Gastroesophageal reflux. Diagnostic and therapeutic approaches

Salivary pepsin A detection related to gastro-oesophageal reflux episodes in children undergoing impedance probe monitoring

AIM

Gastro-oesophageal reflux is routinely diagnosed with invasive intraluminal impedance pH probe monitoring. This study aimed to determine whether gastric pepsin A detected in saliva of children correlates with gastro-oesophageal reflux.

METHODS

Patients undergoing probe monitoring were prospectively recruited between 2014 and 2016 at a paediatric hospital. Standard impedance and demographic data were obtained from electronic medical records. Salivary samples were collected during impedance and measured for gastric pepsin A with an enzyme-linked immunosorbent assay. Impedance probe and pepsin data were analysed and compared for correlation.

RESULTS

From 52 enrolled subjects, 28 males and 24 females with mean age 8.0 ± 5.9 and range 0.58-18.0 years, 417 salivary samples were collected. Positive pepsin was found in 14% of samples and 48% patients. The sensitivity of pepsin A in predicting an abnormal impedance was 43% and specificity, 50%. Among pepsin A positive samples, 72% corresponded with a gastro-oesophageal reflux episode. Pepsin peak levels significantly correlated with acidic reflux.

CONCLUSION

Pepsin A was presented in saliva of children undergoing gastro-oesophageal reflux disease investigation. Positive pepsin A was associated with a gastro-oesophageal reflux episode, and its peak value correlated with acidic reflux. Salivary pepsin as a marker for gastro-oesophageal reflux needs further investigation.

Pathophysiology of aerodigestive pulmonary disorders in the neonate

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

Infantile colic, facts and fiction

Infantile colic is one of the major challenges of parenthood. It is one of the common reasons parents seek medical advice during their child's first 3 months of life. It is defined as paroxysms of crying lasting more than 3 hours a day, occurring more than 3 days in any week for 3 weeks in a healthy baby aged 2 weeks to 4 months. Colic is a poorly understood phenomenon affecting up to 30% of babies, underlying organic causes of excessive crying account for less than 5%. Laboratory tests and radiological examinations are unnecessary if the infant is gaining weight normally and has a normal physical examination. Treatment is limited and drug treatment has no role in management. Probiotics are now emerging as promising agents in the treatment of infantile colic. Alternative medicine (Herbal tea, fennel, glucose and massage therapy) have not proved to be consistently helpful and some might even be dangerous. In conclusion infantile colic is a common cause of maternal distress and family disturbance, the cornerstone of management remains reassurance of parents regarding the benign and self-limiting nature of the illness. There is a critical need for more evidence based treatment protocols.

Planar scintigraphic imaging of the gastrointestinal tract in clinical practice

In the last 30 years, nuclear medicine has paralleled other imaging fields with the development of 3-dimensional techniques, including single-photon emission computed tomography and positron emission tomography. However, conventional nuclear medicine planar scintigraphy remains a common procedure at most imaging centers. Gastrointestinal studies constitute a significant portion of these planar procedures. The most common gastrointestinal studies, including hepatobiliary, gastric emptying, and gastrointestinal bleeding evaluations, resemble their original protocol. However, serial improvements have optimized the diagnostic efficacy of these procedures. Conventional Technetium-99m sulfur colloid liver/spleen imaging and hepatic blood pool imaging with labeled red blood cells now mainly serve an adjunctive role in the evaluation of equivocal findings on computed tomography. Salivary gland imaging is a less commonly requested evaluation, but can be used to evaluate functional capacity in some disease entities.

Clinical Perspectives on Esophageal Disorders in Infants

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

Gastroesophageal reflux scintigraphy: interpretation methods and inter-reader agreement

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.

Longitudinal evaluation of immunohistochemical findings of milk aspiration: an experimental study using a murine model

To examine the longitudinal change of pathological findings of the lung and other organs in milk aspiration, an experimental study using a murine model was carried out. Either 0.5 or 1.0 ml cow's milk was instilled into the trachea of rats. From immediately after to 14 days after instillation, the animals were sacrificed, and the lungs, liver, kidneys, and spleen were removed. The results of immunostaining with anti-human α lactalbumin antibody indicated that not only the lung but also the kidney and spleen showed a positive reaction against the antibody over time. Experimentally aspirated milk was detectable in alveoli until 2 days after instillation. It was also detectable in renal tubules from 1 to 6h after instillation. Macrophages containing granules of aspirated milk were observed in splenic red pulp from 3h to 14 days after instillation. Detection of aspirated milk in other organs except the lung would be clear evidence of intravital milk aspiration and would suggest previous or recurrent milk aspiration.

Estudo comparativo entre as técnicas de nissen e Boix-Ochoa em ratos

OBJETIVO: Comparar, em ratos, a eficiência das técnicas de Nissen e Boix-Ochoa no tratamento do refluxo gastroesofagiano (RGE) induzido pela operação de Heller. MÉTODO: Foram usados 30 ratos Wistar, com idades entre 40 e 60 dias de vida e peso corporal entre 210 g e 342 g. Os animais foram distribuídos em três Grupos (A, B, C) de 10 ratos. Em todos os animais realizou-se a operação de Heller. No Grupo B ela foi seguida de uma operação de Nissen e, no Grupo C, de uma operação de Boix-Ochoa. A pressão intra-gástrica necessária para produzir RGE foi medida em todos os animais: antes de qualquer procedimento; imediatamente após as operações de Heller, Nissen e Boix-Ochoa; e seis semanas depois, quando os animais foram mortos. RESULTADOS: Verificou-se que tanto a recuperação da perda de peso, que caracteriza o quadro de RGE, como a reconstituição mais fisiológica dos gradientes pressóricos gastroesofagianos são obtidos de forma mais eficiente pela técnica de Boix- Ochoa. CONCLUSÃO: As operações de Nissen e Boix- Ochoa são eficientes no tratamento do RGE induzido pela técnica de Heller, em ratos. A segunda, no entanto, restaurou, de forma mais adequada, os valores fisiológicos dos parâmetros estudados neste trabalho: o peso corporal e os gradientes pressóricos gastroesofagianos.

Is there a changing trend in surgical management of gastroesophageal reflux disease in children?

Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD. However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD in children.

Diagnosis of orotracheal aspiration using radionuclide salivagram

There are two main Nuclear Medicine techniques, the gastroesophageal reflux scintigraphy with late lung imaging and the nuclear salivagram, for diagnosis of pulmonary aspiration. Each of the techniques can document the two different, antegrade and retrograde, routes of pulmonary aspiration. In this report, we presented a patient with recurrent respiratory problems and emphasized the importance of concomitant use of the two techniques in the radionuclide diagnosis of aspiration.

Laparoscopic fundoplication in mentally normal children with gastroesophageal reflux disease

Laparoscopic antireflux surgery has been performed in neurologically impaired and scoliotic children. We aimed to assess the effectiveness of laparoscopic fundoplication in mentally normal children with gastroesophageal reflux disease that failed to respond to medical therapy. Data were prospectively collected (symptoms, medical therapy, endoscopies' findings) on 12 children (nine boys, three girls) aged 9-15 years with gastroesophageal reflux disease. Pre- and postoperative ambulatory 24-h pH and DeMeester and Johnson scores were also recorded. Effectiveness of surgery was assessed by comparison of pre- and postoperative total acid exposure time, Visick grade, need for antireflux medication and symptom scores. In total, 11 children underwent a laparoscopic Nissen fundoplication and one underwent a Toupet procedure. Median length of stay was 2 (2-3) nights. The median preoperative pH acid exposure time (AET) was 4.7 (0.8-16.4) percent compared with postoperative AET of 0.4 (0-3) percent. Early postoperative dysphagia occurred in four out of 12 patients, requiring a total of six dilatations. Postoperative Visick scores were: grade I=7 and grade II=5. Laparoscopic fundoplication can be safely performed and is effective in children with GERD who have failed to respond to medical therapy.

Feed thickener for newborn infants with gastro-oesophageal reflux

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.

Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody

To determine the frequency and degree of milk aspiration in infant death cases, immunohistochemical examinations were performed on lung sections from 41 sudden death cases and 64 in-hospital death cases using anti-human alpha-lactalbumin antibody. Milk aspiration to some degree was detected in more than half of the sudden death cases and in about one-third of the in-hospital death cases. A semi-quantitative examination of the amount of aspirated milk was subsequently performed in the positive cases. The amount of aspirated milk in the sudden death cases was significantly higher than that in the in-hospital death cases. The frequency distribution of the amount of aspirated milk was similar in shape in both groups. In most cases, a very small amount of aspirated milk was detected. The aspirated milk was assumed to be a result of occasional gastroesophageal reflux or cardiopulmonary resuscitation. However, in five cases, much larger amounts of aspirated milk were found. In these cases, milk aspiration may have been an important part of the cause of death. We concluded that slight milk aspiration is not rare in infant death cases, and that in a few cases, the aspiration is lethal. An immunohistochemical screening test is available to perform a postmortem diagnosis in these cases.

Effect of intragastric volume and osmolality on mechanisms of gastroesophageal reflux in children with gastroesophageal reflux disease

OBJECTIVE

Both transient lower esophageal sphincter (LES) relaxations (TLESRs) and periods of low/absent LES pressure (LESP) are the main mechanisms of gastroesophageal reflux. These events are believed to be triggered by stimuli from different areas of the upper GI tract. We aimed at investigating the relationship between LESP profile and gastric emptying and distension after meals of different composition in 30 children with gastroesophageal reflux disease (median age 7.0 yr, range 12 months-12 yr).

METHODS

Recordings of LESP and intraesophageal pH for 1 h fasting and for 2 postprandial h were performed with a perfused sleeve catheter and flexible electrode, respectively; gastric emptying and distension of antral area were simultaneously recorded with real-time ultrasonography. Ten patients had a standard meal (group A), 10 had a high-volume meal (group B), and 10 had a high-volume and osmolality meal (group C).

RESULTS

Postprandial esophageal acid exposure was significantly higher in patients of groups B and C than in patients of group A (p < 0.01); it was also more prolonged in patients of group C than in subjects of group B (p < 0.05). A higher postfeeding rate of reflux episodes caused by TLESRs was detected in patients of groups B and C as compared with patients of group A (p < 0.01). This increase did not statistically differ in patients of groups B and C. Patients of group C exhibited a higher postprandial rate of reflux episodes associated with low/absent tone of the LES as well as a more prolonged gastric emptying time and a higher postfeeding gastric distension as compared with patients of groups A and B (p < 0.01). Finally, a significant correlation was only found between the postprandial rate of reflux events resulting from low/absent LESP and the degree of antral distension in patients of group C (p < 0.01).

CONCLUSION

Gastroesophageal reflux is worsened by increasing the volume and osmolality of meals through significant changes of LESP. Meals of high volume and meals with high volume and osmolality cause a comparable increase of reflux episodes as a result of TLESRs. However, meals with high volume and osmolality cause the higher degrees of esophageal acid exposure than meals with high volume resulting from a higher rate of reflux episodes associated with low/absent LESP. This finding correlates with a high postfeeding antral distension.

[Prolonged length of stays in pediatric intensive care. Retrospective study of 100 stays]

New issues have arisen in pediatric intensive care units, especially concerning long-stay patients. The aims of the present study were to describe the etiologic factors of these long-stay patients and to recognize the comorbidities.

MATERIAL AND METHODS

Ninety-five patients who had a total of 100 hospitalizations of more than 30 days were admitted to the pediatric intensive care unit at Robert-Debre Hospital during a 3-year period (1993-1995); this accounted for 9.1% of total admissions. We retrospectively reviewed these 100 long-stay hospitalizations.

RESULTS

Most of these patients were newborns (65%). Patients with severe congenital anomalies (44 patients) and very premature infants (26 patients) constituted the majority of long-stay patients. The mean duration of mechanical ventilation for the 95 patients was 110 days (ranges 17-789 days). Two factors of comorbidity were found: gastroesophageal reflux (41% of cases) and nosocomial infections (89% of cases).

CONCLUSION

In order to prevent long stays, pediatric intensive care units must be directed toward these factors.

Gastroesophageal reflux, allergy and chronic tubotympanal disorders in children

The purpose of this study is to examine the relation between gastroesophageal reflux and allergy as possible causes of chronic tubotympanal pathology. The 30 examined children (ages 2-13) were divided into two groups based on the otological criteria. The 16 examined children suffered from a secretory otitis, which lasted more than four months. Upon further examination with a microscope, seven of these children exhibited symptoms of the adhesive process of the middle ear. Furthermore, 14 patients suffered from a recurrent otitis, i.e. more than five cases of otitis per year, while five patients from this group suffered from a chronic otitis with a central defect of the tympanum. The method used for the examination of the gastroesophageal reflux consisted of a continual 24 h esophageal pH monitoring. The particular apparatus used for this included antimony electrode (Synetics Medical, Sweden), while the analysis we performed was processed through the PC software program Gastrosoft Inc. The reflux index higher than five was considered pathological. At the time of the gastroesophageal reflux examination, we also performed the allergological analysis. The presence of allergy was confirmed by three methods: the positive allergological anamnesis, the positive skin pick test and by the elevated quantities of specific IgEs (Pharmacia CAP system). The examination resulted in the following: 18 of the examined children suffered from the pathological gastroesophageal reflux (60%); further seven of our patients tested positive on the allergological test (23%); and the four who tested positive for allergy also suffered from the pathological gastroesophageal reflux (13%). In comparison with allergies, the pathological GER was substantially more frequent in the patients who suffered from chronic tubotympanal disorders.

Reflux in children

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.

Normal ranges of continuous pH monitoring in the proximal esophagus

BACKGROUND

To determine normal ranges of gastroesophageal reflux (GER) in the proximal esophagus, measured with continuous pH monitoring. Normal ranges in the distal esophagus have been published. Because esophageal pH monitoring is frequently performed in children with atypical manifestations such as chronic respiratory disease, and because one of the possible pathophysiologic mechanisms may be (micro-)aspiration, it may be relevant to establish normal ranges in the proximal esophagus.

METHODS

Twenty-four-hour pH monitoring was performed in 200 children with suspected GER disease. The mean age of the patients was 4.5 months (range, 0.5-17.0 months). After initial analysis, patients were divided into three groups according to the reflux index (RI) in the distal esophagus, because it could be speculated that the amount of reflux reaching the proximal esophagus depends on the amount of reflux in the distal esophagus: Group I (n: 120) children had a distal RI of less than 5% and were considered normal, group II (n:50) had a distal RI of 5% to 10% and was considered to have intermediate disease, and group III (n:30) had a distal RI of more than 10% and was regarded as pathologic. The following parameters are calculated: the RI, the total number of reflux episodes, the number of reflux episodes lasting more than 5 minutes, the duration of the longest reflux episode, and the acid clearance time (ACT).

RESULTS

The median RI in the distal esophagus was 3.8 +/- 0.34 (standard error of the mean [SEM]), and in the proximal esophagus, the RI was 1.2 +/- 0.23. In group I patients, the RI in the proximal esophagus was 0.5% +/- 0.09%, in group II the RI increased significantly to 2.75% +/- 0.34% (P [group I compared with group II] < 0.01), and in group III the RI was 6.15% +/- 0.96% (P [II-III] < 0.01). The number of acid reflux episodes in group I was 17.0 +/- 2.27, in group II the number increased to 62.5 +/- 8.18 (P [I-II] < 0.01), and in group III it reached 102.0 +/- 23.9 (P [II-III] < 0.05). Also the duration of the longest reflux episodes and the number of reflux episodes lasting more than 5 minutes increased from group I to group II, and from group II to group III. The ACT was shorter in the proximal esophagus (group I 0.3 +/- 0.06 minutes; group II 0.48 +/- 0.07 minutes, P [I-II] = not significant [NS]; group III 0.56 +/- 0.17 minutes P [II-III] = NS) than in the distal esophagus (group I 0.49 +/- 0.03 minutes, P [proximal ACT compared with distal ACT] < 0.05; Group II 0.76 +/- 0.05 minutes, P [proximal-distal] < 0.01; Group III 0.89 +/- 0.09 minutes, P [proximal-distal] = NS) suggesting more effective esophageal clearance in the proximal esophagus.

CONCLUSIONS

Protection of the proximal esophagus from acid reflux is significantly related to the incidence and duration of reflux measured in the distal esophagus. These normal ranges in the upper esophagus will be helpful in the interpretation of upper esophageal pH monitoring data.

Role of drug therapy in the treatment of gastro-oesophageal reflux disorder in children

Gastro-oesophageal reflux (GOR) is the effortless passage of gastric contents into the distal oesophagus. It can be classified as functional (or symptomatic), in which the infant remains free from disease, or a pathological (GOR disease, GORD), in which gastrointestinal, respiratory or neurobehavioural signs occur with intraoesophageal acidification and the development of oesophagitis. Functional or symptomatic GOR is successfully treated by conservative measures and does not require investigative diagnostic tools; however, both drug administration and an investigative approach are mandatory in patients with GORD. There is currently a great range of proven therapeutic options for GORD that are directed at counteracting the pathogenetic components of the disorder. In this report we discuss the role of different drug classes for treating GORD in children. The choice of therapy for GORD depends upon the severity of signs and the degree of oesophagitis. The presence of oesophagitis, as documented by endoscopy, suggests the use of antisecretory drugs; H2 receptor antagonists are the first-line agents. Nevertheless, individuals with refractory disease or those patients requiring potent inhibition of acid secretion (for example, GORD with respiratory involvement) can be given proton pump inhibitors. Other groups of patients who need potent inhibition of acid secretion are children with neurological dysfunction and those with Barrett's oesophagus. It is still unclear whether patients with frequent relapses are candidates for long term administration of antisecretory drugs or for surgical fundoplication.

Immunohistochemical examination of the lungs in infant death cases using antibodies against milk components

To examine the use of immunohistochemical staining with antibodies against milk components for detection of aspirated milk on lung sections, eighteen infant death cases were investigated. Immunostaining was performed with anti-human alpha lactalbumin, anti-human IgA, anti-human milk fat globulin 1, and anti-cow whey antibody. Reactivity with each antibody was examined, and semi-quantitative examinations were performed to compare the amount of aspirated milk using anti-human alpha lactalbumin antibody. Materials in the alveoli or bronchioli on lung sections suspected to be aspirated milk showed the most sensitive and clearest reaction with anti-human alpha lactalbumin antibody. Of the eighteen cases, ten cases showed positive reaction with this antibody. The amount of aspirated milk varied widely in each case. In conclusion, immunohistochemical staining with antibodies against human milk components, especially anti-human alpha lactalbumin antibody, can detect small amounts of milk. Using this method, we were able to compare the relative amount of aspirated milk among cases.

Antireflux surgery in children suffering from reflux-associated respiratory diseases

The aim of our study was to evaluate the success, complications, and morbidity following a modified Thal fundoplication in children with reflux-associated respiratory disease (RARD). We used a procedure consisting of retroesophageal hiatal plasty, wrapping the gastric fundus around the gastroesophageal junction 180 degrees, and fixation of the lesser curvature at the abdominal wall. Follow-up by questionnaire of 128 (77 male, 51 females) out of 196 antireflux procedures between 1992 and 1995 was achieved. Surgical therapy was considered justified whenever there was gastroesophageal reflux resulting in severe recurrent respiratory symptoms. Eleven percent of the children suffered from bronchiectasis. The diagnosis of RARD was based on a high index of suspicion, barium swallow with fluoroscopy, 24-hr two-level pH-monitoring, bronchoscopy, bronchoalveolar lavage and detection of lipid-laden alveolar macrophages, esophago-gastroscopy, and esophageal biopsy. Patients with bronchopulmonary diseases such as allergy, immunodeficiency, cystic fibrosis, primary ciliary dyskinesia, and malformation of the bronchial tree or vessels had been excluded. "Evident improvement" as a result of surgery was reported in 88%, "no change" in 10%, and a "change for the worse" in 2% of patients. Persistent mild difficulties in swallowing were observed in 11%. Paraesophageal hernia, gas-bloat syndrome, and dumping syndrome were not observed. Two children needed a second operation because of relapse. The use of emergency steroidal medication for acute respiratory distress decreased impressively (219 single doses/year before surgery vs. 30 single doses/year after surgery). The need for more than 4 times/year of antibiotic therapy before surgery was reduced from 52. 3% before to 14% after surgery. Most (90.6%) of the parents stated they would agree to have surgery done again if medically indicated. In conclusion, Thal fundoplication is sufficient, safe, and effective in the management of RARD. Complications of the procedure were minor and of little consequence to the patient.

Gastroesophageal reflux in children

Gastroesophageal reflux (GER) is a common disorder in infants and children with a high rate of spontaneous resolution. Some children, however, will continue to have problems and progress from functional GER to pathogenic GER. In children with functional GER, diagnostic testing and pharmacologic treatment is unnecessary. In more involved cases, there are a number of tests available that help to quantify and qualify the extent of disease. Treatment begins with conservative measures and progresses to acid neutralization/supression and medications to enhance motility. Should medical management fail to control the consequences of reflux disease, surgical intervention is warranted.

Gastroesophageal reflux in infants and children

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.

Immunohistochemical detection of human milk components aspirated in lungs of an infant

We examined an autopsy case of an infant whose cause of death was suspected to be asphyxia due to human breast milk aspiration. In order to demonstrate aspirated milk in the lungs, we conducted immunohistochemical staining using eight antibodies against the components of human milk. Seven of the eight antibodies reacted positively with the substances suspected to be aspirated milk. We concluded that immunohistochemical staining with these antibodies is useful to demonstrate human milk aspiration and provide some keys for detecting the causes of unexpected infant deaths.

Gastroesophageal reflux--how to mend it?

Gastroesophageal reflux (GER) is a common condition affecting children. The clinical presentation varies widely from innocuous spitting up to life threatening apnea. Various diagnostic tests are available to document the etiology, presence or complications of GER. In most cases, conservative approach is sufficient. In complicated cases, pharmacotherapy is indicated while surgical therapy is reserved for resistant cases with complications.