Positive association between Helicobacter pylori and gastroesophageal reflux disease in children

Helicobacter pylori in children: think before you kill the bug!

Since the discovery of Helicobacter pylori (H. pylori) as the causative organism for gastric and duodenal ulcers four decades ago and subsequent recognition as class 1 gastric carcinogen, countless numbers of studies have been conducted and papers published, on the efficacy of various management strategies to eradicate the infection. In adults, a global consensus by the experts in the field concluded that H. pylori gastritis is an infectious disease and requires treatment irrespective of the presence or absence of symptoms due to the potential for serious complication like peptic ulcer disease and gastric neoplasia. However, although more than half the world's population harbors H. pylori, these serious complications occur only in a small minority of the infected population, even less so in childhood. More importantly, there is accumulating evidence for beneficial role of H. pylori against many chronic health conditions, from several epidemiological and laboratory studies. No doubt, eradication therapy is indicated in children with H. pylori-related peptic ulcer disease. Even though the pediatric guidelines from various learned societies recommend against a "test and treat" strategy, this is not always adhered to. With the accumulating evidence of the possible beneficial role of H. pylori, it is time to pause and think, are we causing more harm than good by eradicating H. pylori in every child who has this bug?

Identifying the Demographic, Clinical, and Endoscopic Findings of Gastroesophageal Reflux Disease in Patients With Helicobacter pylori Infection at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Background: Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease (GERD) are widely spread clinical terms. GERD refers to the backflow of gastric acid to the esophagus and upper gastrointestinal tract, causing irritation. H. pylori is a gram-negative bacillus that adheres mainly to the gastric mucosa, causing peptic ulcers and gastritis. The nature of the relationship between GERD and H. pylori is yet to be explored, and few studies have been conducted. In contrast, some studies suggest a protective role of H. pylori against GERD. This study aimed to identify the demographic, clinical, and endoscopic findings of patients with GERD who underwent H. pylori testing.

Methods: A retrospective review of medical records at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between 2015 and 2021 was conducted in June 2021. Our sample consisted of 255 individuals enrolled based on age and H. pylori status. In univariate analysis, we used frequency tests for qualitative data and measure of central tendency (MCT) for quantitative data. In bivariate analysis, we used the t-test and Pearson’s chi-square test.

Results: Of 255 GERD patients enrolled, 90 were positive and 165 were negative for H. pylori. The majority were females (54 were positive and 93 were negative for H. pylori). Both groups mainly complained of abdominal pain. Endoscopically, gastritis was higher in the H. pylori-positive group than in the H. pylori-negative group.

Conclusion: In conclusion, the majority of GERD patients were H. pylori-negative, females, Saudis, and non-smokers.

Bidirectional association between GERD and asthma in children: two longitudinal follow-up studies using a national sample cohort

BACKGROUND

The causal relationship between asthma and gastroesophageal reflux disease (GERD) is unknown in children.

METHODS

The Korean Health Insurance Review and Assessment Service-National Sample Cohort 2002-2013 was used. The population age <15 years was selected. In study I, 86,096 asthmatic children were 1:1 matched with 86,096 control I participants. In study II, 532 GERD children were 1:2 matched with 1064 control II participants. The stratified Cox proportional hazard ratios for GERD in patients with asthma (study I) and asthma in patients with GERD (study II) were analyzed.

RESULTS

In total, 0.7% (583/86,096) of the asthma group and 0.5% (430/86,096) of the control I group had GERD (P < 0.001). The asthma group demonstrated a 1.36 times higher HR for GERD than the control I group (95% CI = 1.20-1.54, P < 0.001). Subgroup analyses according to age and sex showed consistent results. In total, 15.0% (80/532) of the GERD group and 10.0% (106/1,064) of the control II group had asthma (P < 0.001). The GERD group showed a 1.62-fold higher HR for asthma than the control II group (95% CI = 1.21-2.18, P < 0.001).

CONCLUSION

GERD and asthma demonstrated a bidirectional relationship in children.

Helicobacter pylori infection in children: an overview of diagnostic methods

Children differ from adults regarding Helicobacter pylori (H. pylori) infection in many terms. H. pylori infection represents a key factor in the pathogenesis of duodenal ulcer and chronic gastritis in children. H. pylori infection causes some extraintestinal diseases as well as gastrointestinal diseases. Although, among these illnesses in children, symptoms like recurrent abdominal pain are not specific. Moreover, the role of the pathogen in the growth faltering, iron deficiency anemia, and asthma still remains controversial. A reliable method to detect H. pylori infection is a crucial issue, sand is still a matter of active debate. The tests applied for H. pylori diagnosis are grouped as either invasive or non-invasive methods. Invasive methods consist of endoscopic evaluation, the rapid urease test (RUT), histology, and bacterial culture. Non-invasive tests include the urea breath test (UBT), stool antigen test (SAT), serology, and molecular diagnostic approaches. Use of endoscopy is a pre-requisite for all invasive methods and poses difficulties in children as it is a difficult procedure and requires patient's cooperation. For this reason, the non-invasive tests have been commonly used in children, although their accuracy is not very reliable in some cases. Invasive tests may be opted to confirm the diagnosis as and when needed. This review presents the diagnostic tests used to detect H. pylori infection in children.

Interactions between Helicobacter pylori and gastroesophageal reflux disease

Interactions between Helicobacter Pylori (HP) and gastroesophageal reflux disease (GERD) are a complex issue. Several pathophysiological factors influence the development and the course of GERD, HP infection might be only one of these. Many studies emphasize the co-existence of these diseases. HP infection could contribute to GERD through both a protective and an aggressive role. Gastric acid secretion is a key factor in the pathophysiology of reflux esophagitis. Depending on the type of gastritis related to HP, acid secretion may either increase or decrease. Gastritis in corpus leads to hypoacidity, while antrum gastritis leads to hyperacidity. In cases of antral gastritis and duodenal ulcers which have hyperacidity, the expectation is an improvement in pre-existing reflux esophagitis after eradication of HP. In adults, HP infection is often associated with atrophic gastritis in the corpus. Atrophic gastritis may protect against GERD. Pangastritis which leads to gastric atrophy is commonly associated with CagA strains of HP and it causes more severe gastric inflammation. In case of HP-positive corpus gastritis in the stomach, pangastritis, and atrophic gastritis, reflux esophagitis occurs frequently after eradication of HP. Nonetheless, as a predisposing disease of gastric cancer, HP should be treated. In conclusion, as the determinative factors affecting GERD involving in HP, detailed data on the location of gastric inflammation and CagA positivity should be obtained by the studies at future.

The Probiotic Lactobacillus rhamnosus for Alleviation of Helicobacter pylori-Associated Gastric Pathology in East Africa

The probiotic Lactobacillus rhamnosus GG (LGG) can play a role in establishing a harmless relationship with Helicobacter pylori and reduce gastric pathology in East African populations. H. pylori has the ability to inhabit the surface of the mucous layer of the human stomach and duodenum. In the developing world, an estimated 51% of the population is carrier of H. pylori, while in some Western countries these numbers dropped below 20%, which is probably associated with improved sanitation and smaller family sizes. Colonization by H. pylori can be followed by inflammation of the gastric mucus layer, and is a risk factor in the development of atrophic gastritis, peptic ulcers and gastric cancer. Notwithstanding the higher prevalence of H. pylori carriers in developing countries, no equal overall increase in gastric pathology is found. This has been attributed to a less pro-inflammatory immune response to H. pylori in African compared to Caucasian populations. In addition, a relatively low exposure to other risk factors in certain African populations may play a role, including the use of non-steroidal anti-inflammatory drugs, smoking, and diets without certain protective factors. A novel approach to the reduction of H. pylori associated gastric pathology is found in the administration of the probiotic bacterium Lactobacillus rhamnosus yoba 2012 (LRY), the generic variant of LGG. This gastro-intestinal isolate inhibits H. pylori by competition for substrate and binding sites as well as production of antimicrobial compounds such as lactic acid. In addition, it attenuates the host's H. pylori-induced apoptosis and inflammation responses and stimulates angiogenesis in the gastric and duodenal epithelium. The probiotic LRY is not able to eradicate H. pylori completely, but its co-supplementation in antibiotic eradication therapy has been shown to relieve side effects of this therapy. In Uganda, unlike other African countries, gastric pathology is relatively common, presumably resulting from the lack of dietary protective factors in the traditional diet. Supplementation with LRY through local production of probiotic yogurt, could be a solution to establish a harmless relationship with H. pylori and reduce gastric pathology and subsequent eradication therapy treatment.

Prevalence of Helicobacter Pylori among Sudanese children admitted to a specialized children hospital

The infection by Helicobacter Pylori (HP), a gram-negative bacillus, is more prevalent in the developing countries, and more often among younger people reaching up to 10% of the population in comparison to only 0.5% in more developed world. Generally HP is asymptomatic in children. This study aimed to determining the prevalence of Hp among Sudanese children and to recognize associated epidemiological features. It was a prospective cross sectional study at Gaafar Ibn Aouf children hospital (GCH) in the period between December 2010 and May 2011. GCH is the largest specialized referral hospital in Khartoum and in the Sudan. Those who were diagnosed before as Hp positive were excluded. Full history, Physical examination was performed. A blood sample was taken from every patient and serum was kept at -20°C to be tested for Hp IgG antibodies through ELISA kit (Monobind; Inc., California, USA) as directed by the Manufacturer, and 20 U/mL for antibodies was considered significant and positive. Using SPSS Version 21, categorical variables were compared with Chi-square test where P < 0.05 was taken as statistically significant. This current study included 128/312 (40.1%) children admitted to the hospital who were +ve for HP (56.3% = male). The prevalence of HP is 56.3% among Sudanese children Prevalence of HP increased with age and was directly related to mother and father level of education, socioeconomic status and positive family history.

Helicobacter pylori infection and gastroesophageal reflux in children

Some studies suggest that Helicobacter pylori (H. pylori) infection would be a protective factor for the gastroesophageal reflux. The aim of this study was to explore this fact. A group of 72 children, admitted in a pediatric gastroenterology regional center in Northeast Romania, diagnosed with gastroesophageal reflux by 24-hour continuous esophageal pH monitoring (results were interpreted using the Boix-Ochoa score), underwent upper endoscopy with gastric biopsy to detect the presence of H. pylori by the rapid urease testing and for bacteriological and histologic examination. 19 children (26.39%) had H. pylori infection, while 53 (73.61%) did not. The grade of esophagitis was classified according to the Los Angeles classification system. Out of 47 children with esophagitis A, 16 (34.04%) had H. pylori infection, while out of the 25 children with esophagitis B, only 3 (12%) had H. pylori infection, with statistic significance (χ² = 54.69, P << 0.05, 95% confidence interval [CI]). Regarding the value of the Boix-Ochoa score, it appears that the presence of the H. pylori determines lower pH-metry scores (F = 8.13, P = 0.0015, 95% CI). The presence of the H. pylori was not an important factor in the gastroesophageal reflux. On the other hand its relationship with esophagitis appears to be inverse ratio. The fact that the H. pylori presence is statistically greater in the grade A esophagitis could confirm the hypothesis that the bacteria would slow down the development of the esophagitis.

Outcome evaluation of clarithromycin, metronidazole and lansoprazole regimens in Helicobacter pylori positive or negative children with resistant otitis media with effusion

Objective:

To compare the efficacy of two treatment regimens among Helicobacter pylori stool antigen positive children suffering from resistant otitis media with effusion.

Methods:

The study comprised 258 children with bilateral otitis media with effusion; 134 were positive for H pylori stool antigen, and were equally and randomly allocated to the control group or study group. The control group received standard otitis media with effusion therapy (amoxicillin and clavulanate), while the study group received standard H pylori triple therapy (clarithromycin, metronidazole and lansoprazole).

Results:

In the control group, there was a marked clinical response to treatment in 33 of the 67 children (49.3 per cent). In the study group, there was a marked response in a significantly higher number of children (46 out of 67, 68.7 per cent). The 124 H pylori stool antigen negative children not included in the 2 aforementioned groups received amoxicillin and clavulanate, and a marked response in symptoms was evident in 98 of these children (79 per cent).

Conclusion:

H pylori infection may lead to resistance to traditional otitis media with effusion treatment in some cases. H pylori eradication is associated with a high cure rate.

Nonoral feeding for children and youth with developmental or acquired disabilities

The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/or therapists.

Prevalence of gastroesophageal reflux disease symptoms and related factors in patients with rheumatoid arthritis

Gastroesophageal reflux disease (GERD) is common in patients with many chronic diseases, but has not been well recognized in rheumatoid arthritis (RA). We investigated the prevalence of GERD symptoms in 278 outpatients with RA and their association with such clinical factors as age, sex, height, weight, body mass index, medications drugs, and functional status evaluated by the Modified Health Assessment Questionnaire (MHAQ). GERD symptoms were evaluated by Frequency Scale for the Symptoms of GERD (FSSG). The mean FSSG score for all patients was 5.6, and 82 patients were considered to have GERD symptoms (FSSG score ≥8), thus the overall prevalence of GERD symptoms was 29.5%. MHAQ score and height were significantly higher and lower, respectively, and prednisolone usage was significantly more in the patients with GERD symptoms than those without. These three clinical factors were also significantly associated with GERD symptoms by univariate logistic regression. Multivariate logistic regression analysis demonstrated that MHAQ was the only clinical factor related to GERD symptoms. In conclusion, the prevalence of GERD symptoms in RA patients was high and strongly associated with decreased functional status, suggesting that physicians should pay attention to GERD symptoms in RA management, especially for patients with low functional status.

Helicobacter pylori infection has no impact on manometric and pH-metric findings in adolescents and young adults with gastroesophageal reflux and antral gastritis: eradication results to no significant clinical improvement

The relationship between Helicobacter pylori (Hp) gastritis and gastroesophageal reflux disease (GERD) remains controversial. The aim was to investigate the association between Hp infection and gastroesophageal reflux (GER) and the impact of Hp eradication on esophageal acid exposure and motility in adolescents and young adults with Hp gastritis and GERD. Sixty-four patients with symptoms suggestive for GERD, of which 40 Hp-positive (group A) and 24 Hp-negative (group B), underwent endoscopy-biopsy, esophageal manometry and 24-hour pH-metry. All group A patients received eradication treatment and were re-evaluated six months later again with 24-hour pH-metry, esophageal manometry, endoscopy-biopsy and clinical assessment. At inclusion, there were no significant differences between the two groups regarding sex, age, grade of endoscopic esophagitis, manometric and pH-metry findings. All Hp-positive patients had an antral predominant gastritis. Eradication of Hp was successful in all patients, and gastritis and esophagitis were healed in all patients. The mean lower esophageal sphincter pressure (LESP) increased significantly from 11.25 mmHg before to 11.71 mmHg after eradication (P<0.05). A significant decrease in reflux index was observed (mean RI 6.02% before versus 4.96% after eradication (P<0.05). However clinical symptoms of GER improved not significantly after 6 months follow up. Conclusively, in children and young adults with GER symptoms and GERD, the presence or absence of Hp has no impact on manometric and pH-metric findings. Eradication of Hp infection results in increase in LESP with a consequent decrease in esophageal acid exposure but not significant clinical improvement.

Upper gastrointestinal histopathological findings in children and adolescents with nonulcer dyspepsia with Helicobacter pylori infection

OBJECTIVES

The aim of the study was to investigate the histopathological lesions in the upper gastrointestinal mucosa associated with Helicobacter pylori infection in children with nonulcer dyspepsia.

METHODS

A cross-sectional case-control study was performed on 185 Brazilian children and adolescents (4-17 years, mean 9.5 ± 2.7 years), 63.2% girls, submitted to upper gastrointestinal endoscopy. The histopathological lesions of the esophageal and gastric mucosa were analyzed in biopsy samples.

RESULTS

H pylori infection was identified in 96 children (51.8%). Moderate to severe chronic active gastritis was present in antrum (70.5%) and corpus (45.2%), with higher grading in antrum than in corpus (P < 0.05). The topographic distribution of inflammation was pangastritis (61.9%), followed by antral (32.1%) and corpus (5.9%). H pylori density was higher in antrum than in corpus. Intestinal metaplasia was not found in the H pylori-infected group, nor was significant gastric atrophy. The scores for esophagitis were significantly higher (P < 0.05) in the noninfected group (1.4 ± 0.8) than in the H pylori-infected group (1.07 ± 0.9), with significant negative correlation (r = 0.29; P < 0.05) with the scores of gastric inflammation.

CONCLUSIONS

The prevalence of H pylori infection was high among children with dyspepsia and associated with moderate/severe degrees of gastric inflammation. The high scores of esophagitis in the noninfected group point to 2 distinct groups of pathological conditions sharing similar clinical patterns.

The role of Helicobacter pylori infection in gastro-oesophageal reflux in Iranian children

BACKGROUND

The relationship between Helicobacter pylori and gastro-oesophageal reflux disease (GORD) in children is controversial.

AIM

To determine the role of H. pylori infection and GORD in children living in a region which is endemic for H. pylori infection.

METHODS

A cross-sectional study was undertaken in 263 children aged 3-18 years, all of whom had symptoms of GORD and underwent upper gastro-intestinal endoscopy. H. pylori status was determined by conventional rapid urease test and Giemsa staining of antral and cardiac biopsies. Biopsies of the oesophagus and gastric mucosa were obtained from the lower oesophagus, the antrum and cardia according to standard protocol.

RESULTS

Of the 263 patients, 81 (31·5%) had GORD and 162 (61·5%) had gastritis. There were 59 H. pylori-infected patients (22·4%) and 204 were uninfected. H. pylori infection was detected in 52 (88·1%) of the antral and 10 (1·9%) of the cardiac biopsies. Three (5·1%) of the biopsies revealed infection of both antrum and cardia and in seven (11·8%) only the cardia was infected. The prevalence of H. pylori infection among patients with GORD (13/83, 15%) was significantly lower than in those without GORD (46/180, 26%) (OR 0·54, CI 0·27-0·93, p<0·05). The prevalence of H. pylori infection among those with gastritis (48/162, 30%) was significantly higher than in those without gastritis (11/101, 10·8%) (OR 3·44, CI 1·69-7·015, p<0·001).

CONCLUSION

H. pylori infection might protect against GORD.

Patients with Helicobacter pylori infection have less severe gastroesophageal reflux disease: a study using endoscopy, 24-hour gastric and esophageal pH metry

BACKGROUND AND AIM

The relationship between gastroesophageal reflux disease (GERD) and Helicobacter pylori is controversial. We evaluated endoscopic, 24-h gastric and esophageal acid profile among patients with GERD in relation to H. pylori, as the latter might alter gastric acid secretion.

METHODS

Patients with GERD (n = 123), who were not on acid-suppressive drugs, and had not received anti-H. pylori therapy, underwent gastroduodenoscopy and tests for H. pylori detection. Esophageal manometry, 24-h pH metry, serum pepsinogen-I (PG-I), PG-II and gastrin-17 ELISA were done in all these patients. Univariate and multivariate analyses were performed to assess independent predictors for erosive esophagitis (EE).

RESULTS

Of 123 patients (mean age 40.5 [13.1] years, 85 [69.1%] men), 59 (47.9%) had H. pylori infection. EE was more common in H. pylori non-infected than infected (49 vs. 32, p < 0.001). Among patients older than 40 years, absence of H. pylori was associated with lower esophageal pH and longer reflux (p = 0.02 and p < 0.001, respectively). PG-I/PG-II ratio was lower in H. pylori infected subjects (p < 0.001). In patients with higher LA grade of esophagitis, elevated PG-I levels and PG-I/PG-II ratio were associated with more acidic stomach (p = 0.04 and p = 0.01, respectively). Multivariate analyses showed low gastrin-17 (p = 0.016), higher age (p = 0.013), hiatus hernia (p = 0.004) and absence of H. pylori (p = 0.03) were independent predictors for risk of EE.

CONCLUSION

H. pylori infection is associated with less acidic stomach and less severe GERD. Low gastrin-17, higher age, hiatus hernia and absence of H. pylori were the best predictors for EE risk.

Gastroesophageal reflux, eosinophilic esophagitis, and foreign body

Even though chest pain in children is a common complaint, an underlying gastrointestinal cause is rare. The four common gastrointestinal conditions that present with chest pain include eosinophilic esophagitis, gastroesophageal reflux disease, esophageal dysmotility, and foreign body ingestion. Other than ingestion of certain foreign bodies, most of these conditions are not life-threatening. Associated symptoms and history may be helpful in distinguishing these disorders, but further evaluation is often indicated to identify the precise cause.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Helicobacter pylori infection and childhood

Pediatric-based Helicobacter pylori research continues to contribute significantly to our understanding of both clinical and pathophysiological aspects of this infection. Here, we review the published pediatric H. pylori literature from April 2009-March 2010. Analysis of pediatric H. pylori strains continues to suggest that cagA(+) and cagPAI competent strains are less prevalent than in adult isolates. Studies from the Middle East report a high H. pylori prevalence and intrafamilial transmission. Data continue to show a lack of association between H. pylori and recurrent abdominal pain of childhood, gastroesophageal reflux disease, and growth retardation. Recent probiotic trials have not shown a benefit on H. pylori eradication in children, while sequential therapy remains an attractive therapeutic eradication strategy in children, which requires validation in different geographic regions.

Role of nutrients in the development of neonatal immune response

Nutrients exert unique regulatory effects in the perinatal period that mold the developing immune system. The interactions of micronutrients and microbial and environmental antigens condition the post-birth maturation of the immune system, influencing reactions to allergens, fostering tolerance towards the emerging gastrointestinal flora and ingested antigens, and defining patterns of host defense against potential pathogens. The shared molecular structures that are present on microbes or certain plants, but not expressed by human cells, are recognized by neonatal innate immune receptors. Exposure to these activators in the environment through dietary intake in early life can modify the immune response to allergens and prime the adaptive immune response towards pathogens that express the corresponding molecular structures.

The Association between Childhood Overweight and Reflux Esophagitis

Background. In adults, it has been shown that obesity is associated with gastroesophageal reflux disease (GERD) and GERD-related complications. There are sparse pediatric data demonstrating associations between childhood overweight and GERD. Objective. To investigate the association between childhood overweight and RE. Methods. We performed a retrospective chart review of 230 children (M : F = 114 : 116) who underwent esophagogastroduodenoscopy (EGD) with biopsies between January 2000 and April 2006. Patient demographics, weight, height, clinical indications for the procedure, the prevalence of BMI classification groups, the prevalence of RE and usage of anti-reflux medications were reviewed. For these analyses, the overweight group was defined to include subjects with BMI>/= 85th percentile. The normal weight group was defined to include subjects with BMI 5th to 85th percentile. Results. Among the 230 subjects, 67 (29.1%) had BMI percentiles above the 85th percentile for age and gender. The prevalence of RE in the overweight group did not differ significantly from that in the normal weight group (23.9% versus 24.5%, resp.). Overweight subjects taking anti-reflux medications clearly demonstrated a higher prevalence of biopsy-proven RE compared to overweight subjects not taking anti-reflux medications (34.1% versus 7.7%, P = .009). Conclusions. There was no significant difference in the prevalence of biopsy-proven RE in the overweight group compared to the normal weight group. However, the prevalence of RE was significantly higher in overweight subjects on anti-reflux medications compared to overweight subjects not taking anti-reflux medications. This finding emphasizes the importance of early recognition and treatment of GERD for the overweight pediatric patients with symptoms in conjunction with weight loss program for this population to reduce long-term morbidities associated with GERD.