbling L. Bronchial asthma and acid reflux into the distal and proximal oesophagus. Arch Dis Child 1990; 65:1255-8. [PMID: 2248539 PMCID: PMC1792619 DOI: 10.1136/adc.65.11.1255] [Citation(s) in RCA: 63] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The prevalence of pathological gastro-oesophageal reflux in children and adolescents with asthma was studied by 24 hour two level oesophageal pH monitoring in 42 subjects aged 9-20 years with moderate or severe bronchial asthma. The importance of oesophagobronchial nerve reflexes and of aspiration of gastric acid as triggers in asthma was assessed by studying whether episodes of reflux into the distal and into the proximal oesophagus were followed by asthma attacks. Twenty-one subjects (50%) had a pathological total reflux time in the distal oesophagus and six (16%) in the proximal oesophagus. Nine patients had pathological gastro-oesophageal reflux into the distal oesophagus together with symptoms of asthma during the day on which the recording took place. In three of them the episodes of asthma symptoms were significantly correlated with preceding episodes of reflux into the distal oesophagus, and in one subject to reflux into the proximal oesophagus. We conclude that pathological gastro-oesophageal reflux is common in children and adolescents with asthma, but it seems to provoke symptoms of asthma in only a few. Symptoms of asthma were more often elicited by exposure of the distal oesophagus to gastric acid, possibly by a vagal reflex, than by aspiration of gastric juice.
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Affiliation(s)
- P M Gustafsson
- Department of Paediatrics, University Hospital, Linköping, Sweden
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44
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Padhy AK, Gopinath PG, Sharma SK, Prasad AK, Arora NK, Tiwari DC, Gupta K, Chetty A. Radionuclide detection of gastroesophageal reflux in children suffering from recurrent lower respiratory tract infection. Indian J Pediatr 1990; 57:517-25. [PMID: 2286404 DOI: 10.1007/bf02726761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Radionuclide gastro-esophageal scintigraphy was performed on 25 control and 183 children suffering from recurrent lower respiratory tract infection. Gastro-esophageal reflux (GER) of varying grades was observed in 135 patients. The severity of clinical symptoms in the patients was found to be directly related to the severity of reflux observed in the radionuclide study. In some patients an attempt was also made to quantitate GER by calculating the Gastro-esophageal reflux index. The results of the scintigraphic study were correlated with the results of the other commonly used and more conventional Barium swallow and fluoroscopy study. Gastro-esophageal scintigraphy was found to be much superior in terms of sensitivity, specificity and accuracy in detecting GER. It was also possible to objectively evaluate and monitor response to treatment following conservative or corrective surgical therapy using the radionuclide technique. The results of the study demonstrated a remarkably high incidence of GER in the patients. Whether GER is the cause of recurrent lower respiratory tract infection or not is difficult to establish firmly. But within the preview of the study the association seems to be very strong and cannot be easily ignored.
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Affiliation(s)
- A K Padhy
- Department of Nuclear Medicine, Internal Medicine and Pediatrics, All India Institute of Medical Sciences, New Delhi
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45
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Colson DJ, Campbell CA, Wright VA, Watson BW. Predictive value of oesophageal pH variables in children with gastro-oesophageal reflux. Gut 1990; 31:370-3. [PMID: 2338260 PMCID: PMC1378406 DOI: 10.1136/gut.31.4.370] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sixty three 24 hour oesophageal pH studies were performed in children with known or suspected gastro-oesophageal reflux and their progress was followed for at least a year. Forty two studies were of children who were well at follow up who were not receiving medical treatment for gastro-oesophageal reflux, and had not required antireflux surgery. Twenty one studies were from children who were still on treatment for gastro-oesophageal reflux or had undergone antireflux surgery. The results were analysed using non-parametric statistics to assess the value of pH recordings in predicting which children were likely to have continuing problems. Sleep reflux (minutes/hour) and acid clearing time were the most highly significant variables (p less than 0.0005 and p less than 0.0001 respectively). The results suggest that either sleep gastro-oesophageal reflux of more than 6.4 minutes/hour or an acid clearing time of seven minutes or more are good predictors of the clinical outcome (specificity 88.1%, sensitivity 81.0%). Three of the five children with false positive results were under 10 months of age. Positive results in this age group should therefore be interpreted with caution.
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Affiliation(s)
- D J Colson
- Department of Medical Electronics, St Bartholomews Hospital, London
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46
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Abstract
We have investigated manometrically and endoscopically 60 children with extended pH metering-documented gastroesophageal reflux (GER) and a control group of 14 children of comparable ages. In an attempt to simplify the evaluation of esophageal peristalsis, we measured the frequency of propulsive waves (in waves/hour) and their mean pressure (in mm Hg) in the body of the esophagus and multiplied both values to result in one single figure that reflected esophageal motor efficiency (EME) in some way. We performed the tests in basal conditions (EMEB) and after instillation of 5 mL of 0.1 N CIH into the esophageal lumen (EMECIH). In comparison with controls, refluxing children had a lower sphincter pressure (LESP) (14.9 +/- 8 v 11.8 +/- 6.9 mm Hg, P less than 0.05), an increased proportion of nonpropulsive waves (38.8 +/- 29.3% v 68 +/- 27%, P less than 0.001), and a significantly lower EMEB (896.6 +/- 777 v 375 +/- 306, P less than 0.001). These results suggest that both the sphincteric antireflux barrier and esophageal pump can be damaged in GER. There was a weak, but significant, correlation between EMEB and esophagitis grade (rs = -.25, P less than 0.05). Furthermore, esophageal motor response after CIH instillation may have some prognostic value because EMECIH was significantly higher in those of the 52 children followed-up for more than a year who responded to medical treatment (n = 16) than in those in whom medical treatment was a failure (n = 36) (981.2 +/- 617.4 v 460.5 +/- 452.3, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Arana
- Universidad del Pais Vasco, Hospital Nuestra Señora de Aranzazu, San Sebastián, Spain
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47
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Da Dalt L, Mazzoleni S, Montini G, Donzelli F, Zacchello F. Diagnostic accuracy of pH monitoring in gastro-oesophageal reflux. Arch Dis Child 1989; 64:1421-6. [PMID: 2684030 PMCID: PMC1792777 DOI: 10.1136/adc.64.10.1421] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
One hundred and eleven children admitted with suspected gastro-oesophageal reflux were studied, with 24 hour oesophageal pH monitoring as the first line of investigation. Barium swallow examination, or oesophagoscopy, or both, were carried out only in children with abnormal pH, who subsequently had a trial of 1-12 months medical treatment. All patients were followed up for eight months to two years. A final diagnosis of gastro-oesophageal reflux was made in 41 patients, in all of whom the pH study was abnormal (100% sensitivity). The final diagnosis was different in 70 patients; 66 of these had a normal pH (94% specificity). All children with gastro-oesophageal reflux were treated with drugs. All those with a percentage reflux time of more than 27 and more than 20 episodes of reflux lasting more than 5 minutes failed to improve and needed operation. We conclude that monitoring of the oesophageal pH should be the first line of investigation in patients with gastro-oesophageal reflux and should be used together with clinical data and other investigations, to identify those children who will need operation.
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Affiliation(s)
- L Da Dalt
- Department of Paediatrics, University of Padova, Italy
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48
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Ruley EJ, Bock GH, Kerzner B, Abbott AW, Majd M, Chatoor I. Feeding disorders and gastroesophageal reflux in infants with chronic renal failure. Pediatr Nephrol 1989; 3:424-9. [PMID: 2642112 DOI: 10.1007/bf00850220] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Twenty-two infants (mean age 7.5 months) with chronic renal failure (CRF) were studied for their nutrition, growth, and upper gastrointestinal function. Most infants had a history of poor caloric intake and 7 had received supplemental feeding (SF) prior to the investigation. All infants were undergrown, underweight, and malnourished. The infants were characterized as having only a fair interest in food, refusing feedings, and vomiting excessively. Sixteen of 22 infants (73%) had significant gastroesophageal (GE) reflux demonstrated by 24-h esophageal pH monitoring. Gastroesophageal scintiscans were less sensitive and specific in detecting the reflux. Infants with GE reflux were significantly younger and more often required SF than those without GE reflux. There were no significant differences in the degree of renal failure, growth failure, caloric intake, protein intake, or nutritional status between the infants with and without GE reflux. From these studies we conclude that GE reflux should be considered as one of the factors contributing to the feeding problems of infants with CRF.
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Affiliation(s)
- E J Ruley
- Department of Nephrology, Children's Hospital National Medical Center, George Washington University School of Medicine, Washington, DC 20010
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49
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Caulfield M, Wyllie R, Sivak MV, Michener W, Steffen R. Upper gastrointestinal tract endoscopy in the pediatric patient. J Pediatr 1989; 115:339-45. [PMID: 2671326 DOI: 10.1016/s0022-3476(89)80829-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M Caulfield
- Department of Pediatrics, Cleveland Clinic Foundation, Ohio 44106
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50
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