Gastroesophageal reflux

Incidence and risk factors of unplanned intubation during pediatric sedation for MRI

BACKGROUND

It is often difficult for the pediatric patient to cooperate or to remain immobile during MR scans. Therefore, sedation is usually needed for children.

PURPOSE

To evaluate the incidence and contributing factors of unanticipated intubation during sedation for MRI scan in children.

STUDY TYPE

Retrospective observational study.

POPULATION/SUBJECTS

In all, 1165 charts were reviewed retrospectively of patients who had been sedated by anesthesiologists at a single institution from May 2015 to June 2016.

ASSESSMENT

Patient's demographics, the region of the MRI scan, total amount of medication, duration of sedation, and any adverse event during MRI were assessed. The adverse events during sedation including airway obstruction, apnea, desaturation, bradycardia, and hypotension were also assessed.

STATISTICAL TESTS

Risk factors of unplanned intubation during MRI sedation were identified by univariate and multivariate analysis. Firth's exact logistic regression was used for univariate and multivariate analysis. According to the results from multiple logistic regression, a nomogram was developed to predict the risk.

RESULTS

A total of 1165 children aged 7 days to 18 years with sedation used during an MRI scan during the study period showed an incidence of unexpected intubation as ~2% (n = 23, 95% confidence interval [CI]; 0.0123, 0.0295). Multivariate logistic regression revealed the following risk factors of unplanned intubation: American Society of Anesthesiologists (ASA) class III patients (odds ratio [OR] 1.212, P < 0.001), premature birth (OR 2.317, P < 0.001), and the presence of gastroesophageal reflux disease (GERD) (OR 1.474, P < 0.001) or congenital heart disease (OR 1.118, P < 0.001).

DATA CONCLUSION

This study identified risk factors of unplanned intubation as follows: ASA class III patients, premature birth, and the presence of GERD or congenital heart disease. The physician should screen risk factors of unexpected intubation and maintain adequate sedation during MRI scans in pediatric patients. Level of Evidence 3. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:1053-1061.

US in the diagnosis of gastroesophageal reflux in children

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

Sensibilidade da seriografia do esôfago, estômago e duodeno para o diagnóstico de doença do refluxo gastroesofágico em recém-nascidos prematuros

OBJETIVO: Determinar a sensibilidade da seriografia do esôfago, estômago e duodeno (SEED) para o diagnóstico da doença do refluxo gastroesofágico (DRGE) em recém-nascidos prematuros, tendo como padrão ouro a monitoração prolongada do pH esofágico distal, e descrever a presença de anormalidades anatômicas do tubo digestivo. MATERIAIS E MÉTODOS: Foram incluídos no estudo 41 recém-nascidos, com média de 1.243,9 g, apresentando sinais/sintomas de DRGE e resultados alterados na monitoração do pH (índice de refluxo > 10%). A SEED foi realizada logo que as condições clínicas dos recém-nascidos foram estáveis para a realização dos exames radiológicos. RESULTADOS: A monitoração prolongada do pH e a SEED foram realizadas com 49,8 e 66,8 dias de vida, respectivamente. A sensibilidade da seriografia foi de 39,0% (IC 95%: 25,7–54,3%). Refluxo significativo foi observado em 41,4% dos casos, refluxo médio em 44,8% e refluxo pequeno em 13,8%. A SEED identificou apenas um caso de hérnia de hiato. CONCLUSÃO: A SEED apresentou baixa sensibilidade para a DRGE em prematuros e não se associou com a gravidade do refluxo, na comparação com a monitoração do pH, sendo, entretanto, útil no diagnóstico de alteração anatômica.

Acid gastroesophageal reflux and intensity of symptoms in children with gastroesophageal reflux disease. Comparison of primary gastroesophageal reflux and gastroesophageal reflux secondary to food allergy

The ability to differentiate between primary and secondary causes of gastroesophageal reflux (GER) is extremely important during the diagnostic procedure. At the same time, the quality of symptoms and the intensity of the course of gastroesophageal reflux disease (GERD) should be estimated. Acid GER is assessed using 24-hour esophageal pH monitoring; the results of this diagnostic test should always be interpreted alongside the clinical picture.

PURPOSE

To establish the interdependence between the intensity of the clinical symptoms and the acid reflux index in children with primary GER and GER secondary to cow's milk protein allergy (CMA) and/or other food allergies (FA).

MATERIALS AND METHODS

A total of 138 children of various ages with symptoms of GERD were included in the study. The diagnostic procedure included 24-hour pH monitoring of the esophagus with a 2-channel probe (distal and proximal lead). For this purpose, ESPGAN diagnostic criteria were implemented. The type and intensity of typical manifestations of GERD were assessed with the help of our own scoring system. This diagnostic and therapeutic algorithm which includes an oral food challenge test, was applied to 138 children in order to differentiate primary GER from GER secondary to CMA/FA.

RESULTS

Primary GERD was diagnosed in 76 patients (55.1%) with a mean age: x=25.20 months+/-27.28 (group 1) and GERD secondary to CMA/FA was confirmed in 62 children (44.9%) with a mean age: x=21.53 months+/-17.79 (group 2). The most important pH-metric parameter analyzed in study groups 1 and 2 was the GER index: total and supine. An assessment of the intensity of symptoms and a comparative analysis of intensity was evaluated against the GER index: total and supine. Among study group 1, the following gradation of symptoms was found: in 31 children (40.8%)-degree 3, in 33 children (43.4%)-degree 4, and in 12 children (15.8%)-degree 5, whereas among the patients in group 2:25 (40.3%) were in degree 3, 27 (43.6%) were in degree 4, and 10 (16.1%) were in degree 5. It was estimated that the higher the GER result in both total and supine positions (for both leads), the higher the level of symptoms noted. This interdependence was demonstrated for both groups.

CONCLUSIONS

In seeking to determine any etiopathogenetic connection between primary GER or GER secondary to CMA/FA and their clinical consequences, 24-hour esophageal pH monitoring with a 2-channel probe is recommended, since it provides for better clinical control of GERD and its appropriate treatment.

24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease: Analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis

AIM: To assess values of 24-h esophageal pH-monitoring parameters with dual-channel probe (distal and proximal channel) in children suspected of gastroesophageal reflux disease (GERD).

METHODS: 264 children suspected of gastroesophageal reflux (GER) were enrolled in a study (mean age χ = 20.78 ± 17.23 mo). The outcomes of this study, immunoallerrgological tests and positive result of oral food challenge test with a potentially noxious nutrient, enabled to qualify children into particular study groups.

RESULTS: 32 (12.1%) infants (group 1) had physiological GER diagnosed. Pathological acid GER was confirmed in 138 (52.3%) children. Primary GER was diagnosed in 76 (28.8%) children (group 2) and GER secondary to allergy to cow milk protein and/or other food (CMA/FA) in 62 (23.5%) children (group 3). 32 (12.1%) of them had CMA/FA (group 4-reference group), and in remaining 62 (23.5%) children neither GER nor CMA/FA was confirmed (group 5). Mean values of pH monitoring parameters measured in distal and proximal channel were analyzed in individual groups. This analysis showed statistically significant differentiation of mean values in the case of: number of episodes of acid GER, episodes of acid GER lasting > 5 min, duration of the longest episode of acid GER in both channels, acid GER index total and supine in proximal channel. Statistically significant differences of mean values among examined groups, especially between group 2 and 3 in the case of total acid GER index (only distal channel) were confirmed.

CONCLUSION: 24-h esophageal pH monitoring confirmed pathological acid GER in 52.3% of children with typical and atypical symptoms of GERD. The similar pH-monitoring values obtained in group 2 and 3 confirm the necessity of implementation of differential diagnosis for primary vs secondary cause of GER.

Natural Parenting — Back to Basics in Infant Care

This review examines an age-old approach to parenting recently rediscovered in Western industrialized societies and known by names such as natural parenting, attachment parenting, and instinctive parenting. Its leading principle is utmost sensitivity to the child's innate emotional and physical needs, resulting in extended breastfeeding on demand, extensive infant carrying on the caregiver's body, and cosleeping of infant and parents. The described practices prevailed during the evolutionary history of the human species and reflect the natural, innate rearing style of the human species to which the human infant has biologically adapted over the course of evolution. An overview of research from diverse areas regarding psychological as well as physiological aspects of early care provides evidence for the beneficial effects of natural parenting. Cross-cultural and historical data is cited to reveal the widespread use of the investigated parenting style. It is concluded that the described approach to parenting provides the human infant with an ideal environment for optimal growth both psychologically and physiologically. It is yet to be determined how much departure from this prototype of optimal human parenting is possible without compromising infant and parental wellbeing. The review also invites a critical reevaluation of current Western childrearing practices.

Correlation of color Doppler sonographic findings with pH measurements in gastroesophageal reflux in children

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.

Anaesthesia for manipulation of forearm fractures in children: a survey of current practice

Despite recent recommendations that all children presenting for urgent or emergency surgery should be treated as though they have a full stomach, a local audit had shown a wide variation in technique used for anaesthesia in children after trauma. Therefore, a postal questionnaire was sent to 500 anaesthetists regarding their preferred anaesthetic technique for a 6-year-old child requiring manipulation of a forearm fracture. Four clinical situations were presented differing in the timing of surgery in relation to the injury, starvation times before injury and the administration of opioid analgesia. Rapid sequence induction and tracheal intubation was preferred by 83% of all anaesthetists for surgery on the day of injury if the child had eaten 2 h prior to injury and had received opioid analgesia, but the percentage was significantly lower in experienced anaesthetists (P < 0.05) compared with trainees, and was 34.5% overall if surgery was delayed until the following day. Only 19.3% would perform a rapid sequence induction for surgery on the day of injury if the child had not eaten for 6 h before the injury. We conclude that not all anaesthetists believe that rapid sequence induction is necessary for anaesthesia after forearm fractures, despite recent recommendations.

Population pharmacokinetics of enterally administered cisapride in young infants with gastro-oesophageal reflux disease

AIMS

To investigate the pharmacokinetics of enterally administered cisapride suspension in young infants being treated for gastro-oesophageal reflux disease.

METHODS

Plasma cisapride concentrations in 49 subjects (weight: 825-5010 g; n=108 samples, median two per patient; concentration: 14.8-170 ng ml-1 ) were fitted to a one-compartment model with first-order absorption and elimination in the NONMEM program using a logarithmic transformation of the observed and predicted concentrations. Fitting was achieved using the first order conditional estimation (FOCE) method with interaction between the interpatient and intrapatient variabilities. The interpatient variance of clearance (CL/F ) and volume of distribution (V /F ) and their covariance were estimated using an exponential error model. Intrapatient (residual) variance was estimated using an additive model.

RESULTS

The clearance of cisapride was shown to be linearly related to current body weight, slope: 0.538. The typical population values of CL/F, V /F and Ka (absorption rate constant) were 0.538 l h-1 kg-1, 21.9 l, and 2.58 h-1, respectively. The population coefficients of variation (CV%) for CL/F and V/F were 34.4% and 84.3%, respectively. The squared coefficient of correlation between random effects for CL/F and V /F was 0.45. The intrapatient variance was 0.15. V /F and Ka were not influenced significantly by any patient characteristic.

CONCLUSIONS

Cisapride pharmacokinetics in infants with reflux disease were satisfactorily described by a one-compartment model. Current weight should be taken into account when calculating maintenance cisapride doses in these infants.

Lipid-laden alveolar macrophages (LLAM): a useful marker of silent aspiration in children

At present there is no test available which identifies children suffering from silent aspiration due to gastroesophageal reflux (GER). The purpose of this study was to determine whether lipid-laden alveolar macrophage (LLAM) scoring is a useful method to arrive at the diagnosis. We evaluated bronchoalveolar lavage fluid (BALF) from 68 children aged 6 months to 14 years (median 3.75 years) for the presence of lipid-laden alveolar macrophages. We compared children with chronic chest disease (CCD) and GER to healthy surgical controls without known lung disease, and to children with recurrent pneumonia without GER. By grading the amount of intracellular Sudan Red-positive material, we determined a semiquantitative lipid-laden macrophage (LLAM) score for each patient. Patients with chronic chest disease suspected to be caused by silent aspiration secondary to GER had a significantly higher LLAM score (median, 117; range, 10-956) than children with recurrent pneumonia due to other reasons (median, 29; range, 5-127; P < 0.01) and healthy controls (median, 37; range, 5-188; P < 0.01). We believe that simply observing lipid-laden macrophages is nonspecific, but quantitation of these cells is a useful method for diagnosing silent aspiration in children, especially when the score exceeds 200.

Gastroesophageal reflux and asthma: a review of pathogenesis, diagnosis, and therapy

Gastroesophageal reflux disease (GERD) occurs in up to one-third of the adult US population. Most affected individuals are either unaware of their condition or do not seek medical help, relying on nonprescription acid suppressants and antacids for relief. GERD, a common disorder of infancy, old age, and pregnancy, is particularly prevalent in patients with asthma. A causal relationship between the two diseases has been postulated by many investigators. The physiologic changes of asthma exacerbations and the actions of some of the medications used to treat asthma both aggravate GERD. The adverse effect of GERD on asthma and the pathophysiology of this relationship are still under debate. Some studies showed no objective improvement by spirometry of asthmatics treated for GERD, but recognized improvement in asthma symptoms and decreased use of asthma medication. Other studies, supporting GERD induction of asthma, have been performed to test two hypotheses: that asthma is exacerbated by endotracheal aspiration of gastric contents or by a reflex response to stimulation of esophageal receptors. Clinical experience has shown that early diagnosis and treatment of GERD often leads to better control of asthma.

Effects of HCl-pepsin laryngeal instillations on upper airway patency-maintaining mechanisms

Gastroesophageal reflux has been indicated as an etiopathological factor in disorders of the upper airway. Upper airway collapsing pressure stimulates pressure-responsive laryngeal receptors that reflexly increase the activity of upper airway abductor muscles. We studied, in anesthetized dogs, the effects of repeated laryngeal instillations of HCl-pepsin (HCl-P; pH = 2) on the response of laryngeal afferent endings and the posterior cricoarytenoid muscle (PCA) to negative pressure. The effect of negative pressure on receptor discharge or PCA activity was evaluated by comparing their response to upper airway (UAO) and tracheal occlusions (TO). It is only during UAO, but not during TO, that the larynx is subjected to negative transmural pressure. HCl-P instillation decreased the rate of discharge during UAO of the 10 laryngeal receptors studied from 56.4 +/- 10.9 (SE) to 38.2 +/- 9.2 impulses/s (P < 0.05). With UAO, the peak PCA moving time average, normalized by dividing it by the peak values of esophageal pressure, decreased after six HCl-P trials from 4.29 +/- 0.31 to 2.23 +/- 0.18 (n = 6; P < 0.05). The responses to TO of either receptors or PCA remained unaltered. We conclude that exposure of the laryngeal mucosa to HCl-P solutions, as it may occur with gastroesophageal reflux, impairs the patency-maintaining mechanisms provided by laryngeal sensory feedback. Inflammatory and necrotic alterations of the laryngeal mucosa are likely responsible for these effects.

Pharmacokinetics of metoclopramide in neonates

Despite its wide use as a prokinetic agent in neonates and infants with gastroesophageal reflux (GER), the pharmacokinetics of metoclopramide have not been characterized in this pediatric subpopulation. A single-dose pharmacokinetic study of oral metoclopramide (0.1 to 0.15 mg/kg) was performed in 10 fasted premature infants (weight 1.1 to 3.2 kg) ranging from 31 to 40 weeks postconceptional age. Metoclopramide was quantitated from repeated blood samples (n = 9 over 24 hours) by high-performance liquid chromatography. A one-compartment open model with first-order absorption best described the plasma concentration-time data. No correlations were observed between gestational, postnatal, or postconceptional age and any of the pharmacokinetic parameters studied. Comparison of the pharmacokinetic parameters from the study cohort and those reported previously from a similar study of older infants revealed no statistically significant differences. However, a prolonged apparent plasma clearance (Cl/F) of metoclopramide was observed in 30% of the infants studied, and the mean Cl/F and apparent steady-state volume of distribution (Vdss/F) were approximately 1.4- and 2.1-fold higher, respectively, than values reported in previous studies of metoclopramide disposition in adults. These data suggest that metoclopramide pharmacokinetics may exhibit a developmental dependency. Thus, a metoclopramide dose of 0.15 mg/kg given orally every 6 hours is recommended for the initiation of prokinetic therapy with this agent in infants who are < or = 31 weeks postconceptional age.

Impact of gastroesophageal reflux on growth and hospital stay in premature infants

BACKGROUND

Gastroesophageal reflux (GER) is associated with failure to thrive in term infants with severe GER; however, this association has not been shown in premature infants. A retrospective case-control study of growth velocities, caloric intake, and length of hospital stay in premature infants with GER was conducted to determine the impact of GER on their growth.

METHODS

Twenty-three patients with clinically significant GER were identified from a database containing records for all infants admitted to the University of Connecticut Health Center Neonatal Intensive Care Unit. Patients and control subjects (n = 23) were matched for gestational age, birth weight, gender, and severity of bronchopulmonary dysplasia. Each infant's average weekly weight gain and average weekly caloric intake were calculated, using daily bedside nursing flow sheets. Comparisons were also made of the number of days it took each infant to achieve full oral feedings, number of days from full oral feedings to discharge, and length of hospital stay.

RESULTS

There were no significant differences between patients and control subjects for each week in average weekly weight gain, caloric intake, grams gained per calorie given, or weekly increments gained in length and head circumference. There were, however, significant differences in time required to achieve full oral feedings (32 +/- 13 days versus 19 +/- 12 days; p < 0.0008) and length of hospital stay (99 +/- 27 days versus 70 +/- 31 days; p < 0.002) as well as postmenstrual age (PMA) at discharge (43 +/- 3 weeks versus 39 +/- 3 weeks, p < 0.001).

CONCLUSIONS

GER did not have a significant impact on caloric intake, effective use of calories, or growth velocities in the study population. It is more likely that the constant monitoring of weight gain and caloric intake while in the intensive care environment protects against the failure to thrive often seen in older infants with GER. Premature infants with GER had a significantly increased length of hospital stay. More aggressive medical management and consideration of alternative feeding strategies may help facilitate discharge for premature infants diagnosed with GER.

The triangular test to assess the efficacy of metoclopramide in gastroesophageal reflux

BACKGROUND

Sequential methods are particularly interesting when recruitment is difficult because they may allow a study to be stopped early while maintaining type I and II error rates.

METHODS

This placebo-controlled, randomized double-blind study was aimed at assessing the efficacy of metoclopramide (0.2 mg/kg three times daily during 14 days) on gastroesophageal reflux in infancy. The main end point was the relative variation of the percentage of time at pH < 4 between inclusion (day 0) and evaluation (day 14) assessed on two 24-hour esophageal pH recordings. Statistical analysis was performed with use of a sequential method, the triangular test.

RESULTS

The study was stopped after the seventh analysis (39 infants evaluated: 20 placebo and 19 metoclopramide) without showing the expected benefit. Improvement on the main end point was 30% +/- 48% (mean +/- SD). Corresponding unbiased median estimates were 22% for placebo and 39% for metoclopramide (p = 0.28, sequential analysis). On day 14, the percentage of time at pH < 4 was 8.1% +/- 11.7% for placebo and 6.7% +/- 9.2% for metoclopramide (p = 0.68, t test), and the number of reflux episodes > 5 minutes was 3.0 +/- 3.5 for placebo and 1.9 +/- 3.0 for metoclopramide (p = 0.33, t test).

CONCLUSION

If a tendency for a superior improvement with metoclopramide than with placebo was observed on the main end point, it was lower than expected and the difference was not significant. Compared with the corresponding single-stage design, the triangular test allowed to stop the study with a 15% reduction in sample size.

Differentiation of cows' milk intolerance and gastro-oesophageal reflux

The aim of this study was to compare a non-invasive test of small bowel permeability with a more invasive approach involving endoscopy, mucosal biopsy, and oesophageal pH monitoring for rapidly differentiating gastro-oesophageal reflux (GOR) and cows' milk intolerance in 25 infants with persistent vomiting. Each subject underwent a cellobiose/mannitol permeability study, upper gastrointestinal endoscopy with oesophageal and small bowel biopsies, and a 24 hour pH study. Reflux disease and/or cows' milk intolerance was responsible for vomiting in 24 (96%) of the subjects. Sixteen (64%) of the infants had GOR alone, four (16%) had GOR and cows' milk intolerance, and four (16%) had cows' milk intolerance alone. Morphometric analysis of small bowel biopsies was abnormal in 19% of the patients with GOR alone and in 67% with cows' milk intolerance with or without GOR. The permeability test was abnormal in only 6% of the patients with GOR but in 100% with GOR and cows' milk intolerance and in 100% with cows' milk intolerance alone. The non-invasive permeability study aimed at rapid determination of cows' milk intolerance should pre-empt a more invasive approach in the evaluation of infants with persistent vomiting.

[Frequency of gastroesophageal reflux in infants and in young children with cystic fibrosis]

BACKGROUND

Gastro-esophageal reflux (GER) is common in chronic bronchopulmonary diseases, and may aggravate them. The aim of this study was to study frequency and characteristics of GER in infants and toddlers with cystic fibrosis (CF).

POPULATION AND METHODS

Twenty-five CF patients, 45 to 954 days-old (mean 219 days) without clinical evidence of bronchopulmonary infection, were studied by prolonged pHmetry (19.45 +/- 1.89 hours). Their pulmonary state was evaluated by the number of previous courses of antibiotic treatment and analysis of the X-rays.

RESULTS

Nineteen children had GER (76%); four of them had no clinical sign of GER. All 19 patients had mild or moderate signs of pulmonary impairment. The reflux index (percentage of time with pH < 4) was 12.82%. The GER episodes were more frequent during walking time (p < 0.001), but longer during sleeping time (p < 0.001).

CONCLUSIONS

GER is frequent in CF patients, even the youngest. It seems primary, and not related to pulmonary impairment. Its frequency and its potential severity lead to suggesting a pHmetry to every new CF patient.

Respiratory manifestations of gastroesophageal reflux in children

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.

Functional vomiting disorders in infancy: innocent vomiting, nervous vomiting, and infant rumination syndrome

Pediatric gastroenterologists have tended to view gastroesophageal reflux (GER) as a disease in and of itself--a disease that can be diagnosed "objectively" with use of numerical data from esophageal pH monitoring and cured with pharmacologic or surgical treatment. What is often forgotten is that the data derived from esophageal pH monitoring and other techniques may identify the presence of abnormal GER but tell nothing about its pathogenesis. The usual approach to infants who feed poorly, vomit, or fail to gain weight is to identify the presence of abnormal GER, rule out underlying organic causes of vomiting, and then diagnosis primary GER disease. The baby is then treated with pharmacologic, dietary, or positional therapy and, ultimately, if these therapies fail to eradicate the symptoms attributed to GER, surgical fundoplication, which stops vomiting regardless of its causes. The pediatric literature on infant vomiting and GER is almost devoid of research into the nature and possible relationships among infant stress, vomiting, feeding difficulties, and failure to grow. Clinically, the quality of the maternal-infant relationship is frequently approached superficially, with psychosocial aspects treated as less important in infants considered to have primary organic disease amenable to medical or surgical treatment. Psychosocial factors in the pathogenesis of the infant's symptoms are often not pursued beyond assessment for possible abuse or neglect. It has been known for centuries that stress or excitement affects gastrointestinal function and symptoms. Although the field of infant psychiatry has produced a substantial literature on the nature of stresses that affect both infants and mothers, the pediatric literature on vomiting and failure to thrive seldom acknowledges the existence or importance of these contributions. In clinical practice, failure to explore psychosocial aspects that may contribute to vomiting, feeding difficulties, or failure to thrive may result in missed opportunities for less invasive, more effective therapy at best, and countertherapeutic treatment at worst. This article describes three functional vomiting disorders of infancy, their distinguishing characteristics, hypotheses regarding their pathogenesis, and principles of comprehensive management.

Merycism or rumination disorder. A historical investigation and current assessment

BACKGROUND

In the 'fashionable' field of eating disorders, there has been a notable gap in the historiography of rumination, allowing considerable scope for constructing a comprehensive historical profile of this disorder.

METHOD

A wide-ranging examination of printed material, both etymological and medical, backed by a Medline computer search, uncovered extensive sources, some of considerable rarity, including case reports from the early 17th century onwards. Extracted data focused on incidence, sex distribution, age range, outcome and causation, and the findings are discussed in relation to diagnostic criteria in DSM-III-R and ICD-10.

RESULTS

While confirming the frequency of rumination in infants and the mentally retarded, the study demonstrated, particularly, the need to recognise its occurrence in normal adults, occasionally as a collateral behaviour in anorexia and bulimia nervosa, and suggested that its prevalence, distorted by secrecy, exceeded estimated levels.

CONCLUSIONS

In future reviews of classification, existing anomalies and inadequacies in the status and description of rumination would benefit from integrating some of the historical conclusions.

Domperidone plus magnesium hydroxide and aluminum hydroxide: a valid therapy in children with gastroesophageal reflux. A double-blind randomized study versus placebo

To evaluate the efficacy of different drug combinations in treating severe gastroesophageal reflux (GER), we studied 80 children with GER. The patients were randomly divided into four groups: group A was treated with domperidone plus magnesium hydroxide and aluminum hydroxide, group B with domperidone plus alginate, group C with domperidone alone, and group D received placebo. At the time of diagnosis and 8 weeks after treatment the patients were clinically evaluated and underwent 24-h continuous esophageal pH monitoring. After treatment a complete regression of symptoms was observed in 16 of 20 patients in group A, in 8 of 20 in group B (A versus B, p < 0.018), in 9 of 20 in group C (A versus C, p < 0.034), and in 7 of 20 in group D (A versus D, p < 0.001). Moreover, there was a statistically significant improvement in several pH-metric variables studied in all treatment groups; in addition, a comparison of the pH-metric data of the four groups after treatment indicated that reflux variables were significantly lower in group A than in the other groups. We conclude that the domperidone plus magnesium hydroxide and aluminum hydroxide combination was more effective than the other drugs we used in treating GER and in modifying the objective pH-metric variables in pediatric patients.

Gastroesophageal reflux in children

Operations for the control of complicated gastroesophageal reflux in children are commonly performed procedures in large pediatric centers. The comprehensive diagnostic scheme includes radiologic and endoscopic work-up coupled with extended pH probe analysis. Medical therapy remains the principle form of management, with surgery reserved for treatment failure.

Dose-response study of metoclopramide in gastroesophageal reflux in infancy

Twenty-four infants, 1 to 18 months-old, who were referred to four centers for suspected gastroesophageal reflux and whose esophageal pH after a standard formula meal given at 9 to 10 am (Ho-day 1) fulfilled the criterion of being < 4 for more than 5% of the time between H1 and H6, entered a double-blind placebo-controlled dose-response trial of metoclopramide (M). Twenty-four hours later (day 2), patients were randomly assigned to receive either placebo or a single 0.1, 0.2, or 0.4 mg/kg dose of metoclopramide, 30 min before the formula meal (n = 6/group) and the procedure was repeated. Metoclopramide plasma concentration was measured 1 h after dosing (C1h). On day 1, the time during which the esophageal pH was < 4 (time pH < 4), and five other parameters, were not significantly different in the treatment groups. On day 2, time pH < 4 (m(SD)) decreased from 33(13) to 30(33), 39(27), to 36(47), 42(15) to 18(13) and 48(25) to 31(46) min in the placebo, 0.1, 0.2, and 0.4 mg/kg metoclopramide groups, respectively. Possibly due to the large interindividual variability, no significant differences in parameters were observed between the different groups. None of the parameters correlated with the metoclopramide dose. Time pH < 4 expressed as the difference between day 1 and day 2, relative to day 1, decreased significantly as a function of C1h. No side effects were observed. A similar study should be performed after repeated dosing regimen.

Incidence and management of gastroesophageal reflux after repair of congenital diaphragmatic hernia

During a period of 6 years, 31 of 54 infants with congenital diaphragmatic hernia survived and were evaluated to study incidence and management of gastroesophageal reflux. At 6 months' follow-up 16 patients had gastroesophageal reflux proven by upper gastrointestinal series; at 12 months' follow-up 11 patients. Three patients having gastroesophageal reflux did not respond to medical treatment and underwent Nissen fundoplication. We conclude that after successful treatment, congenital diaphragmatic hernia is likely to be complicated by gastroesophageal reflux. We could not define a predictive feature for gastroesophageal reflux in the individual patient surviving congenital diaphragmatic hernia.

Esophagitis in infants with hypertrophic pyloric stenosis: a source of hematemesis

This study was undertaken to clarify the source of blood in the vomitus of patients with hypertrophic pyloric stenosis (HPS). Twenty-one infants with HPS were examined. Hematemesis was noted in 14 infants. Esophagogastric endoscopy showed a 100% incidence of esophagitis and in one patient gastric erosion was also observed. Histological study of the esophageal mucosa showed evidence of esophagitis in 18 patients (85.7%). Preoperative pH monitoring showed gastroesophageal reflux (GER) in all infants. Excessive acid exposure (> or = 7%) was significantly correlated with the grade of esophagitis and the incidence of hematemesis, whereas acid exposure time was shorter in the cases without histological esophagitis. These results suggested that the source of bleeding in HPS is the esophageal mucosa affected by esophagitis secondary to excessive acid reflux. Although there is obvious massive gastroesophageal reflux in HPS, it is too difficult to evaluate the lower esophageal sphincter function in HPS.

The effect of tube feeding on postprandial gastroesophageal reflux

Distal esophageal pH in supine position was monitored for 6 hours in 13 asymptomatic infants. During this period the patients received 15 to 20 mL/kg of 5% glucose solution twice every 3 hours. Each meal was fed orally or through a pH sensor tube. When the patient was fed through a tube, the meal was introduced into the stomach or into the distal esophagus. The extent of reflux during 2 hours after feeding was compared between oral and tube feeding. Comparing oral and intragastric tube feeding, intragastric tube feeding showed significantly fewer reflux events, a smaller percentage of time in the esophageal pH below 4, and a shorter duration of the longest single reflux event. Comparing oral and intraesophageal tube feeding, intraesophageal tube feeding showed the same pattern. The data indicated that tube feeding significantly diminishes the postprandial reflux.

Current surgical considerations in gastroesophageal reflux disease in infancy and childhood

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.

A bulimic ruminator? The case of Dr Samuel Johnson

Utilizing a wide range of eighteenth- and nineteenth-century biographical sources, the eating pathology of Dr Samuel Johnson is illustrated and examined. His presenting symptoms are considered in the light of modern criteria for eating disorders and current research on bulimia nervosa and rumination disorder.

A novel endoscopic transgastric fundoplication procedure for gastroesophageal reflux: an initial animal evaluation

Complications of gastroesophageal reflux are common in adults and children. A variety of surgical procedures have been successfully used to treat this condition. All current techniques require open surgery and are associated with significant morbidity and mortality, particularly in the high risk, neurologically damaged child. The authors have developed a novel method of creating a gastric fundoplication using an endoscopic transgastric approach in pigs. The procedure involves the creation of an esophageal intussusception into the stomach under direct vision with an endoscope. The gastric fundus is then plicated around the esophagus using a custom stapling device. The transgastric approach allows creation of a fundoplication, is easily performed, is potentially effective at preventing gastroesophageal reflux, and has the obvious advantages of minimally invasive surgery over open techniques of fundoplication.

Clinical imitators of infantile spasms

We report 53 infants who by clinical history were thought to have infantile spasms but who video-electroencephalograms showed were having other episodes that closely mimicked infantile spasms. Nine patients had other types of seizures. Forty-five patients had episodic symptoms that were not seizures: 11 patients had spasticity, four had gastroesophageal reflux, and the other patients had nonepileptic myoclonus, including 19 patients with benign neonatal sleep myoclonus. Three patients had more than one type of symptom. Infantile spasms imitators occurred in neurologically normal or abnormal infants, in patients with normal or abnormal interictal electroencephalograms, and in patients who also had previous or current infantile spasms. Differentiation of these episodes from infantile spasms prevented the initiation or continuation of anticonvulsant treatment appropriate for infantile spasms but inappropriate for these other behaviors.

Recognition of recurrent gastroesophageal reflux following antireflux surgery in the neurologically disabled child: high index of suspicion and definitive evaluation

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.

New insights on gastro-oesophageal reflux in cystic fibrosis by longitudinal follow up

A higher frequency (25%) of gastrooesophageal reflux (GOR) has been previously reported in patients over 5 years old with cystic fibrosis compared with controls without cystic fibrosis. It was believed that GOR was caused by the complications of cystic fibrosis. We looked for GOR in all 26 children younger than 60 months who had cystic fibrosis diagnosed. They had a classical genetic profile and the usual scattered clinical manifestations for age. GOR was confirmed in 21 (81%): 20 by abnormal pH tracings and in one on a clinical basis. After at least one month of adjusted cystic fibrosis treatment, antireflux treatment (cisapride) was given to 16 patients and variables of GOR improved dramatically. Weight gain was significant and recurrent cough and wheeze disappeared. One year later half of the patients still suffered from GOR. GOR is a major problem in the early life of those with cystic fibrosis and is not the consequence of either respiratory or gastrointestinal complications as it improves with age whereas cystic fibrosis becomes worse with age.

Alkaline gastroesophageal reflux in infants and children

The incidence of alkaline gastroesophageal reflux (GER) was examined in 111 consecutive children referred for evaluation of GER during a 1-year period. The results of 24-hour pH monitoring studies and the medical records were retrospectively evaluated. Acid reflux was defined as occurring whenever the pH was less than 4 and alkaline reflux was defined whenever the pH was greater than 7. The percentage of time that reflux occurred, the number of reflux episodes, the number of episodes greater than 5 minutes, and the longest episode were all recorded. Based on these data, four categories of patients were identified as compared with normal values as determined by Pellegrini et al. When using criteria based on the percentage of time that reflux occurred, the largest group of children with GER was found to reflux acid (50%). However, 27 children (24%) had combined acid and alkaline reflux. Eighteen (16%) had predominantly alkaline reflux. Previously, these 18 children would have been considered as having a low likelihood of reflux by pH criteria. Endoscopic examination showed that pathological evidence of esophagitis occurred in four of the children with pure alkaline reflux. This review shows that symptomatic GER in infants and children may be due to acid or alkaline secretions or a mixture of both. A previously unrecognized cohort exists of children who demonstrate primary alkaline reflux. These patients need to be recognized and may benefit from a therapeutic program specifically designed to control alkaline reflux.

Gastroesophageal reflux in the older child: presentation, response to treatment and long-term follow-up

Much attention has been focused on the natural history of gastroesophageal reflux (GER) in neurologically normal infants which generally resolves by two years of age. In contrast, little is known of the outcome of GER diagnosed in normal older children. The charts of 32 children (21 males) without neurologic or esophageal anatomic abnormalities, age 3.5 to 16 years (mean = 9.8) at the time of diagnosis, were reviewed. Diagnosis was based on suggestive presenting symptoms and evaluation of prolonged intraesophageal pH monitoring. Esophagitis was diagnosed by histologic criteria in 16 of the 32 patients. Medical treatment consisted of prokinetic agents (metoclopramide, bethanechol) and H2-receptor antagonists. After a one to eight year follow-up period (mean +/- SD - 3.4 +/- 2.1), the symptoms in 13 children had resolved or were sufficiently improved to discontinue medication. In 13 patients, symptoms were improved but medication was required for adequate control. Four children were symptomatic without improvement in spite of medical therapy and two others required fundoplication for continued severe symptoms and refractory esophagitis. In summary, less than 50% of otherwise normal older children with GER undergo spontaneous resolution of marked improvement in symptoms and the remainder require continued long-term medical and/or surgical management.

The child with spells

The purpose of this article was to discuss paroxysms, both neurologic and non-neurologic, that can mimic seizures. This is summarized in Table 4. It should be clear that the evaluation of any spell in a child should begin with a detailed and complete history. Historical features should focus on all aspects of the event--length of time, situation, appearance, quantity, as well as other features not directly pertaining to the event. Physical and neurologic examinations are frequently normal. Ancillary testing that may prove valuable include routine and video EEG monitoring as well as home video recording.

The risk of sudden infant death from gastroesophageal reflux

Gastroesophageal reflux (GER) has been a suspected cause of infant deaths and sudden infant death syndrome (SIDS). We examined our 10-year experience with 499 consecutive infants 6 months of age or less who had extended (18 to 24 hours) esophageal pH monitoring performed to evaluate for GER. The data extracted from the esophageal pH records included the pH score, the pattern of GER (type I, II, or III), and the mean duration of reflux during sleep (ZMD). All infants were followed to determine the occurrence and cause of death during the first year of life. Of the 19 deaths found in the series, three were classified as SIDS and two were in-hospital deaths caused by reflux-induced aspiration. All five of these infants who died had a prolonged ZMD (greater than 3.8 minutes) and received either basic medical (n = 4) or no (n = 1) antireflux therapy. Four infants also had the type I pattern of GER. There was a 9.1% (4/44; 95% confidence limits, 2.5% to 21.7%) incidence of reflux-related or SIDS deaths in infants with type I GER and a prolonged ZMD who were treated nonoperatively, compared with none (0/83, P = .03) in the same group of infants treated with antireflux surgery. The incidence of SIDS was higher in infants with type I GER and a prolonged ZMD who were treated nonoperatively (3/44, 6.8%) compared with all other infants treated nonoperatively (0/265, 0%; P = .003).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for gastroesophageal reflux in children with normal pH studies

Esophageal pH monitoring is recognized as the best diagnostic procedure for gastroesophageal reflux (GER) and operation is seldom recommended in the absence of abnormal pH data. To emphasize that operation should not be ruled out for children who may have false-negative pH studies, we report 14 patients operated on for GER in spite of normal pH-monitoring. The mean age was 54 months (range, 18 to 90). Clinical features included vomiting, dysphagia, respiratory disease, anemia, and torticollis. All had radiologic evidence of GER, and 10 had endoscopic and histological esophagitis. Conventional pH-monitoring values were normal but lower esophageal sphincter pressure and propulsive peristalsis were significantly decreased whereas nonpropulsive contractions were predominant. Operation was recommended after an average of 24 months of unsuccessful medical treatment. Independent postoperative assessment showed that 13 of the 14 patients were relieved of their symptoms and dysphagia persists in one. We suggest that the diagnosis of GER should be accepted on the basis of sound clinical judgement plus more than one abnormal test even when pH results are normal. Operation should not be withheld when clinically indicated. There are several explanations for false-negative pH studies, of which alkaline reflux is probably the most important and warrants further investigation in children.

Fundoplication and gastrostomy in familial dysautonomia

Fundoplication with gastrostomy has become a frequent treatment for patients with familial dysautonomia, so we evaluated the use of both procedures in 65 patients. Although patients differed widely in presenting signs and age, from 5 weeks to 40 years, gastroesophageal reflux was documented in 95% of patients by cineradiography or pH monitoring. Panendoscopy was a useful adjunct. Preoperative symptoms of gastroesophageal reflux included vomiting, respiratory infections, and exaggerated autonomic dysfunction. Severe oropharyngeal incoordination frequently coexisted and resulted in misdirected swallows with aspiration, dependence on gavage feedings, or poor weight gain and dehydration. Follow-up after surgical correction ranged from 3 months to 11 years; 55 patients (85%) were available for a 1-year postoperative assessment. We had no instances of surgical death. The long-term mortality rate was 14%, primarily related to severe preexisting respiratory disease. Beyond the first postoperative year, 30 patients had pneumonia attributed to continued aspiration, exacerbation of preexisting lung disease, or recurrence of gastroesophageal reflux. Of 11 patients who vomited postoperatively, six had recurrence of reflux. Recurrence of gastroesophageal reflux was documented in eight patients (12%), and we revised the fundoplication in three patients. The number of patients with cyclic crises was reduced from 18 to 7; retching replaced overt vomiting in all but two of these seven patients, neither of whom had recurrence of reflux. Because oropharyngeal incoordination was prominent, concomitant use of gastrostomy and an antireflux procedure was especially effective in the treatment of younger patients with familial dysautonomia, before the development of severe respiratory disease. Despite the development of severe morning nausea in 15 patients, the combination procedure resulted in significantly improved nutritional status, decreased vomiting, and decreased respiratory problems. Appropriate use of gastrostomy feedings also contributed to success of the operation. The generally good outcome of fundoplication with gastrostomy confirms the benefit of this procedure in familial dysautonomia.

Effects of cisapride on parameters of oesophageal motility and on the prolonged intraoesophageal pH test in infants with gastro-oesophageal reflux disease

The effect of cisapride, a new gastrointestinal prokinetic drug, on oesophageal motility and acid reflux was studied in 14 children with gastro-oesophageal reflux disease, receiving either placebo or cisapride 0.15 mg/kg intravenously. Cisapride significantly (p less than 0.01) increased the lower oesophageal sphincter pressure (+124%), the amplitude (+84%) and duration (+24%) of oesophageal peristaltic waves, whereas the placebo treatment did not produce any changes. Subsequently, all 14 children underwent 24 hour oesophageal pH-monitoring before and after four weeks of treatment with oral cisapride 0.2 mg/kg tid given in addition to postural therapy and thickened feedings. The 24 hour intraoesophageal pH recordings and symptomatic scores were compared with those of 10 control patients treated only by postural therapy and thickened feedings. When compared with baseline pH data, cisapride significantly reduced the oesophageal acid exposure time, the mean duration of each reflux episode, the duration of the longest reflux episode and the number of long lasting reflux episodes; the number of reflux episodes was not influenced. The effect of cisapride was marked and consistent during fasting and sleep periods. Oesophageal acid exposure was reduced more significantly in patients given cisapride (-61%) than in controls (-24%; p less than 0.001). Symptom improvement was greater after four weeks of cisapride treatment (score reduction: 61%) than after postural and dietary therapy alone (score reduction: 42%; p less than 0.01). No adverse effects occurred. These findings suggest that cisapride is a valuable drug in the management of gastro-oesophageal reflux disease in children.

Feeding disorders and gastroesophageal reflux in infants with chronic renal failure

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.

Familial occurrence of benign myoclonus of early infancy

Three cases of benign myoclonus of early infancy (BMEI) were observed in the same family. Previously, only sporadic cases have been reported. Electroencephalogram (EEG) recordings were consistently normal, and the affected girls had normal neurological development. Therapy was not administered and the episodes spontaneously disappeared within the first months of life. While etiological mechanisms of BMEI are still unknown, a hereditary mechanism is now hypothesized on the basis of these cases.

Sucralfate in the treatment of reflux esophagitis in children. Preliminary results

In order to evaluate the use of sucralfate in the treatment of children with reflux esophagitis, we studied 66 children aged from 4 months to 12 years (mean 5.9 years, SD 3.5) diagnosed to have gastroesophageal reflux by means of esophageal isotopic examination and radiology. An endoscopic examination was carried out in all cases. None of the patients suffered from kidney disease or had taken antacids, cimetidine, sucralfate or antirheumatic drugs in the two weeks prior to the study. Patients were divided into three groups matched according to age, grade of esophagitis, sex, nutritional state and semiology and treated with sucralfate in tablets, cimetidine, or sucralfate in suspension; no dietetic or postural measures were used. On days 14, 28, 42 and 56, clinical control was carried out and endoscopy was done on day 28, this being repeated on day 56 if the course was not satisfactory. From the statistical analysis of the results we deduce that there are no differences between the three groups. Therefore sucralfate appears to be a useful drug for the treatment of children with esophagitis due to GER.