Esophagitis in distressed infants: poor diagnostic agreement between esophageal pH monitoring and histopathologic findings

The consensus of the Asociación Mexicana de Gastroenterología on the diagnosis and treatment of gastroesophageal reflux and gastroesophageal reflux disease in infants

Gastroesophageal reflux (GER) is a frequent normal phenomenon in children of any age. It is more common in infants, in whom the majority of episodes are short-lived and cause no other symptoms or complications, differentiating it from gastroesophageal reflux disease (GERD). The diagnosis and management of GER and GERD continue to be a challenge for the physician. Therefore, the aim of the Asociación Mexicana de Gastroenterología was to adapt international documents to facilitate their adoption by primary care physicians, with the goal of standardizing quality of care and reducing the number of diagnostic tests performed and inappropriate medication use. The ADAPTE methodology was followed, and the recommendations were approved utilizing the Delphi strategy. The executive committee carried out the review of the guidelines, position papers, and international reviews that met the a priori quality criteria and possible applicability in a local context. The recommendations were taken from those sources and adapted, after which they were approved by the working group. The consensus consists of 25 statements and their supporting information on the diagnosis and treatment of GER and GERD in infants. The adapted document is the first systematic effort to provide an adequate consensus for use in Mexico, proposing a practical approach to and management of GER and GERD for healthcare providers.

Characterization of Upper Gastrointestinal Motility in Infants With Persistent Distress and Non-IgE-mediated Cow's Milk Protein Allergy

BACKGROUND

Persistent crying in infancy is common and may be associated with gastroesophageal reflux disease (GERD) and/or non-IgE-mediated cow's milk protein allergy (CMPA). We aimed to document upper gastrointestinal motility events in infants with CMPA and compare these to findings in infants with functional GERD.

METHODS

Infants aged 2 to 26 weeks with persistent crying, GERD symptoms and possible CMPA were included. Symptoms were recorded by 48-hour cry-fuss chart and validated reflux questionnaire (infant GERD questionnaire [IGERDQ]). Infants underwent a blinded milk elimination-challenge sequence to diagnose CMPA. GERD parameters and mucosal integrity were assessed by 24-hour pH-impedance monitoring before and after cow's milk protein (CMP) elimination. C-octanoate breath testing for gastric emptying dynamics, dual-sugar intestinal permeability, fecal calprotectin, and serum vitamin D were also measured.

RESULTS

Fifty infants (mean age 13 ± 7 weeks; 27 boys) were enrolled. On the basis of CMP elimination-challenge outcomes, 14 (28%) were categorized as non-IgE-mediated CMPA, and 17 (34%) were not allergic to milk; 12 infants with equivocal findings, and 7 with incomplete data were excluded. There were no baseline differences in GERD parameters between infants with and without CMPA. In the CMPA group, CMP elimination resulted in a significant reduction in reflux symptoms, esophageal acid exposure (reflux index), acid clearance time, and an increase in esophageal mucosal impedance.

CONCLUSIONS

In infants with persistent crying, upper gastrointestinal motility parameters did not reliably differentiate between non-IgE-mediated CMPA and functional GERD. In the group with non-IgE-mediated CMPA, elimination of CMP significantly improved GERD symptoms, esophageal peristaltic function, and mucosal integrity.

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

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

Insights into the emerging epidemic of eosinophilic oesophagitis

Eosinophilic oesophagitis (EOE) is a relatively recently recognised condition characterised by an increase in oesophageal eosinophils. EOE occurs in children and adults with a strong male preponderance. There has been a sharp increase in EOE in North America, Europe and Australia. The reasons for this increase remain unclear but are likely to be influenced by genetic and environmental factors, as well as early-life exposures. Based on recent population-based data, the estimated EOE prevalence in the USA is 56.7 per 100,000 persons. The peak prevalence was observed in patients between 35 and 39 years of age. Prevalence figures in Asia and the Middle East generally appear to be lower than in Western countries, but population-based studies are not available. A causal association between coeliac disease and EOE appears unlikely. Data on the seasonal variation of EOE remain inconclusive. Further population-based studies are needed to define the epidemiology of EOE.

Clinical spectrum of food allergies: a comprehensive review

Food allergy is defined as an adverse immune response towards food proteins or as a form of a food intolerance associated with a hypersensitive immune response. It should also be reproducible by a double-blind placebo-controlled food challenge. Many reported that food reactions are not allergic but are intolerances. Food allergy often presents to clinicians as a symptom complex. This review focuses on the clinical spectrum and manifestations of various forms of food allergies. According to clinical presentations and allergy testing, there are three types of food allergy: IgE mediated, mixed (IgE/Non-IgE), and non-IgE mediated (cellular, delayed type hypersensitivity). Recent advances in food allergy in early childhood have highlighted increasing recognition of a spectrum of delayed-onset non-IgE-mediated manifestation of food allergy. Common presentations of food allergy in infancy including atopic eczema, infantile colic, and gastroesophageal reflux. These clinical observations are frequently associated with food hypersensitivity and respond to dietary elimination. Non-IgE-mediated food allergy includes a wide range of diseases, from atopic dermatitis to food protein-induced enterocolitis and from eosinophilic esophagitis to celiac disease. The most common food allergies in children include milk, egg, soy, wheat, peanut, treenut, fish, and shellfish. Milk and egg allergies are usually outgrown, but peanut and treenut allergy tends to persist. The prevalence of food allergy in infancy is increasing and may affect up to 15-20 % of infants. The alarming rate of increase calls for a public health approach in the prevention and treatment of food allergy in children.

Esophagitis in children: an update on current pharmacotherapy

INTRODUCTION

A common diagnostic entity in children is Esophagitis with multiple etiologies and complex immuno-pathogenic mechanisms. Our understanding of these mechanisms and of the pharmacotherapy of esophagitis is still evolving.

AREAS COVERED

Areas of focus for this review were chosen based on recent clinical practice and research interest in esophagitis in infants and children. A literature search was conducted with the relevant keywords ('gastroesophageal reflux disease' in pediatric age group, 'eosinophilia', 'esophageal eosinophilia', 'esophagitis', 'eosinophilic esophagitis', 'proton pump inhibitors'). Use, safety and efficacy of proton pump inhibitors in young infants and older children, the concepts of esophageal eosinophilia and overlap of reflux and eosinophilic esophagitis are discussed here.

EXPERT OPINION

Proton pump inhibitors are effective in healing reflux esophagitis in children of all ages but do not improve gastroesophageal reflux related symptoms in infants. An overlap in clinical and histological features of reflux and eosinophilic esophagitis exists, and proton pump inhibitors may exert their action in pathways other than just acid suppression. The role of weakly acidic/alkaline reflux in gastroesophageal reflux symptoms, development of newer reflux modifying medications and tools to assess efficacy of therapeutic intervention in eosinophilic esophagitis are promising areas for further research and developing knowledge.

Infants under 3 months old with cyanosis at the emergency room: could it be gastroesophageal reflux?

The aim of this study is to describe the prevalence of gastroesophageal reflux disease (GERD) in infants under 3 months old with a history of cyanotic episodes, who were examined at the emergency room of a university hospital. This descriptive study reviews reports of esophageal pH monitoring from a pediatric gastroenterology service over a period of 5 years. The following data were collected: age, sex, pediatric as well as other specialists' evaluations, and the esophageal pH monitoring reports. This study included 67 infants with a history of cyanotic episodes, with no primary cause determined by pediatrician and pediatric specialists' evaluations, who underwent esophageal pH monitoring. The infants were 6-90 days old, 41 (61.2%) of them male. Fifty infants (74.6%) had at least one esophageal pH monitoring parameter above the normal limit. ZMD index was abnormal in 32 cases (48%) and reflux index was abnormal in 31 cases (46%). When other common causes of cyanosis have been ruled out, a significant proportion of infants presenting cyanosis have abnormal pH study, suggesting the role of GERD in cyanosis. The authors highlight that reflux index is not enough to conclude whether a pH study is normal or not. The ZMD index and the presence of episodes longer than 20 minutes are also important parameters for GERD diagnosis.

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

Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. It is a frequently experienced physiologic condition occurring several times a day, mostly postprandial and causes no symptoms. These infants are also called 'happy spitters'. GER disease (GERD) occurs when reflux of the gastric contents causes symptoms that affect the quality of life or pathologic complications, such as failure to thrive, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, apnea, and apparent life-threatening events. About 70-85 % of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95 % of infants by 1 year of age. The predominant mechanism causing GERD is transient lower esophageal sphincter (LES) relaxation, which is defined as an abrupt decrease in LES pressure to the level of intragastric pressure, unrelated to swallowing and of relatively longer duration than the relaxation triggered by a swallow. Regurgitation and vomiting are the most common symptoms of infant reflux. A thorough history and physical examination with attention to warning signals suggesting other causes is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER. Choking, gagging, coughing with feedings or significant irritability can be warning signs for GERD or other diagnoses. If there is forceful vomiting, laboratory and radiographic investigation (upper gastrointestinal series) are warranted to exclude other causes of vomiting. Irritability coupled with back arching in infants is thought to be a non-verbal equivalent of heartburn in older children. Other causes of irritability, including cow's milk protein allergy, neurologic disorders, constipation and infection, should be ruled out. The presentation of cow's milk protein allergy overlaps with GERD, and both conditions may co-exist in 42-58 % of infants. In these infants, symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein from the diet. For non-complicated reflux, no intervention is required for most infants. Effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux. Sandifer syndrome, apnea and apparent life-threatening events are the extraesophageal manifestations of GERD in infants. Pharmacotherapeutic agents used to treat GERD encompass antisecretory agents, antacids, surface barrier agents and prokinetics. Currently, North American Society for Pediatric Gasroenterology, Hepatology and Nutrition (NASPGHAN) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) practice guidelines concluded that there is insufficient evidence to justify the routine use of prokinetic agents. Esomeprazole (Nexium) is now approved in the US for short-term treatment of GERD with erosive esophagitis in infants aged from 1 to 12 months. Although Nissen fundoplication is now well established as a treatment option in selected cases of GERD in children, its role in neonates and young infants is unclear and is only reserved for selective infants who did not respond to medical therapy and have life-threatening complications of GERD.

Outcomes of endoscopy and novel pH-impedance parameters in children: is there a correlation?

OBJECTIVES

Discordance exists between outcomes of endoscopy, multichannel intraluminal impedance monitoring (pH-MII), MII baselines, and gastroesophageal reflux symptoms. The aim of the present study was to determine the association between endoscopy, pH-MII and MII baselines, in children with gastroesophageal reflux symptoms.

METHODS

Endoscopies were graded for reflux esophagitis (RE). Biopsies of the distal esophagus were assessed for signs suggestive of esophagitis. Reflux index (RI), symptom association probability (SAP), number of reflux episodes, and mean baseline values were calculated. pH-MII was considered positive in children when RI was ≥ 3% and/or SAP was ≥ 95% and for infants when RI was ≥ 10% and/or SAP was ≥ 95%. Baselines were manually calculated and compared with an automated analysis. For MII baselines, patients were divided in 3 groups: normal endoscopy and negative overall pH-MII; normal endoscopy and an overall positive pH-MII; and RE.

RESULTS

A total of 26 children and 14 infants were included, median age: 26.5 months (2 months-16.2 years). Thirteen (32.5%) had RE. A significant negative association was found for RI and MII baselines (P = 0.009) and between SAP and RE (P = 0.039, odds ratio 1.018). MII baseline values were predictive for neither conventional pH-MII parameters nor RE. Manual analysis and automated calculation of MII baselines showed a perfect correlation. Distal MII baselines were significantly lower in children with a positive overall pH-MII outcome compared with the proximal esophagus (P = 0.049). No significant changes were found in baselines among the different groups 1 to 3.

CONCLUSIONS

Acid-related parameters are significantly related to MII baselines. A perfect correlation between manual- and automated analysis of MII baselines was found. Large prospective studies are needed to confirm the exact role of endoscopy and MII baselines.

Determination of thalidomide concentration in human plasma by liquid chromatography-tandem mass spectrometry

A rapid, sensitive and specific analytical method based on high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS) has been developed for the determination of thalidomide concentration in human plasma. The analyte and internal standard were extracted by liquid-liquid extraction with ether-dichloromethane (3:2, v/v) and separated on a TC-C₁₈ column using methanol-10 mM ammonium acetate-formic acid (60:40:0.04, v/v/v) as the mobile phase at a flow rate of 0.9 ml/min. The detection was performed using an API 4000 triple quadrupole mass spectrometer in the positive electrospray ionization (ESI) mode and completed within 3.0 min. The multiple reaction monitoring (MRM) transitions were m/z 259.1→84.0 for the analyte and m/z 195.9→138.9 for temozolomide. The calibration curve exhibited a linear dynamic range of 2–1500 ng/ml (r>0.9991). The intra-and inter-day precisions (as relative standard deviation; RSD) were 6.8–13.5% and 4.3–5.0% respectively and the accuracy (as relative error; RE) was 2.0–3.5%. The recoveries and matrix effects were satisfactory in all the biological matrices examined. This method was successfully used in a pharmacokinetic study of thalidomide in healthy male volunteers receiving an oral administration of a 200-mg dose.

Cow's Milk Allergy among Children with Gastroesophageal Reflux Disease

Background/Aims

Gastroesophageal reflux disease (GERD) and cow's milk allergy (CMA) are two common conditions that occur in infancy. This study was performed to investigate the frequency of CMA in a group of patients with GERD.

Methods

Eighty-one children with signs and symptoms of GERD were enrolled in this study. All subjects received omeprazole for 4 weeks after the initial evaluation. Empirical elimination of cow's milk from the diet was started for the patients who did not respond to the omeprazole treatment.

Results

Seventy-two cases presented with gastrointestinal signs and symptoms, whereas the remaining nine cases presented with respiratory complaints. After the initial treatment with omeprazole, two thirds of the cases (54 patients, 66.7%) responded well, and all of their symptoms were resolved. Cow's milk was eliminated from the diets of the remaining 27 patients. All signs and symptoms of GERD were resolved in this group after a 4 week elimination of cow's milk from the diet.

Conclusions

A diagnosis of CMA was considered in one third of the pediatric cases with signs and symptoms of GERD. This finding shows that CMA can mimic or aggravate all signs and symptoms of severe GERD during infancy.

Eosinophilic esophagitis: trials and tribulations

Eosinophilic esophagitis (EE) is a recently recognized form of pan-esophagitis, which is characterized by the presence of at least 15 eosinophils per high power field on esophageal histology. EE is closely associated with atopic disorders and occurs predominantly in male patients. Young children are more likely to be sensitized to food allergens whilst aeroallergen sensitization predominates in older children and adults--a pattern reminiscent of the "atopic march". EE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or refusal in infancy, in addition to dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained incidentally in patients undergoing gastroscopy for other suspected gastrointestinal conditions, such as gastroesophageal reflux disease or celiac disease. Complications mainly relate to subepithelial remodeling and fibrosis which may result in dysmotility, dysphagia and esophageal strictures. The proportion of EE patients at risk of these complications is unknown due to a paucity of data on the natural history of EE. There are only few randomized controlled trials assessing the efficacy of treatment modalities for EE, which currently either involve food allergen elimination or use of swallowed aerosolized corticosteroids. This article aims to discuss the complex issues of the diagnosis and long-term management that confront clinicians who care for children with EE.

Emerging management concepts for eosinophilic esophagitis in children

Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.

Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review

INTRODUCTION

Use of proton-pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD) in children has increased enormously. However, effectiveness and safety of PPIs for pediatric GERD are under debate.

OBJECTIVES

We performed a systematic review to determine effectiveness and safety of PPIs in children with GERD.

METHODS

We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for randomized controlled trials and crossover studies investigating efficacy and safety of PPIs in children aged 0 to 18 years with GERD for reduction in GERD symptoms, gastric pH, histologic aberrations, and reported adverse events.

RESULTS

Twelve studies were included with data from children aged 0-17 years. For infants, PPIs were more effective in 1 study (compared with hydrolyzed formula), not effective in 2 studies, and equally effective in 2 studies (compared with placebo) for the reduction of GERD symptoms. For children and adolescents, PPIs were equally effective (compared with alginates, ranitidine, or a different PPI dosage). For gastric acidity, in infants and children PPIs were more effective (compared with placebo, alginates, or ranitidine) in 4 studies. For reducing histologic aberrations, PPIs showed no difference (compared with ranitidine or alginates) in 3 studies. Six studies reported no differences in treatment-related adverse events (compared with placebo or a different PPI dosage).

CONCLUSIONS

PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking.

Effect of different pH criteria on dual-sensor pH monitoring in the evaluation of supraesophageal gastric reflux in children

BACKGROUND AND AIM

Existing tests for supraesophageal gastric reflux (SEGR) that focus on pH drops <4 in the proximal esophagus have had limited sensitivity and specificity. The aim of the present study was to evaluate the effect of newly proposed pH criteria on SEGR detection.

PATIENTS AND METHODS

Twenty-four-hour dual-sensor pH tracings of 32 patients were reviewed. Proximal esophageal pH data were evaluated according to the conventional definition of pH drop <4 and 2 proposed definitions: pH drop <5.5 while upright and <5.0 while supine and pH drop of >10% from a running baseline. For each potential SEGR event, the preceding 1-minute window was examined for corresponding distal acid reflux.

RESULTS

Of the 542 distal acid reflux events detected, 200 were associated with a proximal pH drop <4; this number increased to 295 using the definition of proximal pH drop <5.5 (upright)/<5.0 (supine) and 301 using the definition of proximal pH drop >10%. A proportion of proximal events, however, was not associated with distal acid reflux: 21 of 200 (10.5%) proximal pH <4 events, 119 of 414 (29%) proximal pH <5.5 (upright)/<5.0 (supine) events, and 272 of 573 (47%) proximal pH drop >10% events lacked a preceding or simultaneous drop in distal pH <4.

CONCLUSIONS

Although the use of more liberal pH criteria increased the diagnostic yield for SEGR events with dual-sensor monitoring, a significant proportion of proximal pH events did not correlate with distal acid reflux. These events could represent either false-positive measurements or association with weakly acid reflux.

Management of gastroesophageal reflux disease and erosive esophagitis in pediatric patients: focus on delayed-release esomeprazole

OBJECTIVE

To review the literature on the treatment of gastroesophageal reflux disease (GERD) with emphasis on proton pump inhibitors (PPIs), particularly on delayed-release esomeprazole, and to identify properties and adverse effects of PPIs observed in the treatment of GERD in children and adolescents.

SOURCES

Electronic search of PubMed/Medline and Cochrane Collaboration databases, and of abstracts on DDW, NASPGHAN, and ESPGHAN. We focused on controlled and randomized studies published since 2000 and identified reviews that presented a consensual position, and directives published within the last 10 years.

MAIN RESULTS

PPIs are considered better antisecretory agents than H(2)-receptor antagonists. Although all PPIs are similar, they are not identical in their pharmacologic properties. For example, the acid-suppressive effect of esomeprazole, the S-isomer of omeprazole, persists for more than 16 hours after administration of the morning dose. Therefore, it can control acidity after night meals better than a single dose of omeprazole. Moreover, the onset of the suppressive effect of esomeprazole is faster. It achieves acid inhibition faster than other PPIs.

CONCLUSION

Currently, the mainstream treatment for GERD in children is a PPI. Although PPIs are safe drugs, effective in healing erosive esophagitis, and in relieving symptoms, studies with esomeprazole have shown that this drug has as powerful an ability to inhibit acid secretion as omeprazole. It also seems that some pharmacologic properties of esomeprazole are actually better for the treatment of GERD.

Gastroesophageal reflux disease and eosinophilic esophagitis in infants and children. A study of esophageal pH, multiple intraluminal impedance and endoscopic ultrasound

OBJECTIVE

Eosinophilic esophagitis (EE) and gastroesophageal reflux disease (GERD) in childhood share aspects of symptomatology. In order to characterize EE and GERD in infants and children with symptoms of GERD we performed a prospective investigation including prolonged esophageal pH measurement, multiple intraluminal impedance (MII) and esophageal wall estimation by endoscopic ultrasound (EUS).

MATERIAL AND METHODS

Infants and children (0-15 years) with typical symptoms of GERD persisting after a 14-days proton pump inhibitor trial were included in a prospective study protocol. Upper endoscopy and EUS of the esophageal wall were performed followed by combined esophageal MII and pH measurement for 24 h.

RESULTS

A total of 78 infants and children were investigated: EE patients (n = 6), GERD patients (n = 28) and a group of infants and children with normal investigations (n = 44). The GERD group did not show a significantly higher number of non-acid reflux episodes (p = 0.9) than the patients with normal investigations. In all patients gastroesophageal reflux regularly extended into the proximal esophagus. EUS in four EE patients suggested an increased thickness of the mucosal layers both in the distal and in the proximal part of the esophagus.

CONCLUSIONS

Esophageal MII indicated that neutral non-acid reflux episodes do not occur frequently in pediatric GERD or in EE. MII and pH-metry indicated that the majority of reflux episodes both in patients and controls pass into the proximal esophagus. EUS measurements suggested in EE patients a thickened mucosa both in the proximal and the distal part of the esophagus as compared to children with GERD and disease controls.

Efficacy and safety of pantoprazole delayed-release granules for oral suspension in a placebo-controlled treatment-withdrawal study in infants 1-11 months old with symptomatic GERD

OBJECTIVE

The objective of this study was to assess the efficacy of pantoprazole in infants with gastroesophageal reflux disease (GERD).

MATERIALS AND METHODS

Infants ages 1 through 11 months with GERD symptoms after 2 weeks of conservative treatment received open-label (OL) pantoprazole 1.2 mg x kg(-1) x day(-1) for 4 weeks followed by a 4-week randomized, double-blind (DB), placebo-controlled, withdrawal phase. The primary endpoint was withdrawal due to lack of efficacy in the DB phase. Mean weekly GERD symptom scores (WGSSs) were calculated from daily assessments of 5 GERD symptoms. Safety was assessed.

RESULTS

One hundred twenty-eight patients entered OL treatment, and 106 made up the DB modified intent-to-treat population. Mean age was 5.1 months (82% full-term, 64% male). One third of patients had a GERD diagnostic test before OL study entry. WGSSs at week 4 were similar between groups. WGSSs decreased significantly from baseline during OL therapy (P < 0.001), when all patients received pantoprazole. The decrease in WGSSs was maintained during the DB phase in both treatment groups. There was no difference in withdrawal rates due to lack of efficacy (pantoprazole 6/52; placebo 6/54) or time to withdrawal during the DB phase. The greatest between-group difference in WGSS was slightly worse with placebo at week 5 (P = 0.09), mainly due to episodes of arching back (P = 0.028). No between-group differences in adverse event frequency were noted. Serious adverse events in 8 patients were considered unrelated to treatment.

CONCLUSIONS

Pantoprazole significantly improved GERD symptom scores and was well tolerated. However, during the DB treatment phase, there were no significant differences noted between pantoprazole and placebo in withdrawal rates due to lack of efficacy.

Clinical features and prevalence of gastroesophageal reflux disease in infants attending a pediatric gastroenterology reference service

CONTEXT: In infants, it is not always easy to distinguish between pathological and physiological gastroesophageal reflux based only on clinical criteria. In Brazil, studies about gastroesophageal reflux disease in infants are few and are even rare those that used prolonged esophageal pH monitoring for its evaluation. OBJECTIVE: To describe the clinical features of gastroesophageal reflux disease and to determine its prevalence in infants with gastroesophageal reflux attending a tertiary Pediatric Gastroenterology Service and submitted to esophageal pH monitoring for investigation. METHODS: Descriptive study in 307 infants in whom esophageal pH monitoring (Mark III Digitrapper, Synectics Medical AB, Sweden) was performed during the period December, 1998-December, 2008. The clinical features studied were age group (1-12 months and 13-24 months), and clinical manifestations that motivated the indication of pH monitoring. RESULTS: One hundred twenty-four (40.4%) were female and 183 (59.6%) male with mean age 12.2 ± 6.2 months (1-23 months). The prevalence of gastroesophageal reflux disease was 18.2% (56/307). One hundred forty-eight (48.2%) were 1-12 months old and 159 (51.8%), 13-24 months. No significant difference was found between the prevalence of these two age groups (P = 0.3006). Gastroesophageal reflux disease was more frequent in those with digestive manifestations (24.2%), crisis of cyanosis/apnea (23.8%) and mixed manifestations (21.5%). Respiratory manifestations were the most frequent indication (39.1%) of pH monitoring. However, the prevalence of gastroesophageal reflux disease was lower (12.5%) in this group compared with in those with digestive manifestations (P = 0.0574), crisis of cyanosis/apnea (P = 0.0882) and mixed manifestations (P = 0.1377). All infants that presented clinical manifestations as crisis of cyanosis/apnea and abnormal pH-metry were < 3 months of age. CONCLUSIONS: In our Service, the prevalence of gastroesophageal reflux disease associated with acid reflux in infants revealed elevated. Infants with crisis of cyanosis/apnea constitute risk population for gastroesophageal reflux disease in which diagnostic investigation needs to be considered.

Esophageal impedance and esophagitis in children: any correlation?

AIM

: The aim of this study was to correlate the data obtained with multiple intraluminal esophageal impedance and pH (MII-pH) recordings in infants and children referred for suspected gastroesophageal reflux disease with esophageal histology.

MATERIALS AND METHODS

: In a prospective study, results of esophageal biopsies and MII-pH recording obtained in 45 children (mean age +/- SD: 69 +/- 55 months) were analyzed. Regarding the MII-pH data, an automatic (Autoscan Bioview Analysis Software, version 5.3.4, Sandhill Scientific Inc, Highlands Ranch, CO) and a manual reading were performed; an automatic pH analysis (meal included) was also performed.

RESULTS

: Acidic, weakly acidic, and alkaline reflux episodes accounted, respectively, for 48.7%, 49.5%, and 1.8% of the total number of reflux episodes detected by MII-pH. Esophagitis was present in 25 (56%) children. Concordance between classic pH-study analysis (alone) and esophageal histology was found in 19 of 45 (42%) children. According to the MII-pH analysis, the mean and median value of the pH were significantly higher in the group with esophagitis than in the group with normal esophageal histology. A longer clearance time was found in the group with esophagitis than in subjects with normal histology. Gas reflux episodes represented 21% of the total reflux episodes and were comparable in both groups.

CONCLUSIONS

: Multiple intraluminal esophageal impedance and pH analysis does not provide a distinct parameter to predict esophageal mucosal injury in children. In our population, MII-pH shows comparable acidic, weakly acidic, alkaline, and gas reflux in children with and without esophagitis. Further research is needed to analyze clearance parameters.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population

OBJECTIVES

To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.

METHODS

Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.

RESULTS

There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.

CONCLUSIONS

The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.

Controversies in the treatment of gastroesophageal reflux disease in preterm infants

Gastroesophageal reflux (GER) is common in preterm infants and usually is a physiologic phenomenon with little clinical consequence. GER resulting in clinical signs and symptoms is considered pathologic gastroesophageal reflux disease (GERD). Correlation of clinical signs and symptoms with GER has been poor in most studies. The efficacy of GERD therapy has not been studied systematically in preterm infants. Furthermore, GERD therapy, particularly with prokinetic agents and surgery, carries potential risks that must be considered before initiation of therapy. Alternative diagnoses, pretreatment diagnostic testing, and desired treatment outcomes should be considered before initiating GERD therapy. Cessation of empiric GERD therapy should be considered, particularly if treatment does not result in the desired clinical outcome.

Role of the multichannel intraluminal impedance technique in infants and children

Recently, multichannel intraluminal impedance (MII) was added to the repertoire of tests available to study esophageal (patho)physiology in children. MII has since been used in 2 major areas. First, it has been used as a diagnostic test for gastroesophageal reflux disease (GERD). The main advantage over traditional pH monitoring is its ability to detect both acid and nonacid gastroesophageal reflux (GER) and to discern between liquid and gas GER.Although feasible with multiple pH sensors, the MII technique routinely detects the proximal extent of a GER episode. When a pH sensor is added to the MII-catheter, important information about the acidity of a GER event can be gathered.The second area in which the role of MII has been investigated is that of esophageal function testing. Manometry classically reveals information about esophageal pressure patterns and sphincter function, but does not inform us about bolus flow. MII not only detects the presence of esophageal flow but also adds information on the direction of flow, duration of bolus presence, completeness of bolus clearance, and composition of a bolus.The combination of MII with manometry enables determination of the relationship between esophageal pressures and flow and, therefore, enhances evaluation of esophageal function in terms of assessment of mechanisms of esophageal volume clearance. In addition, this technique will improve our understanding of (patho)physiological mechanisms in pediatric GERD and other esophageal motility disorders.

Endoscopic and histopathologic findings associated with H. pylori infection in very young children

Most of the individuals infected with H. pylori acquire the infection early in life. However, there is limited data regarding endoscopic and histopathologic findings of H. pylori infection when it is acquired during infancy. The aim of this study was to investigate the H. pylori-related endoscopic and histopathological findings in children younger than 2 years of age. One hundred and fifty-two infants who underwent upper gastrointestinal endoscopy were included in the study. The diagnosis of H. pylori infection was based on histopathology and a positive rapid urease test. Forty of 152 (26.3%) infants were infected with H. pylori, and 65% of the infected infants had histopathologic gastritis. There were no clinical or endoscopic findings suggestive of H. pylori infection. No correlation could be found between the density of H. pylori and the severity of gastritis. H. pylori infection is associated with various degrees of gastritis in more than half of the infected infants. Since the likelihood of normal histopathology is rare in H. pylori-infected infants, its long-term complications should be cautiously followed up in endemic areas.

Allergic gastrointestinal motility disorders in infancy and early childhood

Gastro-oesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. Gastrointestinal food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. The diagnosis of food protein-induced gastrointestinal motility disorders is hampered by the absence of specific clinical features or useful laboratory markers. Gastrointestinal biopsies before commencing a hypoallergenic diet may provide the most important diagnostic clues. Early recognition is essential for the optimal management of these patients to prevent nutritional sequelae or aversive feeding behaviours. Treatment relies on hypoallergenic formulae, as well as maternal elimination diets in breast-fed infants. Further research is required to better define the pathological mechanisms and diagnostic markers of paediatric allergic gastrointestinal motility disorders. The following article will present three instructive cases followed by discussion of the clinical presentation, diagnosis, treatment and natural history of food allergic motility disorders in infancy and early childhood.

Oesophagitis in children: reflux or allergy?

The prevalence of eosinophilic oesophagitis appears to be increasing in many countries, sometimes rapidly, although this may be partly due to increased disease recognition. Histological methods of assessment and diagnostic criteria vary considerably between major clinical centres. Oesophagitis with over 20 intraepithelial eosinophils per high power field is more likely to be due to allergy than gastro-oesophageal reflux induced acid-peptic mucosal injury. Typical eosinophilic oesophagitis shows involvement of the entire oesophagus, with basal cell proliferation occupying more than 50% of the thickness of the surface epithelium, and high numbers of intraepithelial eosinophils, sometimes concentrated on the surface or as contiguous clusters. Ulceration and prominent neutrophils are atypical and should suggest an alternative or co-existent disease. On endoscopy, the oesophagus may display the typical 'corrugated' mucosal appearance. Clinically, dysphagia or food impaction are the most characteristic symptoms. There is a strong association with other atopic diseases, especially asthma and eczema. To date no evidence has emerged of an increased malignancy risk. Patients with eosinophilic oesophagitis typically fail to respond to acid suppressive medications but respond well to either elemental/elimination diets or aerosolised swallowed corticosteroids. Long-term uncontrolled oesophageal eosinophilic inflammation may lead to progressive subepithelial fibrosis, potentially resulting in strictures or oesophageal narrowing.

Appropriateness of upper gastrointestinal endoscopy in children: a retrospective study

BACKGROUND

Upper gastrointestinal endoscopy (UGIE) is appropriate in many situations in adults and children. Recommendations for UGIE use in children were published recently by the French-language Paediatric Hepatology, Gastroenterology, and Nutrition Group (GFHGNP).

PATIENTS AND METHODS

We retrospectively reviewed the 293 UGIE procedures undertaken in 251 children between January 1, 2001 and June 30, 2003 by 2 senior endoscopists. The UGIE procedures were categorized as appropriate or inappropriate based on GFHGNP recommendations, and diagnostic efficiency was compared in the 2 groups with the chi2 test followed by multivariate logistic regression analysis.

RESULTS

Of the 293 UGIE procedures, 52 (17.7%) were considered inappropriate. Diagnostic efficiency was 51% in the appropriate group versus 17.3% in the inappropriate group (odds ratio, 4.2; 95% CI, 2-8.7; P < 10(-3)). The proportion of appropriate UGIE procedures was higher among inpatients than outpatients (odds ratio, 2.51; 95% CI, 1.24-5.08; P = 0.01). Inappropriate reasons for performing UGIE included isolated failure to thrive and follow-up after neonatal esophagogastroduodenitis. Nine inappropriate UGIE procedures contributed useful information: ulcerative esophagitis in 1 patient, hemorrhagic esophagitis in 4 patients, duodenitis in 1 patient, and malabsorption in 3 patients caused in 1 case by cow's milk allergy and in 2 cases to fully documented celiac disease.

CONCLUSIONS

UGIE was usually performed appropriately in our pediatric hospital. Inappropriate UGIE procedures were more common in outpatients than in admitted patients. Awareness of the recommendations for appropriate UGIE use needs to be improved among office-based and hospital-based physicians.

Gastroesophageal reflux disease, colic and constipation in infants with food allergy

PURPOSE OF REVIEW

This review assesses the role of food allergy in the pathophysiology of gastroesophageal reflux disease, colic and constipation in infancy.

RECENT FINDINGS

Frequent regurgitation, persistent crying and constipation are common clinical problems in infancy. A subgroup of infants with these conditions may respond to hypoallergenic diets, but only few randomized clinical trials have been conducted. Skin prick testing and food-specific antibody levels are usually not elevated in these infants, whereas atopy patch testing may diagnostic. The mechanisms by which cow's milk and other food allergens induce gastrointestinal motility disorders are not understood. Apart from cell-mediated reactions, non-immunological effects of food constituents on gastrointestinal motility and gut microbiota may be involved in the pathogenesis. In the absence of reliable diagnostic tests, dietary elimination and re-challenge are usually required to confirm food allergy. A trial of amino acid-based formula or an oligoantigenic maternal elimination diet may be indicated in infants who have failed conventional medical treatment.

SUMMARY

Food allergy may contribute to gastroesophageal reflux disease, colic or constipation in infancy. Infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet. Further research is needed to define the mechanisms and clinical markers of gastrointestinal food allergy in infancy.

Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress

BACKGROUND

Gastro-oesophageal reflux (GOR) is common in infants with persistent crying. Empirical treatment with antireflux medications is common practice, although on clinical grounds it may be difficult to determine whether GOR is abnormal.

AIMS

To examine the diagnostic accuracy of clinical predictors of pathological GOR in infants with persistent crying.

METHODS

One hundred and fifty-one infants (82 male; median age 2.5 months, range 0.5-8.2 months) with persistent crying were prospectively studied. Crying and fussing were charted for 24 h, and parents completed a validated questionnaire on reflux symptoms. All infants underwent oesophageal 24-h pH monitoring.

RESULTS

Twenty-seven (17.9%) infants had pathological GOR with a fractional reflux time (FRT) >10%. There was no significant association between total crying duration per 24 and FRT (P = 0.84) or the number of reflux episodes (P = 0.68). Pathological GOR was more common in infants under 3 months, compared to older infants (P = 0.04). Feeding difficulties were significantly associated with pathological GOR (P = 0.02). Backarching was not increased in infants with GOR (P = 0.30). Pathological GOR was significantly associated with the frequency of regurgitation (P = 0.04), but not with vomitus volume (P = 0.62). Regurgitation more than 5 times daily was the most specific reflux symptom (specificity 70.9%), but was a poor predictor of pathological GOR (positive predictive value 22.2%). In the absence of frequent regurgitation or feeding difficulties, pathological GOR was unlikely (negative predictive value 87-90%).

CONCLUSIONS

Investigation and treatment of GOR in infants with persistent crying should be primarily directed at infants presenting with frequent regurgitation or feeding difficulties.

Oral ranitidine and duration of gastric pH >4.0 in infants with persisting reflux symptoms

BACKGROUND

Ranitidine is a drug commonly used in pathological gastro-oesophageal reflux (GOR) in infants. Non-responsiveness has been reported. Data regarding the effect of ranitidine on oesophageal acid exposure and reduction of gastric acid secretion are limited in this age group.

OBJECTIVE

To evaluate oesophageal acid exposure, reduction of gastric acid secretion and histology of oesophageal biopsies in infants who clinically do not respond to oral ranitidine.

PATIENTS AND DESIGN

103 infants (mean age 3.3 +/- 1.8 mo) with persisting symptoms of reflux despite administration of ranitidine, prescribed previously by a referring physician, at a mean (SD) dose of 9.4 (+/- 3.3) mg/kg/d for at least 2 wk (mean 30 d), were submitted to a 24-h pH study and oesophageal biopsy (90/103 patients).

RESULTS

Histological oesophagitis was present in 21/90 (23%). The oesophageal reflux index (RI) was >5% and >10% in 21/103 (20%) and 6/103 (6%) infants, respectively. Gastric pH was >4.0 during <50%, >50%, >75% and >90% of the duration of pH monitoring in 33/103 (32%), 70/103 (68%), 22/103 (21%) and 7/103 (7%), respectively. By simple regression analysis, the dosage of ranitidine correlated with the oesophageal RI (r = 0.21; p = 0.05), but not with the duration of time gastric pH was >4.0 (r = 0.09; p = 0.39). Histological oesophagitis did not correlate with ranitidine dosage, duration of treatment, duration gastric pH was >4.0 and oesophageal reflux index.

CONCLUSION

Some infants presenting with symptoms assumed to be GOR and acid related fail to respond to acid suppression with ranitidine, either because they need better acid suppression or because the symptoms are not acid related.

Effect of antireflux medication, placebo and infant mental health intervention on persistent crying: a randomized clinical trial

OBJECTIVE

To assess the effect of medical antireflux treatment, and of an infant mental health consultation (IMHC), on persistent crying in infants and maternal distress.

METHODS

Infants under 9 months of age with persistent crying, and their mothers, were enrolled in a randomized placebo-controlled trial. At enrollment, a questionnaire on demographic and clinical details was completed by mothers, and maternal distress was measured (Experience of Motherhood Questionnaire; EMQ). Oesophageal 24-h pH monitoring was performed in all infants on day 2. At week 4, the cry chart and EMQ were repeated in conjunction with a final interview.

RESULTS

One hundred and three infants (56 under 3 months of age; 55 male) who were randomized to active medication (ranitidine plus cisapride; n = 34), placebo (n = 29) or IMHC (n = 40) completed the trial. There was a significant reduction in crying duration from baseline to week 4 (253 +/- 96.5 min vs 159 +/- 92.3 min per 24 h; P < 0.001), without differences between treatment groups (AVOVA: F = 0.75; P = 0.48). There was a modest improvement in EMQ scores from 44.9 +/- 8.6 at day 1 to 42.8 +/- 9.4 at week 4; P = 0.006. The improvement in maternal stress was similar in all treatment groups (Kruskal-Wallis chi2 = 0.354; P = 0.84), but subsequent admission to a mother-infant unit was significantly less frequent in the IMHC group (P < 0.05).

CONCLUSION

Antireflux medications and IMHC were not superior to placebo in treating infants with persistent crying. Although the reduction in maternal distress was similar in all treatment groups, the individualized IMHC reduced the need for subsequent admission to a mother-infant unit.

The diagnosis and management of gastro-oesophageal reflux in infants

Gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD) occur frequently during the first months of life. Gastro-oesophageal reflux may be a primary gastro-intestinal motility disorder, but it may also be secondary to other conditions such as cow's milk protein allergy. Objective diagnosis can be difficult because there may be absence of correlation between history, results of pH monitoring and histology. Severe GORD may cause minor symptoms, and minor GOR may cause severe symptoms. Several different therapeutic interventions exist. Simply stated, thickened formula reduces regurgitation and alginates and proton pump inhibitors can be used to decrease acid GOR, depending on the severity of the GORD. Efficacy data of prokinetic drugs are either lacking or disappointing. Regarding side-effects, interest has been focused on cisapride, although other molecules have similar effects. Long-term side-effects such as the nutritional consequence of therapeutic management have been insufficiently studied, especially for the acid-reducing molecules.

Gastroesophageal reflux disease in infants: how much is predictable with questionnaires, pH-metry, endoscopy and histology?

Symptoms of gastroesophageal reflux disease (GERD) are common in infants. It is often difficult to discriminate between physiological and pathologic gastroesophageal reflux, although this discrimination is essential to determine which infants to evaluate and treat.

OBJECTIVES

To identify the prevalence of reflux symptoms in infants and to evaluate the predictive value of a questionnaire and the correlation between pH study, histology and clinical score.

METHODS

Parents of 100 unselected infants visiting the well-baby clinic and 100 infants suspected of having gastroesophageal reflux disease were asked to fill in a 35-item questionnaire. A validated score, the Orenstein I-GERQ, was applied for selected questions. All infants suspected of having gastroesophageal reflux disease underwent prolonged esophageal pH monitoring and 44 or 100 underwent upper gastrointestinal tract endoscopy with esophageal biopsy.

RESULTS

Parents of infants with suspected gastroesophageal reflux disease reported significantly more regurgitation (68% versus 45%, P < 0.05) and crying (51% versus 20%, P < 0.01) compared with the parents of healthy infants. A pathologic pH study (reflux index > 10%) was found in 21 of 100 (21%) infants and was significantly associated only with pneumonia, apnea with fussing (P = 0.013 for both), defecation less than once a day (P = 0.033) and constipation (P = 0.05). Esophagitis was present in 17 of 44 (39%) and no one question was found to be significantly predictive. 38% of infants with a pathologic pH study had a normal esophageal biopsy and 53% of infants with histologic esophagitis had a normal pH study. Discordance between pH study and biopsies occurred in 14 of 44 (32%) patients. The Orenstein I-GERQ cut-off score failed to identify eight of 31 (26%) infants with gastroesophageal reflux disease. Conversely, the score was positive in 17 of 22 (81%) infants with normal biopsy and pH study and in 14 of 47 (30%) infants with normal pH study.

CONCLUSIONS

Clinical symptoms, histology and pH study show poor correlation in infants. Clinical symptoms such as regurgitation and crying are less frequent in unselected infants than in infants suspected of gastroesophageal reflux disease. However, questionnaires are poorly predictive for the severity of gastroesophageal reflux disease, as they do not correlate with esophageal acid exposure as measured by pH-metry and with esophagitis as evaluated by histology of esophageal biopsies.

Glass and antimony electrodes for oesophageal pH monitoring in distressed infants: how different are they?

OBJECTIVE

Although antimony electrodes are by far the most popular for performing oesophageal pH monitoring, there are few data comparing the accuracy of glass and antimony electrodes. Therefore, we tested the accuracy of both electrodes in the prediction of oesophagitis.

METHOD

pH monitoring using a glass electrode and an antimony electrode was performed in 60 distressed infants, aged between 1 and 6 months. An upper endoscopy with oesophageal biopsies was also performed in all infants.

RESULTS

A reflux index (percentage of the total time with pH < 4.0) greater than 5% was considered to be abnormal and was found in 40/60 patients. Histological oesophagitis was present in 26/60 infants. The reflux index was > 5% with the glass electrode in 18/26 children with histological oesophagitis and with the antimony electrode in 10/26 children with histological oesophagitis. Histology of the oesophagus was normal in 22/40 children with abnormal pH monitoring. With the glass electrode, the mean reflux index in the group with oesophagitis was significantly higher than in the group with normal histology, although there was an important overlap. With the antimony electrode, the mean reflux indices in the groups with and without oesophagitis were not different. Regarding normal/abnormal, there was discordance in 35% of the pH studies. No reflux index could be related to a clinically useful sensitivity and specificity to predict oesophagitis.

CONCLUSION

The reflux index does not accurately predict oesophagitis. Oesophageal pH monitoring and endoscopy provide complementary information.

Severe gastroesophageal reflux disease and cow milk hypersensitivity in infants and children: disease association and evaluation of a new challenge procedure

BACKGROUND

Gastroesophageal reflux disease (GERD) and cow milk hypersensitivity are frequent disorders of infancy. A possible causative association between these two entities has been suggested.

OBJECTIVE

The primary aim was to elucidate whether a causative relationship between the two entities could be established in a population of infants and children. A secondary aim was to evaluate whether cow milk challenge during esophageal pH monitoring is useful as an objective method to identify this subgroup of patients.

METHODS

Upper endoscopy followed by a 48-hour esophageal pH monitoring with cow's milk elimination diet at day 1 and challenge at day 2. Cow milk hypersensitivity was later verified by elimination diet and a second open (in patients < 3 years of age) or double-blind placebo-controlled (in patients > or = 3 years of age) challenge. Skin prick test, specific serum immunoglobulin E and skin patch test were used as supplementary procedures. Follow-up endoscopy and pH monitoring were performed after 3 months of treatment (omeprazole versus elimination diet dependent on evidence of food hypersensitivity).

RESULTS

Eighteen of 42 investigated patients had severe GERD, defined as endoscopic esophagitis and/or a reflux index > 10%. Among these patients, a group of 10 patients with GERD and cow milk hypersensitivity was identified. This group had a significantly higher reflux index compared with children with primary GERD. No significant increase was noted in reflux index during simultaneous pH monitoring and milk challenge.

CONCLUSIONS

An association between GERD and cow milk hypersensitivity was observed in both infants and children with severe GERD. Simultaneous cow milk challenge and pH monitoring had limited value as a method to identify this subgroup.

Discerning differences: gastroesophageal reflux and gastroesophageal reflux disease in infants

Gastroesophageal reflux (GER) is a frequently encountered problem in infancy; it commonly resolves spontaneously by 12 months of age. Caregivers are challenged to discriminate between physiologic GER and the much less common and more serious condition of pathologic gastroesophageal reflux disease (GERD). Pathologic GERD may require more extensive clinical evaluation and necessitate treatment. GERD may be primary or secondary; secondary GERD is associated with a number of genetic syndromes, chromosomal abnormalities, birth defects, or a host of neurologic conditions frequently seen in the newborn intensive care unit. This article reviews the unique anatomic, physiologic, developmental, and nutritional vulnerabilities of infants that make them susceptible to GER and GERD. The North American Society of Pediatric Gastroenterology and Nutrition have recently developed a comprehensive evidence-based clinical practice guideline that structures the diagnostic approach and treatment option in infants with suspected and confirmed GERD. These guidelines provide clear definitions of GER and GERD to aid the clinician in distinguishing between the 2 conditions. They emphasize the use of history and physical examination and discuss the indications for the use of other diagnostic procedures, such as upper gastrointestinal studies, nuclear medicine scintiscan, esophagogastroduodenoscopy with biopsy, and esophageal pH probe monitoring. Management of GERD begins with a nonpharmacologic approach; the emphasis is on positioning, a trial of a hypoallergenic formula, and thickening of feedings. When these measures fail to control symptoms, a trial of either histamine(2) antagonists or a proton pump inhibitor may be indicated. Finally, surgical treatment may be needed if all other management measures fail. New sleep recommendations for infants with GERD are now consistent with the American Academy of Pediatrics' standard recommendations. Prone sleep positioning is only considered in unusual cases, where the risk of death and complications from GERD outweighs the potential increased risk of sudden infant death syndrome (SIDS). The nursing care of infants with GER and GERD, as well as relevant issues for parent education and support, are reviewed and are essential elements in managing this common condition.

Investigation of regurgitation and other symptoms of gastroesophageal reflux in Indonesian infants

AIM: To evaluate the incidence of regurgitation and other symptoms of gastroesophageal reflux in Indonesian infants.

METHODS: In a cross-sectional study at the University Outpatient Clinic for vaccination in Jakarta, 138 mothers of healthy infants less than 12-mo old were prospectively asked to report the frequency of regurgitation.

RESULTS: Whatever the age was, some infants did not regurgitate (from 10% during the first month of life to 67% in 1-year-old infants). Regurgitation of at least once a day was reported in 77% of infants younger than 3 mo. Daily regurgitation decreased to 12% in the 9-12 mo old group. Reported peak prevalence was 81% (26/32) during the first month of life. Regurgitation decreased sharply between the 4-6 and 7-9 mo old groups (from 44% to 9%). The longer the regurgitation persisted, the more frequently the mother perceived regurgitation as a problem. Volume and frequency of regurgitation, back arching, irritability, crying and refusal of feeding were the symptoms causing maternal anxiety. The longer the regurgitation persisted, the more frequently the mothers viewed it as a health problem.

CONCLUSION: Regurgitation occurs frequently in Indonesian infants, and is a frequent cause of concern to mothers.

Redefining gastroesophageal reflux (GER)

BACKGROUND

The detection of gastroesophageal reflux (GER) has to date been limited to acid exposure observed on 24-h pH monitoring. It is clear, however that nonacid reflux can be a significant clinical problem. Recently, as impedance technology with the capacity to detect all types of reflux (acid, nonacid, liquid, mixed, and air) has been developed.

METHODS

Seventeen asymptomatic healthy volunteers underwent combined 24-h pH and impedance testing. In all patients, pH was measured at 5 cm above the lower esophageal sphincter (LES), and simultaneous impedance changes were recorded at 3, 5, 7, 9, 15, and 17 cm above the LES. Refluxes were classified as acid (drop in pH <4 for >5 sec), Nonacid, short acid, or nonacid delta based on chemical properties; they were further classified as liquid, mixed, or gas based on the physical refluxate detected by impedance changes. The height of the reflux entering the esophagus was classified as distal (<5 cm), intermediate (5-9 cm), or proximal (9-17 cm).

RESULTS

A total of 868 reflux events were characterized. Fifty-nine percent of them were not conventional acid reflux and could only be detected by impedance changes. Less than 2% of the events that were detected by a fall in pH to <4 were not detected by impedance changes. Pure liquid reflux was seen in 35.4%, a mixed pattern in 36.3%, and a gas reflux in 26.7%. Liquid was confined to the distal esophagus in 30%; it reached the midesophagus in 58% and the proximal esophagus in 11%.

CONCLUSIONS

Over half of GER events are not detected by pH studies. Liquid reflux reaches the mid and proximal esophagus 69% of the time and gas nearly always does (92%). The additional information provided by impedance technology is likely to have a major impact on the understanding and clinical management of patients with gastroesophageal reflux disease (GERD).

Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux

OBJECTIVE

To assess the efficacy of omeprazole in treating irritable infants with gastroesophageal reflux and/or esophagitis.

STUDY DESIGN

Irritable infants (n=30) 3 to 12 months of age met the entry criteria of esophageal acid exposure >5% (n=22) and/or abnormal esophageal histology (n=15). They completed a 4-week, randomized, double-blind, placebo-controlled crossover trial of omeprazole. Cry/fuss diary (minutes/24 hours) and a visual analogue scale of infant irritability as judged by parental impression were obtained at baseline and the end of each 2-week treatment period.

RESULTS

The reflux index fell significantly during omeprazole treatment compared with placebo (-8.9%+/-5.6%, -1.9%+/-2.0%, P<.001). Cry/fuss time decreased from baseline (267+/-119), regardless of treatment sequence (period 1, 203+/-99, P<.04; period 2, 188+/-121, P<.008). Visual analogue score decreased from baseline to period 2 (6.8+/-1.6, 4.8+/-2.9, P=.008). There was no significant difference for both outcome measures while taking either omeprazole or placebo.

CONCLUSIONS

Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability. Irritability improved with time, regardless of treatment.

Food allergies

Adverse reactions to foods are commonly implicated in the causation of ill health. However, foreign antigens, including food proteins and commensal microbes encountered in the gastrointestinal tract, are usually well tolerated. True food allergies, implying immune-mediated adverse responses to food antigens, do exist, however, and are especially common in infants and young children. Allergic reactions to food manifest clinically in a variety of presentations involving the gastrointestinal, cutaneous, and respiratory systems and in generalized reactions such as anaphylaxis. Both IgE-mediated and non-IgE-mediated immune mechanisms are recognized. Important advances in the clinical features underlying specific food hypersensitivity disorders are reviewed.

Cow's milk allergy in infancy

Cow's milk allergy affects approximately 2% of infants under 2 years of age. This review summarizes the recent advances in understanding its pathophysiology and immunological mechanisms. Apart from IgE-mediated atopic manifestations, T cell-mediated reactions have been demonstrated in infants with cow's milk allergy. The clinical spectrum ranges from immediate-type reactions, presenting with urticaria and angioedema to intermediate and late-onset reactions, including atopic dermatitis, infantile colic, gastro-oesophageal reflux, oesophagitis, infantile proctocolitis, food-associated enterocolitis and constipation. The exact mechanisms of these disorders are still poorly understood. Double-blind, placebo controlled food challenge, the definitive diagnostic test for cow's milk allergy, is increasingly being replaced by the measurement of food-specific antibodies, in combination with skin-prick or atopy patch testing. The treatment of cow's milk allergy relies on allergen avoidance and hypoallergenic formulae, or maternal elimination diets in breast-fed infants.