Reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients

Association between follicular tracheitis and gastroesophageal reflux

OBJECTIVE

Follicular tracheitis (also known as tracheal cobblestoning) is an entity that is poorly described and of unclear significance. The objective of this study was to better define follicular tracheitis and determine the association between the clinical finding of follicular tracheitis on bronchoscopy and objective evidence of gastroesophageal reflux disease.

METHODS

Retrospective chart review of children with recurrent croup having undergone a rigid bronchoscopy and an investigation for gastroesophageal reflux between 2001 and 2013.

RESULTS

117 children with recurrent croup children age 6-144 months were included in the study. Follicular tracheitis was noted on 41% of all bronchoscopies. Fifty-nine percent of all children who underwent bronchoscopy were diagnosed with gastroesophageal reflux on at least one investigation. Forty-nine of 117 children underwent a pH probe study, and 51% were found to have evidence of reflux on this study. Nine children were diagnosed with eosinophilic esophagitis. Three patients underwent a biopsy of the follicular tracheitis lesions, which revealed chronic inflammation. There was no evidence of an association between findings of follicular tracheitis and a positive test for gastroesophageal reflux (p=0.52) or a positive pH probe study (p=0.64). There was no association between follicular tracheitis and subglottic stenosis (p=0.33) or an history of asthma and/or atopy (p=0.19).

CONCLUSION

In children with recurrent croup, follicular tracheitis remains an unspecific finding associated with an inflammatory disorder of unknown etiology.

Continuous 48-Hour Wireless Esophageal pH Monitoring in Children: Comparison Between Days 1 and 2

AIM

Comparison of days 1 and 2 to each other and to the total recording of 48 hours in continuous 48-hour wireless esophageal pH monitoring in children.

METHODS

A retrospective study of 105 patients who underwent 48-hour pH monitoring (Bravo) studies between January 1992 and June 2010 was performed. Reflux variables were compared between days 1 and 2.

RESULTS

A total of 58 (55.2%) patients were men. The number of reflux episodes, number of long reflux >5 minutes, duration of the longest reflux (minutes), time pH <4 (minutes), fraction time pH <4 supine (%), fraction time pH <4 upright (%), reflux index, and DeMeester score did not differ between days 1 and 2.

CONCLUSIONS

No effect of anesthesia was observed on the gastroesophageal reflux parameters on children.

Comparison of the efficiencies of esophageal manometry, vector volume analysis and esophagus pH monitoring in the diagnosis of gastroesophageal reflux

AIM

In this study, we aimed to compare the superiorities of esophageal manometry, vector volume analysis and 24-hour pH meter studies in showing gastroesophageal reflux disease.

MATERIAL AND METHODS

The files of the patients who presented to pediatric surgery and pediatric gastroenterology outpatient clinics of our hospital with suspicious gastroesophageal reflux disease between 2011 and 2012 and who were investigated were examined and 21 patients whose investigations had been completed were included in the study. The patients were evaluated by treatment method and were divided into three groups as Group 1 who were followed up with medical treatment, Group 2 in whom surgical intervention was performed and Group 3 who were not treated. Chi-square test was used in evaluation of the categorical variables, Kruskal Wallis test was used in comparison of the mean values between the groups and Dunn test was used in subgroup analyses when Kruskal Wallis test was found to be significant. A p value of <0.05 was considered statistically significant.

RESULTS

Thirteen of 21 patients included in the study were female and eight were male. The mean age of the patients was 5.71 years (one-16 years). In the 24-hour pH monitoring study, the mean reflux index was found to be 48.7% in Group 1, 42.4% in Group 2 and 28.3% in Group 3. In esophageal manometry studies, the pressure difference at lower esophageal sphincter (LES) was found to be 13,4 cm H2O in Group 1, 31.8 cm H2O in Group 2 and 4.3 cmH2O in Group 3. In vector volume analyses, the mean vector volume was calculated to be 96.01 cm(3) in Group 1, 2 398.9 cm(3) in Group 2 and 196.3 cm(3) in Group 3. In the 24-hour pH monitoring study, a statistically significant difference (p<0.05) was found in terms of showing reflux, whereas statistical significance could not be shown in terms of need for surgical treatment or need for medical treatment in any other method (p>0.05).

CONCLUSIONS

Twenty-four-hour pH monitoring was found to be efficient in making a diagnosis of gastroesophageal reflux disease, whereas esophageal manometry and vector volume analyses were not found to be efficient.

Effect of anesthesia on gastroesophageal reflux in children: a study using BRAVO wireless pH study measurements

BACKGROUND

Adult studies suggest conscious sedation increases gastroesophageal reflux (GER), but the role of anesthesia on GER in children is unclear. Our aim was to study the anesthesia effects on GER and pH study interpretation in children.

METHODS

Children undergoing BRAVO wireless pH capsule placement under anesthesia and study duration >36 h were included. We evaluated the pH parameters (number of reflux episodes >5 min, duration of longest reflux episode, time pH <4 and fraction time pH <4) at 1, 2, 6-h and total study duration blocks using 2 cutoff values (5.3% and 6%) for the worst day, average of both days, and 1st day alone. We compared time blocks to evaluate the effect of anesthesia on GER and the proportions of studies changing interpretation after excluding the 1st hour and 1st 2-h blocks to evaluate anesthesia effect on study interpretation.

KEY RESULTS

A total of 150 children were included. We found a significant increase on the pH parameters in the 1st hour compared to subsequent block times suggesting an effect of anesthesia on GER. We found no significant change in the proportion of studies interpreted as normal vs abnormal, however, excluding the initial 2 h of the study would change the study interpretation from abnormal to normal in up to 5% of patients.

CONCLUSIONS & INFERENCES

We found an effect of anesthesia increasing the GER parameters mainly in the 1st hour and up to the first 6 h of the study that may result in a change in the study interpretation.

The relationship between gastroesophageal reflux and cough in children with chronic unexplained cough using combined impedance-pH-manometry recordings

INTRODUCTION

Assessment of the reflux-cough association in children is challenging. Esophageal (impedance) pH recording is sensitive to recognize reflux. However, cough recorded by an event marker, possibly lacks accuracy. We aimed to study the exact time relationship between reflux and cough in children with chronic cough.

METHODS

Twenty-six children (12 boys; 1-10.5 years) with chronic unexplained cough underwent ambulatory impedance-pH-manometry recordings. Manometry was used for precise cough recognition. Reflux was assessed with impedance-pH monitoring and defined as acid (pH <4), weakly acidic (WA) (pH 4-7), weakly alkaline (WALK) (pH ≥7), or acid only (pH <4 for ≥4 sec without impedance pattern). Cough was considered "induced by" reflux, if it started ≤2 min after reflux. The Symptom Association Probability (SAP) was calculated and considered positive if >95%. Cough-induced reflux if it occurred 30 sec before the reflux event.

RESULTS

Impedance-pH detected 30 (21-52) reflux episodes/patient (55.2% acid, 41.5% WA, and 3.3% WALK). Additionally 59 acid only events were identified [1 (0-21)/patient]. Manometry detected 47 (5-203) cough bursts/patient. Reflux-cough was found in 22/26 patients. Ten patients had a +SAP for reflux-cough (one acid, six WA, and three acid + WA gastroesophageal reflux [GER]), of which nine had a normal acid exposure. Six out of 10 patients with +SAP using manometry had a +SAP using the event marker. Cough-reflux was detected in 19 patients [3 (0-7)/patient]. Only a small fraction of the esophageal acid exposure [9.6 (0.4-31.8%)] was secondary to cough.

CONCLUSION

Both acid and WA GER may precede cough in children with unexplained cough, but cough does not induce GER. Objective cough recording improves symptom association analysis.

Regurgitation in healthy and non healthy infants

Uncomplicate regurgitation in otherwise healthy infants is not a disease. It consists of milk flow from mouth during or after feeding. Common causes include overfeeding, air swallowed during feeding, crying or coughing; physical exam is normal and weight gain is adequate. History and physical exam are diagnostic, and conservative therapy is recommended. Pathologic gastroesophageal reflux or gastroesophageal reflux disease refers to infants with regurgitation and vomiting associated with poor weight gain, respiratory symptoms, esophagitis. Reflux episodes occur most often during transient relaxations of the lower esophageal sphincter unaccompanied by swallowing, which permit gastric content to flow into the esophagus. A minor proportion of reflux episodes occurs when the lower esophageal sphincter fails to increase pressure during a sudden increase in intraabdominal pressure or when lower esophageal sphincter resting pressure is chronically reduced. Alterations in several protective mechanisms allow physiologic reflux to become gastroesophageal reflux disease; diagnostic approach is both clinical and instrumental: radiological series are useful to exclude anatomic abnormalities; pH-testing evaluates the quantity, frequency and duration of the acid reflux episodes; endoscopy and biopsy are performed in the case of esophagitis. Therapy with H2 receptor antagonists and proton pump inhibitors are suggested.

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.

Tolerability and clinical utility of the Bravo pH capsule in children

GOALS

To prospectively evaluate the tolerability and clinical utility of the Bravo pH capsule in children.

BACKGROUND

Acid reflux is common in children, and pH testing can be used to correlate acid exposure with symptom expression. The tolerability and clinical utility of the Bravo capsule in children has not been prospectively evaluated.

METHODS

This was a prospective, open-label trial conducted at an academic medical center. Patient demographics, symptoms, and medication use were recorded in an outpatient setting. After Bravo capsule placement, patients were followed to determine whether the results of the Bravo capsule study changed clinical management.

RESULTS

Fifty children (mean+/-SD=13+/-3 y; 52% female) were studied; no complications occurred. Reflux symptoms (40%), abdominal pain (18%), and nausea/vomiting (14%) were the 3 most common symptoms leading to Bravo capsule placement. Nearly all studies (96%) were performed off acid-suppressing medications. Results of the Bravo pH study changed clinical care in 88% of children; management changed more frequently in children with an abnormal study (94%) versus those with a normal study (78%; P<0.0001).

CONCLUSIONS

The Bravo pH capsule is a safe, well-tolerated test to evaluate acid reflux symptoms in children, and the data obtained frequently changes patient management.

Prevalence and associated features of gastroesophageal reflux symptoms in a Caucasian-predominant adolescent school population

OBJECTIVE

To determine the prevalence of esophageal symptoms and associated symptoms of gastroesophageal reflux symptoms in 14-18 year-old high school students and the percentage of symptomatic adolescents who saw a physician or received medications.

DESIGN AND SETTING

A cross-sectional questionnaire administered to students at two high schools.

PARTICIPANTS

1,286 completed questionnaires were analyzed. The study sample consisted of 57% Caucasians and 57% males, with a mean age of 15.7 (+/-1.3) years.

INTERVENTION

No intervention was used. Participants completed questionnaires only.

RESULTS

714 students (56%) reported at least one esophageal or respiratory symptom. Esophageal symptoms reported were: heartburn (22%), regurgitation (21%), and dysphagia (15%). Respiratory symptoms reported were: shortness of breath (24%), wheezing (20%), and cough (18%). Students with at least one esophageal symptom were more likely to experience at least one respiratory symptom than were students with no esophageal symptoms (52% vs. 25%; p < 0.001). Cigarette, alcohol, and non-steroidal anti-inflammatory drug use were risk factors for both respiratory and esophageal symptoms. Of those experiencing one or more of these symptoms, 4% reported that the symptoms affected their daily activities, 23% visited a physician, and 25% took medication in the past year.

CONCLUSIONS

Esophageal symptoms of gastroesophageal reflux are frequent in adolescents. Fewer than 25% of students with gastroesophageal reflux symptoms consulted a physician and/or took medications.

Accuracy and tolerability of the Bravo catheter-free pH capsule in patients between the ages of 4 and 18 years

OBJECTIVE

The aim of this study was to determine if the Bravo pH capsule is comparable to the nasally placed pH catheter in terms of pH-metry, safety, and tolerability in children.

METHODS

Ten patients each in the age ranges of 4 to 6 years, 7 to 10 years, and >10 years were tested simultaneously with the catheter and the capsule. Six each were tested with the catheter alone or the capsule alone. Subjects recorded adverse events and graded tolerance (in terms of activity, appetite, and satisfaction) on a scale of 1 to 5, with a score of 5 indicating that the device was well tolerated. A 24-hour reflux index and 24- and 48-hour reflux indices were generated from the catheter and capsule, respectively. Student t test, Mann-Whitney U test, and Fisher exact test were used to compare reflux index, tolerability, and adverse events between the catheter and capsule.

RESULTS

Sixty-six patients 4 to 16 years of age (mean, 9.4 years) were enrolled. There was no statistically significant difference between the mean reflux indices (RIs) obtained simultaneously with the catheter and capsule in all patients combined on day 1 (P = 0.0665). There was a significant difference between day 2 and days 1 and 2 combined with the capsule versus the catheter (P = 0.007 and P = 0.0107); however, a discordant result of normal RI on day 1 and pathological RI on day 2 was seen in only 1 patient. The capsule was better tolerated than the catheter in terms of appetite (P = 0.029), activity (P = 0.001), and satisfaction (P = 0.003). There were no significant complications.

CONCLUSIONS

The Bravo pH capsule was as accurate and safe and better tolerated than the conventional pH catheter in children 4 years of age and older.

Gastrointestinal phenotype of ATR-X syndrome

X-linked alpha thalassemia mental retardation (ATR-X) syndrome is associated with profound developmental delay, facial dysmorphism, genital abnormalities, and alpha thalassemia. Patients with ATR-X syndrome frequently present with gastrointestinal problems, in particular feeding difficulties, regurgitation and vomiting, abdominal pain, distension, and chronic constipation. Parental reports of prolonged food refusal and distress in these children are common and although these episodes are suspected to be gastro-intestinal in origin they are rarely investigated. Death in early childhood from aspiration of vomitus or from pneumonia presumed to be secondary to aspiration has been recorded in a number of ATR-X cases. In this report we review the gastrointestinal phenotype of ATR-X syndrome in 128 cases. We also demonstrate that in two siblings, regurgitation was secondary to gastric pseudo-volvulus, a condition in which the stomach does not have a normal system of peritoneal ligaments and changes position with possible torsion around itself. Furthermore, ultra-short Hirschsprung disease with colonic hypoganglionosis was shown and this may contribute to the severe constipation affecting these children.

Diagnostic and management problems of laryngopharyngeal reflux disease in children

OBJECTIVE

Reflux is a common pediatric disorder and an association between reflux and otolaryngological conditions has been described. However, to prove a causal relationship a pathophysiological pathway must be identified, diagnostic test with high specificity and sensitivity must be developed and conservative or surgical treatment of reflux should be shown to predictably improve the otolaryngological problems. This review study aims at examining the available evidence for the above controversial issues.

METHODS

Articles on pediatric laryngopharyngeal reflux published in English during the last decade were searched using Ovid and PubMed.

RESULTS

A lack of consensus was found in four separate but interdependent areas: clinical manifestations, diagnostic testing, interpretation of findings and treatment. Although clinical experience and uncontrolled case series suggest that laryngopharyngeal reflux may possibly contribute to apnea, recurrent upper respiratory infections, laryngeal symptoms (mainly laryngomalacia and subglottic stenosis), sinusitis and otitis convincing data are lacking. For pediatric studies, the diagnostic role of pH monitoring, barium esophagram, scintigraphy, impedance monitoring, laryngoscopic examination, laryngeal biopsy and symptom assessment questionnaires remain to be defined. Interpretation of pharyngeal reflux events is controversial and the lack of established normative values as well as the existing variability in the diagnostic criteria (reflux definition, duration and number of pathological reflux events) limits the ability to directly compare results. Proposed laryngopharyngeal reflux treatment (lifestyle modification, medical or surgical therapy) is mostly empiric, with no significant placebo-controlled trials of treatment and outcomes.

CONCLUSIONS

Limited evidence exists to support a causative relationship between reflux and any otorhinolaryngological condition or the effectiveness of treatment. Epidemiological and large-scale prospective controlled studies are required to clarify these issues.

Gastroesophageal reflux disease in children with asthma: treatment implications

An association between asthma and gastroesophageal reflux disease (GERD) has long been recognized both mechanistically and epidemiologically. The clinical relevance of this interplay continues to be explored, with special interest given to the role of GERD in the worsening of asthma. The effect of GERD is most frequently contemplated in patients with asthma that is difficult to control. Medical and surgical anti-reflux trials attempting to alter asthma symptoms have reported mixed but generally underwhelming results, although asthma symptom scores are generally improved following effective treatment of GERD. Many of the pharmaceutical studies can be criticised for having too short a duration or for likely incomplete acid suppression. Few trials have specifically studied pediatric populations. Because GERD is a common condition, particularly in young children, the role reflux plays in the worsening of asthma symptoms and the potential benefit on asthma of anti-reflux therapy warrants further exploration. Whether or not treating symptomatic GERD reduces the symptoms and severity of asthma in children, GERD coexisting with asthma should be aggressively treated. GERD symptoms in most patients with or without asthma can be controlled medically with continuous use of proton pump inhibitors such as omeprazole and lansoprazole and to a lesser extent by histamine H(2) receptor antagonists such as famotidine and cimetidine.

Tolerance and reliability of wireless pH monitoring in children

OBJECTIVES

The purpose of this study was to determine whether the placement of a wireless capsule pH monitoring system improved the reproducibility and patient comfort of pH probe studies in children.

METHODS

The records of 50 children who underwent wireless pH monitoring were retrospectively reviewed. Among this group, 44 children (27 males and 17 females) met inclusion criteria. The average age was 11.8 years, with a range from 6 years to 19 years. Each of these patients had a capsule placed 6 cm above the squamocolumnar junction and underwent pH telemetry for 2 days. In addition, 38 of the 44 families were contacted for follow-up to determine the tolerability of the catheter-free monitoring.

RESULTS

Data analysis revealed that the overall reproducibility of a single 24 hour period was 77%. Studies were considered reproducible if the reflux index was normal (pH <4 for less than 5% of study period) or abnormal on both study days. Using McNemar's exact test, we found no significant difference between the two days (P = 0.11). Ten of 44 patients had conflicting results on day 1 compared with results on day 2. The majority (68%) of patients reported some degree of discomfort during the study; however, this pain was generally mild. Ninety-five percent of parents would be willing to have their child undergo pH monitoring in the future with the wireless pH monitoring.

CONCLUSIONS

Catheter-free prolonged esophageal pH monitoring is feasible in children older than 6 years of age. A lack of consistent reproducibility in sequential 24 hour recordings with this technique concurs with findings using the conventional catheter methodologies. The catheter-free system is often associated with discomfort during the study, but these symptoms were generally well tolerated.

Gastroesophageal reflux disease in children: association between symptoms and pH monitoring

OBJECTIVE

The prevalence of symptoms associated with gastroesophageal reflux disease (GERD) in patients with abnormal results of pH monitoring has been investigated in adults and infants. A questionnaire suitable for children between 7 and 16 years of age has been proposed, but this tool has so far not been validated. In the present study the items of the questionnaire are validated against results from an esophageal 24-h study of pH.

MATERIAL AND METHODS

Ninety-nine children aged from 7 to 16 years referred from two outpatient clinics for suspected GERD completed the 7-point questionnaire regarding symptoms during the week prior to a pH study. The frequency of symptoms was investigated in patients with abnormal versus normal pH (reflux index >/< 5.0). A group of healthy children (n = 284) served as controls to estimate the frequency of symptoms in the normal population.

RESULTS

It was found that 37/99 (37%) of patients had an abnormal pH study result. Regurgitation/vomiting yielded the best symptom discrimination, and was reported by 46% with abnormal versus 24% with normal pH-study results (p = 0.029). A weighted score including the five best discriminating symptoms was positive in 75% versus 44% (OR 3.78, CI 1.52-9.37, p = 0.006). In a comparison of children with abnormal pH studies and healthy controls, a correct diagnosis based on five symptoms could be obtained in 75% and 94%, respectively.

CONCLUSIONS

A relatively weak association was found between reflux symptoms and a positive pH study in 7-16-year-old children referred for pH monitoring. Thus, the questionnaire is not a diagnostic tool, and its potential use is limited to epidemiological studies.

[Chronic cough in childhood]

Introduction

La toux chronique de l’enfant bien que moins fréquente que les toux répétées liées aux infections virales reste un problème diagnostique parfois difficile à résoudre.

États des connaissances

La majorité des auteurs estiment que sa durée doit être supérieure à trois semaines. Peu d’études ont été consacrées au diagnostic étiologique de la toux chronique chez l’enfant mais celles-ci retrouvent les mêmes causes principales que chez l’adulte : l’asthme, les pathologies ORL (dont la sinusite), le reflux gastro-œsophagien. Chaque tranche d’âge connaît des étiologies plus spécifiques ; notamment malformatives entre 0 et 1 an, et toux psychogène chez l’adolescent.

Perspectives

Des techniques « nouvelles » comme l’étude de l’expectoration induite permettent d’affiner le diagnostic d’une toux chronique de l’enfant en tout cas après 7 ans. La découverte d’une bronchite à éosinophiles quelle soit associée ou pas à une hyperréactivité bronchique a des conséquences thérapeutiques indiscutables compte tenu de sa corticosensibilité.

Conclusions

L’exploration d’une toux chronique de l’enfant doit reposer sur un raisonnement anatomique et sur des arguments de fréquence. Le contrôle et la disparition de la toux ne seront possibles qu’avec un diagnostic précis et un traitement adapté.

Diagnostic interpretation of extended pH monitoring: is there a single best method?

Our aims were to compare the specificity and sensitivity of the reflux index (RI), Euler and Byrne score (EBS), and area under the curve (AUC) at pH < 4.0 in infants 1 year old for identifying pathologic gastroesophageal reflux (GER) and to identify new cutoffs on formula feedings. We undertook a prospective investigation of extended pH monitoring (EPM) in 117 infants with symptoms of GER. Infants were categorized as having pathologic reflux by three measures: RI > or = 5%, EBS > or = 50, or AUC pH < 4.0 or < or = 21.3, as determined by receiver operating characteristic (ROC) curve analysis. Using the RI as a criterion, 27 infants (23%) had pathologic reflux. When EBS and AUC were used, 65 (56%), and 67 (57%) respectively, were classified as having pathologic reflux. The specificities of RI, EBS, and AUC were 97.8, 100.0, and 100.0%, respectively, and the sensitivities were 93.0, 91.5, and 94.4, respectively. A new cutoff value for RI of 2.1% was determined using ROC curve analysis to improve the specificity and sensitivity of RI to the above values. The number of infants with pathologic GER is likely to be significantly less using the traditional RI alone on formula feedings, however, the revised RI cutoff value and AUC analysis by computerized pH tracings can enhance the accuracy on formula feedings.

Effects of thickened feeding on gastroesophageal reflux in infants: a placebo-controlled crossover study using intraluminal impedance

OBJECTIVE

Thickening of formula feedings is part of the therapeutic approach for gastroesophageal reflux (GER) in infants. However, its mechanism of action, especially regarding the occurrence of nonacid (pH >4) GER, has not yet been clearly described. The aim of this randomized, placebo-controlled crossover study was to examine the influence of formula thickened with carob (St. John's bread) bean gum on acid and nonacid GER.

METHODS

Infants with recurrent regurgitation and without other symptoms were fed alternately (A-B-A-B-A-B) with thickened (A) and nonthickened (B) but otherwise identical formula. Documentation of GER episodes during the study was performed by simultaneous intraesophageal impedance measurement (intraluminal electrical impedance; IMP) and pH monitoring. The IMP technique is able to detect bolus movements inside a luminal organ. The use of multiple measuring segments on a single catheter allowed the analysis of direction, height, and duration of the bolus transport. Continuous videorecording and visual surveillance of regurgitation frequency and amount resulted in a severity score.

RESULTS

Fourteen infants (42 +/- 32 days old) were examined during 6 feeding intervals each for a total measuring time of 342 hours. A total of 1183 GER episodes and 83 episodes of regurgitation were registered. Regurgitation frequency (15 vs 68 episodes) and amount (severity score 0.6 vs 1.8) were significantly lower after feedings with thickened formula. The difference regarding the occurrence of GER documented by IMP was also pronounced (536 vs 647 episodes). Although not statistically significant, maximal height reached by the refluxate in the esophagus was decreased after thickened feedings. Mean GER duration and the frequency of acid (pH <4) GER were not altered.

CONCLUSIONS

Thickened feeding has a significant effect on the reduction of regurgitation frequency and amount in otherwise healthy infants. This effect is caused by a reduction in the number of nonacid (pH >4) GER episodes, but also because of a decrease of mean reflux height reached in the esophagus. However, the occurrence of acid GER is not reduced. The combination of IMP and pH monitoring allows the complete registration and description of these GER episodes. Thickening of formula feedings with carob bean gum is an efficient therapy for uncomplicated GER in infants.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Gastro-oesophageal reflux: clinical profiles and outcome

OBJECTIVES

To assess the clinical features, investigations and outcome of 69 children (40 males, 29 females) with gastro-oesophageal reflux (GOER) referred to a tertiary referral centre in paediatric gastroenterology.

METHODS

A study of all patients with significant GOER seen at the Paediatric Gastroenterology Unit, Queen Elizabeth Hospital for Children, Hackney Road, London, between December 1994 and August 1995.

RESULTS

The median age at referral was 16 months. Presenting symptoms were recurrent vomiting (72%), epigastric and abdominal pain (36%), feeding difficulties (29%), failure to thrive (28%) and irritability (19%). Continuous 24-h lower oesophageal pH studies performed in 57 children showed 20 (35%) had a reflux index of between 10% to 20%, 14 (25%) had a index > 20%, and six (11%) had a postprandial reflux index > 10%. Reflux was shown in 38 (62%) of 62 children who underwent barium studies. None had significant anatomical abnormalities, but in the 22 children who had a negative barium studies, six had severe reflux (reflux index > 20%). Upper gastrointestinal endoscopy performed in 47 children showed reflux oesophagitis in 29 (62%), oesophageal ulceration in three, and Barrett's oesophagus in one. All of the children were treated with standard medical therapy. Sixty-six per cent were able to discontinue medication within 12 months and remained well. Four children (6%) required Nissen's fundoplication for failure to respond to medical therapy.

CONCLUSIONS

Most infants with GOER have an uncomplicated course. False negative results were noted in both pH monitoring and barium meal. Up to 80% of children, with therapy, will improve within 12 months.

The otolaryngologic manifestations of gastroesophageal reflux: when is a pH study indicated?

PURPOSE

The aim of this study was to evaluate the pertinence of pH studies for persistent ear, nose, and throat (ENT) symptoms and their eventual relationship to gastroesophageal reflux (GER).

METHODS

Retrospective analysis was performed of age, reason for referral, pH study, treatment, and follow-up of patients with ENT symptoms suspected to have GER.

RESULTS

Of 3,000 esophageal pH studies performed over 16 years, 105 children were referred for ENT symptoms by an otorhinolaryngologist to rule out GER. Mean age was 33 months; 65% were boys. Reasons for referral included (number and mean age): stridor (n = 31, 8 months), laryngomalacia (n = 18, 13 months), recurrent otitis (n = 12, 42 months), laryngitis (n = 16, 50 months), dysphonia (n = 14, 59 months), laryngeal papillomatosis (n = 8, 62 months), sinusitis (n = 5, 56 months), and dysphagia (n = 1). Overall, 41% of study results were positive: stridor (58%), laryngomalacia (61%), laryngitis (56%) and sinusitis (40%). Patients with otitis, dysphonia and laryngeal papillomatosis had GER in 1%, 14%, and 25%, respectively. Follow-up in the three larger groups of patients showed resolution of the ENT symptoms after medical treatment of the reflux in 83% of patients with stridor and reflux, 86% with laryngitis and reflux, and 80% with laryngomalacia and reflux. Four fundoplications were performed: one neurologically impaired patient, and four nonresponders.

CONCLUSIONS

The authors recommend that a pH study be performed in children with stridor, laryngomalacia, laryngitis, and sinusitis when faced with failure of the usual treatment. However, a pH study does not seem as beneficial for recurrent otitis, dysphonia, or laryngeal papillomatosis.

Approach to the difficult pediatric asthmatic

Wheezing in infants and children presents a difficult differential diagnosis contingent on the presenting symptoms and age of the child. A determination of the anatomy of the lower airway, combined with allergic, infectious, and noninfectious irritants, is requisite to a complete evaluation. The intervention strategies to decrease wheezing and bronchial hyperresponsiveness may include both nonpharmacologic and pharmacologic management. The nonpharmacologic management of asthma in children is contingent on aggressive treatment of dietary protein sensitivity and strict environmental control. The treatment of bronchial hyperresponsiveness with pharmacologic intervention in infants and children is relegated to the optimal use of sodium cromoglycate and inhaled corticosteroid.