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

Diagnostic thresholds and optimal collection protocol of salivary pepsin for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is primarily diagnosed based on symptoms and response to a proton-pump inhibitor (PPI) trial. Gold standard testing requires an invasive endoscopic procedure, often with ambulatory pH monitoring. Salivary pepsin is a potential noninvasive modality for GERD diagnosis. This study aimed to assess diagnostic performance of salivary pepsin thresholds for GERD and determine optimal collection protocol of saliva in an external validation cohort. Over 10 months, adults with symptoms of GERD undergoing esophagogastroduodenoscopy with wireless pH-monitoring off PPI were enrolled. Saliva was self-collected by participants over 4 days across three different time points: fasting ante meridiem (AM), post-prandial, and bedtime (PM). Pepsin levels were calculated via Peptest. Pepsin variability and agreement were determined using linear mixed effects models and intraclass correlation. Validation of diagnostic threshold and performance characteristics were evaluated by receiver-operator curve analysis. Twenty participants enrolled in the study; 50% with physiologic acid exposure (acid exposure time < 4% no GERD) and 50% with elevated acid exposure (GERD). Mean pepsin concentrations were significantly lower in the AM (22.6 ± 25.2 ng/mL) compared to post-prandial (44.5 ± 36.7 ng/mL) and PM (55.4 ± 47.0 ng/mL). Agreement between pepsin concentrations across 3 days was substantial for AM samples (kappa 0.61), with lower agreement for post-prandial and PM samples. A single AM pepsin concentration of 25 ng/mL was 67% accurate for GERD with 56% sensitivity and 78% specificity. This validation study highlights fair accuracy and performance characteristics of a single fasting AM salivary pepsin concentration for the diagnosis of GERD.

Impact of Ramadan Fasting on the Severity of Symptoms Among a Cohort of Patients With Gastroesophageal Reflux Disease (GERD)

INTRODUCTION

 Gastroesophageal reflux disease (GERD) is a condition caused by the reflux of stomach contents into the esophagus. Heartburn, chest discomfort, and regurgitation are the main symptoms. Medications, surgical procedures, and lifestyle modification are considered treatment options. Fasting is believed to be one of the lifestyle modifications that helps minimize GERD symptoms. Muslims abstain from eating, drinking, and smoking from dawn until dusk. The objectives of our study were to investigate the relationship between fasting and GERD symptoms and evaluate how fasting affects GERD symptoms in Saudi Arabia.

METHODOLOGY

This was a longitudinal study that selected GERD patients for its consecutive sampling. The patients answered the questionnaires at two separate times: once during Ramadan and once after Ramadan. A validated gastroesophageal reflux disease health-related quality of life (GERD-HRQL) self-administered survey was used.

RESULT

After Ramadan, heartburn symptoms significantly decreased, particularly when lying down. Overall, the 45-point heartburn score decreased from 17.9 during Ramadan to 14.3 thereafter. The regurgitation score decreased from 12.3 during Ramadan to 9.9 after fasting, with statistical significance (P = .049). Although satisfaction was much higher after Ramadan (17% vs. 15.1%), there was no statistical significance (P = .422), and 45.3% of the patients were satisfied with their health state during Ramadan compared to 34% after Ramadan. There was no relationship between the severity of GERD symptoms before or after fasting and the type of food, the timing of eating, or the amount of food consumed.

CONCLUSION

The results suggested that Ramadan fasting may improve GERD symptoms. However, more studies are required to validate these results and comprehend the underlying mechanisms.

Gastroesophageal reflux disease in children: What’s new right now?

Gastroesophageal reflux (GER) in children is very common and refers to the involuntary passage of gastric contents into the esophagus. This is often physiological and managed conservatively. In contrast, GER disease (GERD) is a less common pathologic process causing troublesome symptoms, which may need medical management. Apart from abnormal transient relaxations of the lower esophageal sphincter, other factors that play a role in the pathogenesis of GERD include defects in esophageal mucosal defense, impaired esophageal and gastric motility and clearance, as well as anatomical defects of the lower esophageal reflux barrier such as hiatal hernia. The clinical manifestations of GERD in young children are varied and nonspecific prompting the necessity for careful diagnostic evaluation. Management should be targeted to the underlying aetiopathogenesis and to limit complications of GERD. The following review focuses on up-to-date information regarding of the pathogenesis, diagnostic evaluation and management of GERD in children.

Factors that Impact Day-to-Day Esophageal Acid Reflux Variability and Its Diagnostic Significance for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disease affecting a significant number of adults both globally and in the USA. GERD is clinically diagnosed based on patient-reported symptoms, and the gold standard for diagnosis is ambulatory reflux monitoring, a tool particularly utilized in the common scenario of non-response to therapy or atypical features. Over the past 20 years, there has been a shift toward extending the duration of reflux monitoring, initially from 24 to 48 h and more recently to 96 h, primarily based on a demonstrated increase in diagnostic yield. Further, multiple studies demonstrate clinically relevant variability in day-to-day acid exposure levels in nearly 30% of ambulatory reflux monitoring studies. For these reasons, an ongoing clinical dilemma relates to the optimal activities patients should engage in during prolonged reflux monitoring. Thus, the aims of this review are to detail what is known about variability in daily acid exposure, discuss factors that are known to influence this day-to-day variability (i.e., sleep patterns, dietary/eating habits, stress, exercise, and medications), and finally provide suggestions for patient education and general GERD management to reduce variation in esophageal acid exposure levels.

Pathophysiology of Pediatric Gastroesophageal Reflux Disease: Similarities and Differences With Adults

Gastroesophageal reflux (GOR) is defined as "the passage of gastric contents into the esophagus with or without regurgitation and vomiting" and gastroesophageal reflux disease (GORD) is defined "when GOR leads to troublesome symptoms affecting the daily functioning and/or complications." This definition was first developed in 2006 by the Montreal consensus group (1) and later on adopted by pediatric gastroenterology societies such as ESPGHAN and NASPGHAN in 2009 (2). The definition of gastroesophageal reflux reveals little about its pathophysiology and is focused on symptomatology. In this way, it acts as an umbrella term for the multifactorial causes of the disease and the various phenotypes encountered; from functional heartburn to hypersensitive esophagus and nonerosive reflux disease, to erosive esophagitis and Barrett's esophagus. This article is devoted to the pathophysiology of pediatric GORD in comparison to adult GORD and is divided in 2 parts. In the first part, we will systematically describe the different mechanisms for the generation and clearance of reflux events, while on the second part we will discuss the mechanisms involved in symptoms generation. Finally, we will discuss the similarities and differences between pediatric and adult GORD.

Quality Assurance in Lactation: Reliability of OM-6050 Station System to Test Mother's Milk Osmolality

BACKGROUND

Mother's own milk does not provide enough nutrients to feed a preterm baby born before 32 weeks' gestation; therefore, human milk fortifiers are needed. However, human milk fortifiers increase the osmolality, and enteral administration of high osmolality fluids has been associated with gastrointestinal symptoms. For this reason, it is necessary for laboratories to have a validated system in order to measure human milk osmolality.

RESEARCH AIM

The aim of this study was to validate the OM-6050 Station System for measuring the osmolality of fortified mother's milk samples.

METHODS

Osmolality was measured using the osmometer OM-6050 Station System. Milk samples from healthy mothers (N = 3) unfortified and with two fortifiers (Almirón Fortifier^® or NAN FM85^®), as well as a nutritional supplement (Duocal MCT^®) were used in the validation study through precision and linearity analysis.

RESULTS

In the precision study the mean intra-assay coefficient of variation was 1.2% and 1.7% for mother's milk and fortified mother's milk, respectively. The mean inter-assay coefficient of variation was ≤ 1% in both cases. In the linearity study the regression analysis had a linear response to fortified mother's milk osmolality between 294 mOsm/kg and 539 mOsm/kg.

CONCLUSION

The osmometer OM-6050 Station was reliable for determining the osmolality of fortified and unfortified mother's milk. It may be useful in the clinical practices within Neonatal Intensive Care Units.

An Initiative to Reduce Preterm Infants Pre-discharge Growth Failure Through Time-specific Feeding Volume Increase

Very low birth weight infants often demonstrate poor postnatal longitudinal growth, which negatively impacts survival rates and long-term health outcomes. Improving extrauterine growth restriction (EUGR) among extremely premature infants has become a significant focus of quality improvement initiatives. Prior efforts in the University of Massachusetts Memorial Medical Center neonatal intensive care unit were unsuccessful in improving the EUGR rate at discharge.

Fortifier selection and dosage enables control of breast milk osmolarity

BACKGROUND

Human breast milk (BM) fortification is required to feed preterm newborns with less than 32 weeks of gestation. However, addition of fortifiers increases osmolarity and osmolarity values higher than 450 mOsm/kg may be related to gastrointestinal pathology. Hence, fortifier selection and dosage are key to achieve optimal feeding.

OBJECTIVES

To compare the effect on osmolality of adding different fortifications, including recently developed formulations, to BM and to study evolution of osmolarity over time in supplemented BM.

METHODS

Frozen mature BM from 10 healthy mothers of premature newborns was fortified with each of the following human milk fortifiers (HMF): AlmirónFortifier®, NANFM85®, or PreNANFM85®. In addition, fortified BMs were modified with one of the following nutritional supplements (NS): Duocal MCT®, Nutricia® AminoAcids Mix, or Maxijul®. Osmolality of BM alone, fortified and/or supplemented was measured at 1 and 22 hours after their preparation. All samples were kept at 4°C throughout the study.

RESULTS

Osmolality of BM alone was close to 300 mOsm/kg and did not change over 22 hours. When equicaloric amounts of HMF AlmirónFortifier®, NANFM85®, and PreNANFM85® were added to BM, osmolality increased roughly to 480 mOsm/kg with the first two fortifiers and only to 433±6 mOsm/kg with the third one. Upon addition of any of four different NSs to BM modified with AlmirónFortifier® and NANFM85®, osmolality reached values greater than 520 mOsm/kg, while osmolality of PreNANFM85® with two out of the four NSs remained below 490 mOsm/kg. NSs supplementing carbohydrates and hydrolysed proteins resulted into a higher increase of BM osmolarity. Osmolality increased significantly with time and, after 22h, only BM modified with PreNANFM85® remained below 450 mOsm/kg.

CONCLUSIONS

Upon addition of the HMFs tested, BM osmolality increases significantly and keeps raising over time. All HMFs but the recently developed PreNAN FM85® at 4% exceed the AAP recommended threshold for osmolarity of 450 mOsm/kg. Addition of NSs to PreNAN FM85® at 4% significantly increases osmolality above 450 mOsm/Kg. Thus, using PreNAN FM85® at 5% may be preferable to adding nutritional supplements since nutritional recommendations by the ESPGHAN are reached with a lower increase in osmolality.

The effect of dietary carbohydrate on gastroesophageal reflux disease

BACKGROUND

Acid changes in gastroesophageal reflux with vary component in the food have less been studied, especially carbohydrate. We plan to clarify the effect of different carbohydrate density on low esophageal acid and reflux symptoms of patients with gastroesophgeal reflux disease.

METHODS

Twelve patients (52 ± 12 years old; five female) with gastroesophageal reflux disease were recruited for the prospective crossover study. Each patient was invited for panendoscope, manometry and 24 h pH monitor. The two formulated liquid meal, test meal A: 500 ml liquid meal (containing 84.8 g carbohydrate) and B: same volume liquid meal (but 178.8 g carbohydrate) were randomized supplied as lunch or dinner. Reflux symptoms were recorded.

RESULTS

There are significant statistic differences in more Johnson-DeMeester score (p = 0.019), total reflux time (%) (p = 0.028), number of reflux periods (p = 0.026) and longest reflux (p = 0.015) after high carbohydrate diet than low carbohydrate. Total reflux time and number of long reflux periods more than 5 min are significant more after high carbohydrate diet.

CONCLUSION

More acid reflux symptoms are found after high carbohydrate diet. High carbohydrate diet could induce more acid reflux in low esophagus and more reflux symptoms in patients with gastroesophageal reflux disease.

The relationship of human milk leptin and macronutrients with gastric emptying in term breastfed infants

BackgroundInfants breastfed on demand exhibit a variety of feeding patterns and self-regulate their nutrient intake, but factors influencing their gastric emptying (GE) are poorly understood. Despite research into appetite regulation properties of leptin, there is limited information about relationships between human milk leptin and infant GE.MethodsGastric volumes were calculated from ultrasound scans of infants' stomachs (n=20) taken before and after breastfeeding, and then every 12.5 min (median; range: 3-45 min) until the next feed. Skim milk leptin and macronutrient concentrations were measured and doses were calculated.ResultsThe leptin concentration was (mean±SD) 0.51±0.16 ng/ml; the leptin dose was 45.5±20.5 ng per feed. No relationships between both concentration and dose of leptin and time between the feeds (P=0.57; P=1, respectively) or residual stomach volumes before the subsequent feed (P=0.20; P=0.050) were found. Post-feed stomach volumes (GE rate) were not associated with leptin concentration (P=0.77) or dose (P=0.85).ConclusionGE in term breastfed infants was not associated with either skim milk leptin concentration or dose. Further investigation with inclusion of whole-milk leptin and other hormones that affect gastrointestinal activity is warranted.

Volume marker inaccuracies: A cross-sectional survey of infant feeding bottles

A cross-sectional examination of the accuracy of volume markers on infant feeding bottles available for sale in Australia between December 2013 and February 2014 was carried out. Ninety-one bottles representing 28 different brands were examined. Eighty-eight bottles were hard sided. Volumes in these bottles were marked in a combination of milliliters and ounces. Thirty-six (41%) bottles claimed compliance with the European standard EN14350, five (6%) with non-existent Australian standards, and forty-seven (54%) bottles had no standard claim. Nineteen bottles (22%) had at least one measured marking outside the tolerance of EN14350. Bottles claiming compliance with EN14350 were not less likely to have inaccurate markings than those that made no claim. More expensive bottles did not have fewer inaccurate markings. Three bottles were disposable liner systems and had particularly large volume inaccuracies (up to 43% outside the marked volume). Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Over-concentrated and under-concentrated infant formula can cause serious illness or malnutrition. Over-concentrated infant formula may contribute to obesity. Bottles with inaccurate volume markers are unfit for purpose; disposable liner bottles are particularly poor in this regard and should be prohibited from having volume markers on the bottle casing. To avoid individual or public harms, well-enforced standards are needed. Guidance for parents, carers, and health professionals is needed to ensure that infant formula is accurately reconstituted.

Gastro-Intestinal Tolerance and Renal Safety of Protein Oral Nutritional Supplements in Nursing Home Residents: A Randomized Controlled Trial

BACKGROUND/OBJECTIVE

High protein oral nutritional supplements (ONS) are regularly prescribed to undernourished patients; however usage of these in older adults is being discussed, as their renal function might have declined with age. Therefore, the aim of the current study was to evaluate the effects of 8 week long consumption of high protein ONS on the renal function of nursing home residents in need of supplementation. Furthermore, within the same setup, differences in gastro-intestinal tolerance between a standard and a more concentrated version of an ONS were investigated.

DESIGN

Randomized, controlled, single-blind, parallel-group, multi-country trial (NTR2565).

SETTING

Nursing home.

PARTICIPANTS

67 nursing home residents in need of ONS (energy-dense, small volume group n=32; standard volume group n=35).

INTERVENTION

Protein supplementation was provided by either a standard (200ml, 300kcal, 20g protein) or an energy-dense, small volume (125ml, 300kcal, 18g protein) ONS during the 8 week long study.

MEASUREMENTS

Primary outcome was gastro-intestinal tolerance, assessed by daily stool frequency and consistency, and occurrence and intensity of self-reported gastro-intestinal symptoms. Safety was measured via the occurrence of (serious) adverse events, vital signs, as well as liver- and kidney function monitoring.

RESULTS

No clinically relevant and, except for flatulence, no statistically significant differences in gastro-intestinal tolerance were observed between groups. No significant difference between groups was found for estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio at baseline and week 8, nor for the changes from baseline. Adverse events and the changes in monitored renal parameters over the study period did not point to a deterioration of renal function.

CONCLUSION

High protein ONS seems to be well-tolerated and safe; there is no indication that it affects renal function in nursing home residents, including patients with stage 3 chronic kidney disease, under the conditions tested. Results did not suggest a difference in the effect on renal function between standard and energy-dense small volume ONS format.

Systematic review of the impact of feed protein type and degree of hydrolysis on gastric emptying in children

Background

The choice of infant formula is thought to play an important role on gastric emptying (GE) in a variety of gastrointestinal disorders. It is known that many ingredients impact on GE, including the type of protein and level of hydrolysis. In clinical practice, feeds are often recommended due to putative improved GE related to the type of protein and level of hydrolysis, however whether this is scientifically justified still needs to be established. A systematic review comparing the impact of protein type and hydrolysis on GE in children was therefore performed.

Methods

The Patient, Intervention, Comparison and Outcome system was used. A structured literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, searching PubMed, Cochrane databases and Google Scholar from 1990 to 2014. We only included articles published in full text English language using specific search terms, including both scintigraphy and C13-octanoic acid breath test.

Results

We identified 126 publications of which 20 were eligible for inclusion but only 8 were included. Studies reviewed GE in both healthy children as well as those with neurodevelopmental delay and reflux. Two studies investigating GE of breast milk versus formula indicated a faster GE for breast milk. Four studies found that feeds containing whole whey in varying amounts emptied faster than predominant whole casein feeds and one study found no difference in GE. Five studies investigated a mix of whole versus hydrolysed protein and found conflicting results related to study population and hydrolysis.

Conclusions

Breast milk has a faster GE than formula milk. Although there seems to be a trend towards whey feeds emptying faster, different methodologies, feed compositions and patient groups makes it difficult to draw firm conclusions. Future studies should be performed with comparable feeds in populations where increased GE may be of clinical benefit.

Managing gastroesophageal reflux symptoms in the very low-birth-weight infant postdischarge

Gastroesophageal reflux and gastroesophageal reflux disease symptoms are common challenges for very low-birth-weight infants (<1500 g). These symptoms frequently result in feeding difficulties and family stress. Management of symptoms across healthcare disciplines may not be based on current evidence, and inconsistency can result in confusion for families and delayed interventions. The feeding relationship between infant and caregivers may be impaired when symptoms are persistent and poorly managed. An algorithm for managing gastroesophageal reflux-like symptoms in very low-birth-weight infants (from hospital discharge to 12 months corrected age) was developed through the formation of a multidisciplinary community of practice and critical appraisal of the literature. A case study demonstrates how the algorithm results in a consistent approach for identifying symptoms, applying appropriate management strategies, and facilitating appropriate timing of medical consultation. Application to managing gastroesophageal reflux symptoms in the neonatal intensive care unit will be briefly addressed.

Risk factors for gastroesophageal reflux disease: the role of diet

Introduction

Nutrition can contribute to the development of gastroesophageal reflux disease (GERD). The relevant studies often provide contradictory results.

Aim

To determine GERD risk factors associated with dietary habits.

Material and methods

A total of 513 subjects were included. The study group consisted of adults with a recent clinically confirmed diagnosis of GERD, and the control group were healthy adults. The research tool was a proprietary questionnaire. Risk factors were evaluated by logistic regression models.

Results

An association was found between the severity of typical GERD symptoms and a certain diet (p < 0.001). The symptoms were experienced more often after fatty, fried, sour, or spicy food and sweets. The univariate logistic regression analysis showed the following risk factors: eating 1–2 meals per day (OR = 3.50, 95% CI: 1.75–6.98), everyday consumption of peppermint tea (OR = 2.00, 95% CI: 1.14–3.50), and eating one, big meal in the evening instead of dinner and supper (OR = 1.80, 95% CI: 1.05–3.11). The multivariate analysis confirmed that frequent peppermint tea consumption was a risk factor (OR = 2.00, 95% CI: 1.08–3.70).

Conclusions

Taking into consideration the results of this study, it seems that patients should be recommended to eat more than three meals a day and eat dinner and supper at appropriate times instead of one, big meal in the evening. The role of frequent peppermint tea consumption in GERD development requires further studies.

Upper gastrointestinal motility: prenatal development and problems in infancy

Deglutition, or swallowing, refers to the process of propulsion of a food bolus from the mouth into the stomach and involves the highly coordinated interplay of swallowing and breathing. At 34 weeks gestational age most neonates are capable of successful oral feeding if born at this time; however, the maturation of respiration is still in progress at this stage. Infants can experience congenital and developmental pharyngeal and/or gastrointestinal motility disorders, which might manifest clinically as gastro-oesophageal reflux (GER) symptoms, feeding difficulties and/or refusal, choking episodes and airway changes secondary to micro or overt aspiration. These problems might lead to impaired nutritional intake and failure to thrive. These gastrointestinal motility disorders are mostly classified according to the phase of swallowing in which they occur, that is, the oral preparatory, oral, pharyngeal and oesophageal phases. GER is a common phenomenon in infancy and is referred to as GERD when it causes troublesome complications. GER is predominantly caused by transient relaxation of the lower oesophageal sphincter. In oesophageal atresia, oesophageal motility disorders develop in almost all patients after surgery; however, a congenital origin of disordered motility has also been proposed. This Review highlights the prenatal development of upper gastrointestinal motility and describes the most common motility disorders that occur in early infancy.

An antiregurgitation milk formula in the management of infants with mild to moderate gastroesophageal reflux

BACKGROUND

Thickened milk formulas are used to treat infants with gastroesophageal reflux (GER), but these substances often increase the duration of reflux episodes and worsen symptoms, and they have been associated with diarrhea, constipation, and cough.

OBJECTIVES

The aims of this study were to determine the efficacy of an antiregurgitation milk formula in the clinical and laboratory setting in infants with proved GER, to investigate any possible adverse events (cough and change in the number of bowel movements or the consistency of stools), and to identify its effects on height and body weight.

METHODS

Infants with recurrent vomiting and GER who were not responsive to standard treatment were eligible for the study. Infants in the treatment group (group A) were managed for 4 weeks with a specific antiregurgitation milk formula (with cornstarch and an increased amount of casein), and those in the control group (group B) were given a standard milk formula. The number of episodes of vomiting, regurgitation, and cough, as well as the frequency and consistency of stool, height, and body weight were noted at least 10 days before and during the study. A second pH monitoring was performed after 4 weeks in both groups.

RESULTS

Fifty-six infants (30 boys, 26 girls; mean [SD] age, 3.1 [1.2] months) were included in the study; 30.4% had mild GER; 44.6%, moderate GER; and 25.0%, severe GER. Significantly more infants in group A than in group B (50.0% vs 14.3%, respectively) with mild or moderate GER had normal findings on the second pH monitoring (P<0.05). Changes in the reflux index and in the mean number of vomiting and regurgitation episodes were significantly different between the 2 groups (P<0.05). No significant differences in changes in the mean number of bowel movements and cough events or in the consumption time of the 2 formulas were found between the 2 groups.

CONCLUSION

Infants with mild or moderate GER can be managed effectively with this antiregurgitation milk formula. Improved clinical and laboratory findings were seen in the majority of infants, and the formula was well tolerated, without adverse events.

The influence of the speed of food intake on multichannel impedance in patients with gastro-oesophageal reflux disease

BACKGROUND

There is a general belief that gastro-oesophageal reflux increases after meals and especially following a rapid intake.

OBJECTIVE

To evaluate the impact of rapid vs. slow food intake on gastro-oesophageal reflux disease (GORD) patients.

MATERIALS AND METHODS

Forty-six GORD patients with heartburn and / or acid regurgitation once a week or more often common were included in this study. Participants were asked to eat the same standard meal within either 5 or 30 minutes under observation in a random order on 2 consecutive days. A total of 28 hours of recording were obtained by intraoesophageal impedance pH and number of liquid and mixed reflux episodes within 3 hours of the slow- and fast-eating postprandial periods were calculated.

RESULTS

While all patients defined GORD symptoms, 10 (21.7%) had pathological 24-h intraoesophageal impedance measurement, 15 (32.6%) had pathological DeMeester and 21.7% had erosive oesophagitis. No difference has been shown according to the eating speed when all reflux episodes were taken together (754 vs. 733). Speed of food intake also did not have an impact on patients with normal vs. pathological 24-h intraoesophageal impedance or erosive vs. non-erosive. During the first postprandial hour, approximately half of the reflux events were non-acid, compared to 34.2% during the second hour and 26.8% during the third hour (p < 0.001). The number of acid reflux episodes was significantly higher than non-acid reflux especially during the second and third hours and in total for 3 hours.

CONCLUSIONS

This first study addressing the effect of eating speed on reflux episodes in GORD patients did not support the general belief that reflux increases following fast eating. Acid and non-acid reflux were similar at the first postprandial hour, then acid reflux episodes were predominantly higher, which implicate the importance of acid pockets.

Effect of liquid meals with different volumes on gastroesophageal reflux disease

BACKGROUND AND AIM

Patients with gastroesophageal reflux disease (GERD) are often advised to avoid large meals, based on their complaints of increased symptoms after eating too much, and epidemiological evidence of a link between high volume intake and the presence of GERD. However, the precise effects of meal volume on gastroesophageal reflux have not been well studied. We aimed to clarify the effect of meal volume on acid regurgitation and symptoms in patients with GERD.

METHODS

Fifteen patients (10 female, 5 male; mean 54 ± 10 years old) with GERD were studied twice each in random order, during 24 h ambulatory pH monitoring. On one day, they consumed a 600 mL liquid test meal three times (breakfast, lunch, and dinner), and on the other, they consumed a 300 mL test meal six times (breakfast, snack, lunch, snack, dinner, and snack). Gastric fundus and antral areas and antral contractions were measured by transabdominal ultrasound. Symptoms were recorded using questionnaires.

RESULTS

During the 600 mL regimen, there were more reflux episodes (17 ± 4 vs 10 ± 2, P = 0.03) and a greater total acid reflux time (12.5 ± 5.9% vs 5.5 ± 3.6%; P = 0.045) than the 300 mL regimen. Both the cross-sectional area of the gastric fundus (P = 0.024) and the number of antral contractions (P = 0.014) were greater for the 600 mL regimen.

CONCLUSIONS

Larger meals are associated with distension of the gastric fundus and an increase in gastroesophageal reflux when compared with smaller, more frequent meals.

Inspiratory muscle training improves antireflux barrier in GERD patients

The crural diaphragm (CD) is an essential component of the esophagogastric junction (EGJ), and inspiratory exercises may modify its function. This study's goal is to verify if inspiratory muscle training (IMT) improves EGJ motility and gastroesophageal reflux (GER). Twelve GER disease [GERD; 7 males, 20-47 yr, 9 esophagitis, and 3 nonerosive reflex disease (NERD)] and 7 healthy volunteers (3 males, 20-41 yr) performed esophageal pH monitoring, manometry, and heart rate variability (HRV) studies. A 6-cm sleeve catheter measured average EGJ pressure during resting, peak inspiratory EGJ pressures during sinus arrhythmia maneuver (SAM) and inhalations under 17-, 35-, and 70-cmH2O loads (TH maneuvers), and along 1 h after a meal. GERD patients entered a 5-days-a-week IMT program. One author scored heartburn and regurgitation before and after IMT. IMT increased average EGJ pressure (19.7 ± 2.4 vs. 29.5 ± 2.1 mmHg; P < 0.001) and inspiratory EGJ pressure during SAM (89.6 ± 7.6 vs. 125.6 ± 13.3 mmHg; P = 0.001) and during TH maneuvers. The EGJ-pressure gain across 35- and 70-cmH2O loads was lower for GERD volunteers. The number and cumulative duration of the transient lower esophageal sphincter relaxations decreased after IMT. Proximal progression of GER decreased after IMT but not the distal acid exposure. Low-frequency power increased after IMT and the higher its increment the lower the increment of supine acid exposure. IMT decreased heartburn and regurgitation scores. In conclusion, IMT improved EGJ pressure, reduced GER proximal progression, and reduced GERD symptoms. Some GERD patients have a CD failure, and IMT may prove beneficial as a GERD add-on treatment.

Double-blind comparative trial with 2 antiregurgitation formulae

BACKGROUND AND AIM

Many mothers consult physicians because of frequent infant regurgitation. Guidelines recommend reassurance and dietary treatment as first approaches. The aim of the present study was to test and compare the efficacy of 2 antiregurgitation formulae (ARF).

METHODS

A prospective, double-blind, randomized cross-over trial was performed for a 1-month period in 115 formula-fed infants (ages 2 weeks-5 months) comparing 2 ARF (ARF-1: nonhydrolyzed protein, locust bean gum; ARF-2: specific whey hydrolysate, locust bean gum, specially treated starch). The primary endpoint was the incidence of regurgitation.

RESULTS

At inclusion, mean age was 9.1 weeks; anthropometric parameters did not differ between the groups. According to the intention-to-treat analysis, the mean number of episodes of regurgitation decreased from 8.25 to 2.32 with ARF-1 and to 1.89 with ARF-2 (statistically significant difference between both ARF, P = 0.0091). The mean score of regurgitated volume decreased significantly more with ARF-2 than with ARF-1 (P = 0.0265). There was no significant difference in stool frequency and consistency between both groups.

CONCLUSIONS

The efficacy of both ARF was demonstrated by the decreased number and volume of regurgitations. ARF-2 was statistically more effective than ARF-1. Comparative trials enable the selection of the best therapeutic option.

Nonpharmacological management of gastroesophageal reflux in preterm infants

Gastroesophageal reflux (GOR) is very common among preterm infants, due to several physiological mechanisms. Although GOR should not be usually considered a pathological condition, its therapeutic management still represents a controversial issue among neonatologists; pharmacological overtreatment, often unuseful and potentially harmful, is increasingly widespread. Hence, a stepwise approach, firstly promoting conservative strategies such as body positioning, milk thickening, or changes of feeding modalities, should be considered the most advisable choice in preterm infants with GOR. This review focuses on the conservative management of GOR in the preterm population, aiming to provide a complete overview, based on currently available evidence, on potential benefits and adverse effects of nonpharmacological measures. Nonpharmacological management of GOR might represent a useful tool for neonatologists to reduce the use of antireflux medications, which should be limited to selected cases of symptomatic babies.

Gallbladder and gastric motility in obese newborns, pre-adolescents and adults

BACKGROUND AND AIM

Impaired gallbladder and gastric motility have been associated with obesity in adults. The timing of appearance of this dysfunction, however, is unclear.

METHODS

Lean and obese subjects from three different age groups were studied noninvasively: 50 newborns (1-12 months old, six obese), 18 pre-adolescents (7-8 years old, seven obese), and 99 adults (22-80 years old, 32 obese) classified according to standard normal tables and body mass index. Changes of fasting/postprandial gallbladder and gastric motility were assessed simultaneously by functional ultrasonography in response to milk (newborns and pre-adolescents) and to a liquid test meal (adults).

RESULTS

In newborns, fasting and postprandial gallbladder volumes and gastric emptying were similar between obese and lean subjects. In pre-adolescents, obese subjects had a larger fasting gallbladder volume, with slower postprandial gastric emptying than lean subjects. In obese adults, the most evident dysfunction emerged, with larger fasting and postprandial residual gallbladder volume, and slower postprandial gastric emptying than lean subjects.

CONCLUSIONS

Obese subjects display abnormal gallbladder and gastric motility patterns, which first appear in pre-adolescents and deteriorate in adults. Such abnormalities are absent in obese newborns. Functional ultrasonography can detect altered cholecysto-gastric motility at the earliest stage. Our findings suggest an age-related decline of motility, probably secondary to excessive fat and insulin-resistance.

Lactobacillus reuteri accelerates gastric emptying and improves regurgitation in infants

BACKGROUND

Young infants are frequently affected by uncomplicated regurgitation that may persist despite dietetic and conservative interventions. On this basis, we studied the putative effects of probiotics on the frequency of regurgitation and gastric emptying time in infants with functional gastroesophageal reflux (GER).

PATIENTS AND METHODS

Forty-two infants with regurgitation were randomized to assume Lactobacillus reuteri DSM 17938 at a dose of 1 × 10(8) CFU per day and placebo for 30 days. The episodes of regurgitation were recorded by the parents each day. Gastric emptying time was recorded using real-time ultrasound at baseline and at the end of the study. Twenty-one infants without regurgitation were enroled to compare anthropometric and physiological parameters before the intervention diet.

RESULTS

Thirty-four infants completed the study (19 infants receiving probiotics and 15 placebo).At baseline, the whole group of infants was similar to the control group as regards anthropometric and physiological data. The median fasting antral area was significantly reduced, (P = 0·01) the delta in gastric emptying rate was significantly increased (P = 0·01) and the median episodes per day of regurgitation was reduced (, P < 0·001) in the probiotic group compared to the placebo group. In the whole group, the frequency of regurgitation and the basal antral area showed a positive correlation (r = 0·53, P = 0·004).

CONCLUSIONS

In infants with functional GER, L. reuteri DSM 17938 reduce gastric distension and accelerate gastric emptying. In addition, this probiotic strain seems to diminish the frequency of regurgitation.

Protein content and fortification of human milk influence gastroesophageal reflux in preterm infants

OBJECTIVES

: Preterm human milk (HM) may provide insufficient energy and nutrients and thus may need to be fortified. Our aim was to determine whether fat content, protein content, and osmolality of HM before and after fortification may affect gastroesophageal reflux (GER) in symptomatic preterm infants.

METHODS

: Gastroesophageal reflux was evaluated in 17 symptomatic preterm newborns fed naïve and fortified HM by combined pH/intraluminal-impedance monitoring (pH-MII). Human milk fat and protein content was analysed by a near-infrared reflectance analysis. Human milk osmolality was tested before and after fortification. Gastroesophageal reflux indexes measured before and after fortification were compared and were also related to HM fat and protein content and osmolality before and after fortification.

RESULTS

: An inverse correlation was found between naïve HM protein content and acid reflux index (RIpH: P = 0.041, rho =-0.501). After fortification, osmolality often exceeded the values recommended for infant feeds; furthermore, a statistically significant (P < 0.05) increase in nonacid reflux indexes was observed.

CONCLUSIONS

: Protein content of naïve HM may influence acid GER in preterm infants. A standard fortification of HM may worsen nonacid GER indexes and, due to the extreme variability in HM composition, may overcome both recommended protein intake and HM osmolality. Thus, an individualised fortification, based on the analysis of the composition of naïve HM, could optimise both nutrient intake and feeding tolerance.

The Case of the Wretched Retcher

Fundoplication is an effective treatment for severe gastroesophageal reflux disease (GERD) because it provides a mechanical solution to what is essentially a mechanical, not a medical, problem. However, manifestations of feeding intolerance postfundoplasty are well known and include dysphagia, gastric dysfunction, retching, gagging, intestinal dysfunction, and gas bloat syndrome. These difficulties are exacerbated by feeding plans that disregard the mechanical constraints imposed by the operation, particularly limited gastric volume, decreased gastric compliance, diminished ability to burp, sensitivity to osmolarity, and formula composition. These complications are preventable and treatable by informed construction of feeding plans that limit boluses (around 15 mL/kg/bolus), promote proper motility, manage intraluminal air, and limit polypharmacy. This case presentation describes a postfundoplasty infant with severe retching and intolerance treated according to these principles.

The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms

BACKGROUND & AIMS

The effects of diet on gastroesophageal reflux disease are not well understood. This study assessed the effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms in patients with reflux symptoms.

METHODS

Patients referred for the investigation of reflux symptoms were recruited (most with nonerosive disease). A catheter-free system provided esophageal pH monitoring over 4 days in 4 dietary conditions. A high-fat (50%) vs low-fat (25%) diet (calorie-controlled), and a high-calorie (1000 kcal) vs low-calorie (500 kcal) diet (fat-controlled) were provided in randomized order, and meal volume was controlled. The effects of meal consistency also were studied.

RESULTS

Complete data were available for 15 patients (6 men, 9 women; age, 48 y; range, 26-70 y; body mass index, 26 kg/m2; body mass index range, 21-35 kg/m2). Demographic variables and meal sequence had no effect on reflux parameters. Dietary composition had effects on esophageal acid exposure (F statistic [analysis of variance] = 7.4, P < .005) and symptoms (Friedman test = 24.2, P < .001). No effect of meal consistency was present. Esophageal acid exposure was greater during the high-calorie than the low-calorie diet (mean, 8.6% +/- 2.0% vs 5.2% +/- 1.4% time pH < 4/24 h; P < .01). No difference was observed between the high-fat and low-fat diets (mean, 8.6% +/- 2.0% vs 8.2% +/- 1.6% time pH < 4/24 h; P = NS). In contrast, the frequency of reflux symptoms was not affected by calorie density (median, 6; range, 2-12 vs median, 8; range, 2-13; P = NS) but was increased by the high-fat compared with the low-fat diet (median, 11; range, 5-18 vs median, 6; range, 2-12; P < .05).

CONCLUSIONS

Calorie density determines the severity of esophageal acid exposure in gastroesophageal reflux disease after a meal; however, the percentage fat content of the diet has important effects on the frequency of reflux symptoms.

Osmolality of preterm formulas supplemented with nonprotein energy supplements

BACKGROUND

Addition of energy supplements to preterm formulas is an optional strategy to increase the energy intake in infants requiring fluid restriction, in conditions like bronchopulmonary dysplasia. This strategy may lead to an undesirable increase in osmolality of feeds, the maximum recommended safe limit being 400 mOsm/kg. The aim of the study was to measure the changes in osmolality of several commercialized preterm formulas after addition of glucose polymers and medium-chain triglycerides.

METHODS

Osmolality was measured by the freezing point depression method. Six powdered formulas with concentrations of 14 g/100 ml and 16 g/100 ml, and five ready-to-feed liquid formulas were analyzed. All formulas, were supplemented with 10% (low supplementation) or 20% (high supplementation) of additional calories, respectively, in the form of glucose polymers and medium chain triglycerides, maintaining a 1:1 glucose:lipid calorie ratio. Inter-analysis and intra-analysis coefficients of variation of the measurements were always < 3.9%.

RESULTS

The mean osmolality (mOsm/kg) of the non-supplemented formulas varied between 268.5 and 315.3 mOsm/kg, increasing by 3-5% in low supplemented formulas, and by 6-10% in high supplemented formulas. None of the formulas analyzed exceeded 352.8 mOsm/kg.

CONCLUSION

The supplementation of preterm formulas with nonprotein energy supplements with up to 20% additional calories did not exceed the maximum recommended osmolality for neonatal feedings.

Variability of the 13C-acetate breath test for gastric emptying of liquids in healthy children

PURPOSE

Scintigraphy is considered as the "gold standard" for measuring gastric emptying (GE). The C-acetate breath test (C-ABT) offers an attractive alternative to measure GE of liquids as it is nonradioactive. The aim of this study was to assess the variability of the C-ABT for GE of liquids in healthy children using nondispersive infrared spectrometry (NDIRS).

METHODS

The C-ABT was repeated at least 2 times in 21 healthy children (6 girls and 15 boys), aged between 6.2 and 16.4 years, 2 to 7 days apart. After an overnight fast, a standardized milk drink, labeled with 50 or 100 mg C-acetate according to weight, was administered. Breath samples were taken before feeding, at 5-minute intervals for the first 40 minutes and at 10-minute intervals for the following 140 minutes after feeding. Breath samples were analyzed using NDIRS, and C recovery was used to calculate values for gastric half-emptying time (t1/2), time of peak C exhalation, or gastric lag phase (tlag) and gastric emptying coefficient (GEC). Intraindividual variabilities of the parameters t1/2, tlag, and GEC were expressed as coefficient of intrasubject variation (CV).

RESULTS

The median CV of t1/2 was 8.3% (CV range, 1.6%-16.2%; t1/2 interindividual range, 65-112 minutes; and t1/2 intraindividual range, 4-33 minutes). The median CV of tlag was 16.6% (CV range, 2.0%-26.6%; tlag interindividual range, 31-76 minutes; and tlag intraindividual range, 1-35 minutes). The median CV of GEC was 4.3% (CV range, 0.8%-15.7%; GEC interindividual range, 3.81-4.89; GEC intraindividual range, 0.08-1.31). The CVs of t1/2, tlag, and GEC were independent of age, sex, weight, height, and measured values of t1/2, tlag, and GEC.

CONCLUSIONS

The C-ABT using NDIRS is an easy, noninvasive, and nonradioactive procedure with a large intraindividual variation for measuring GE of liquids in healthy children, but comparable to the variation reported with other techniques.

Ultrasonographic study of postcibal gastro-esophageal reflux and gastric emptying in infants with recurrent respiratory disease

AIM

To check the utility of postcibal ultrasonography for the evaluation of reflux in relation to gastric emptying in infants with recurrent respiratory symptoms and to link imaging with clinical data.

METHODS

Esophageal reflux (hyperechoic retrograde filling) and gastric emptying (antral areas) were quantified before and after ingestion of a standard formula in 35 untreated infants (13 with chronic cough, 22 with recurrent bronchitis) and in 31 controls.

RESULTS

The prevalence of abnormal (> or =8 episodes) postcibal refluxes was 74% in patients and 3% in controls. Number, duration of the longest episode and extent of refluxes were significantly higher in patients compared to controls. Number of refluxes was higher in patients with symptomatic refluxes than in those without. Infants with recurrent bronchitis had more refluxes than those with chronic cough and controls. Extent and timing of gastric emptying were similar in patients and controls.

CONCLUSION

Esophageal ultrasonography is a useful and physiological test in infants with recurrent respiratory diseases, which have a high prevalence of abnormal postcibal esophageal reflux and a gastric emptying similar to that of normal controls. Esophageal reflux is more severe in subjects with recurrent bronchitis than in those with chronic cough.

Gastroesophageal reflux and cow milk allergy: is there a link?

Gastroesophageal reflux (GER) and cow milk allergy (CMA) occur frequently in infants younger than 1 year. In recent years, the relation between these 2 entities has been investigated and some important conclusions have been reached: in up to half of the cases of GER in infants younger than 1 year, there may be an association with CMA. In a high proportion of cases, GER is not only CMA associated but also CMA induced. The frequency of this association should induce pediatricians to screen for possible concomitant CMA in all infants who have GER and are younger than 1 year. With the exception of some patients with mild typical CMA manifestations (diarrhea, dermatitis, or rhinitis), the symptoms of GER associated with CMA are the same as those observed in primary GER. Immunologic tests and esophageal pH monitoring (with a typical pH pattern characterized by a progressive, slow decrease in esophageal pH between feedings) may be helpful if an association between GER and CMA is suspected, although the clinical response to an elimination diet and challenge is the only clue to the diagnosis. This article reviews the main features of GER and CMA, focusing on the aspects in common and the discrepancies between both conditions.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) affects many patients and has a negative effect on quality of life. Along with the increasing prevalence of GERD is an increase in GERD-related complications, including Barrett esophagus and esophageal adenocarcinoma. The past year has yielded new insights into the pathophysiology of GERD that can help us to better understand the relationship between reflux episodes and symptoms of mucosal damage and to provide a tailored treatment targeting individual pathophysiologic defects. The issues addressed in this report include gastric secretory and motor dysfunction; failure of the antireflux barrier caused by hiatal hernia and transient lower esophageal sphincter relaxations; characterization of the refluxate, particularly of nonacid reflux; prevalence and prognostic value of esophageal dysmotility in GERD; presence and eradication of Helicobacter pylori; Barrett esophagus and extraesophageal manifestations of GERD; and, finally, advances in medical, endoscopic, and surgical treatments of GERD.