Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

The article reviews several frequent clinical diagnostic/management issues and provides two algorithms with suggested evaluation/treatment for infants and older children. 5.6 Based on expert opinion, the working group recommends a 4-8 week course of H2RAs or PPIs for treatment of typical symptoms (i.e. heartburn, retrosternal or epigastric pain) in children with GERD (Algorithm 2).

However, in Joint recommendation of NASPGHAN and ESPGHAN from 2009 was stated that in rare occasions in which a relation between symptoms and GER is suspected or in those with recurrent symptoms, MII/pH monitoring in combination with polysomnographic recording and precise, synchronous symptom recording may aid in establishing potential causal relationship [2]. In the same recommendations apnea spells are included in signs that may be associated with gastroesophageal reflux [2]. A relation between GER and short, physiologic apnea has been shown [19]. One recently published study demonstrated that pathologic apnea can occur as a consequence of GER [20].

Alginates precipitate in the stomach to form a low-density but viscous gel that forms a foam that floats on the surface of gastric content and can preferentially enter the esophagus instead of gastric content during reflux episodes [107]. Studies performed both in infants and children showed a significant reduction in the height of reflux episodes, along with an improvement of symptomatic scores [108, 109, 110, 111, 112, 113]. On-demand use of antacids and alginates may provide prompt relief from reflux symptoms in children and adolescents [114]. Nevertheless, although alginates seem to have a good safety profile, antacids have possible adverse effects, such as increased serum levels of aluminum, magnesium, or calcium, which represent a major drawback to their long-term use [113, 115, 116]. Although the role of delayed gastric emptying in the pathogenesis of GERD has never been clarified and remains controversial, prokinetic agents have been used as first-choice treatment for reflux symptoms in children for many years.

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A single pediatric study by Boccia et al. showed a low microscopic esophagitis recurrence rate and GERD symptom recurrence long term after healing with omeprazole, irrespective of the maintenance therapy.(222) Therefore, based upon evidence from adult literature and expert opinion, the working group recommends PPIs as first-line treatment.(223) However, the working group also concluded that the decision of which to use should be based on practical considerations, such as ease of administration and medication cost and suggests H2RAs as a second line therapy in the treatment of esophagitis caused by acid reflux when PPIs are not available. Choice of PPIs or H2RA depends entirely on availability and cost, as no evidence supports superiority of any one PPI or H2RA over another.

Several studies investigated possible correlation between endoscopic findings and clinical symptoms in this vulnerable cohort of children and failed to demonstrate any association [12,28,29]. Most of them failed to confirm correlation between reflux episodes detected by MII monitoring and endoscopy findings [12,29]. Study by Hojsak et al. showed that children with GI symptoms and endoscopically proven esophagitis had a higher number of all reflux episodes detected by pH-MII, but not by pH-metry alone [8]. The other survey established the relationship between the parameters of pH-MII and the presence of endoscopic reflux esophagitis in children [11].

The rate of erosive esophagitis in children presenting with solely extraesophageal symptoms is not known and is complicated by the widespread use of PPIs. Up to 32% of children presenting solely with extraesophageal symptoms have microscopic esophagitis, and up to 8% of children with these symptoms have eosinophilic esophagitis, only presenting with cough or other respiratory symptoms.(47-49) Therefore, the main reason for endoscopy in this population with extraesophageal symptoms is to uncover reflux masqueraders such as eosinophilic esophagitis.

PHARMACOLOGIC TREATMENT

  • “Childhood GERD is diagnosed commonly by clinical evaluation and often without the use of objective measures,” explains Cabrini LaRiviere, MD, MPH. A
  • As such, routine use of upper GI barium contrast study in the evaluation of infants and children with GERD, especially uncomplicated GERD, is not supported by literature or clinical practice.
  • More than half of patients undergoing these procedures were 6 months of age or younger.
  • A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population.
  • While the presence of warning signs obviously merits additional testing, the more difficult subgroup of patients is the group of infants presenting with fussiness, crying and arching with or without spitting but who otherwise are thriving.

Further investigations are needed in order to elucidate these hypotheses.

www.merckmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/drug-treatment-of-gastric-acidity#section_7. Accessed November 7, 2015. Diagnosis and management of gastro-oesophageal reflux in preterm infants in neonatal intensive care units. 0.

However, given the mounting data in adults questioning the safety of these medications in multiple organ systems, these medications should be prescribed only when there is a clear diagnosis of GERD and, whenever possible, the lowest doses should be prescribed for the shortest length of time possible. There is a critical need for PPI safety studies in pediatrics, particularly because of the high rates of prescribing in this vulnerable population. While pH-metry can be used to determine if there is persistent esophageal acid exposure despite therapy, pH-MII catheters can determine this as well as how much non-acid reflux is present in children taking acid suppression. Rosen et al. found that the mean-sensitivity of MII-pH was 76±13% compared to pH-metry whose mean-sensitivity was 80 ± 18%.

2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines

Besides regurgitation and vomiting, GERD may present in children with many other signs or symptoms, the most frequent of which are heartburn, food refusal, dysphagia, feeding or sleeping disturbances, failure to thrive, persisting hiccups, impaired quality of life, and dental erosions. Respiratory symptoms, such as chronic cough, wheezing, hoarseness, laryngitis, chronic asthma, aspiration pneumonia, ear problems, and sinusitis, are atypical symptoms possibly associated with GERD. Nevertheless, the paucity of clinical studies, varying disease definitions, and small sample sizes do not allow to draw firm conclusions about their association with reflux [8].

05). Additionally, GERD was determined in 76 (34.1%) children by pH monitoring alone, and in 78 (35%) children by MII monitoring alone. When the pH-metry was compared to pH-MII, sensitivity of pH-metry was 59.4%. Particularly, sensitivity of pH-metry was very low in infants (sensitivity was 22.9%), with increasing tendency over older age groups (sensitivity was 68.4% in Group 2 and sensitivity was 76.4% in Group 3).

We evaluated endoscopic healing of erosive esophagitis with esomeprazole in young children with gastroesophageal reflux disease and described esophageal histology. Recent advances in the pathogenesis of reflux-induced respiratory symptoms have followed the introduction in clinical practice of MII-pH, which is available for pediatric use since 2002 [26]. Combined esophageal pH and impedance monitoring offer several advantages over a standard pH assessment, including the ability of detecting non-acid reflux events, determining the height and composition of the refluxate (liquid, gas, or mixed), recognizing swallows from authentic reflux episodes, assessing the bolus clearance time, and measuring symptom association with reflux (symptom association probability, SAP) even while the patient is assuming acid-suppressive medications [27].

However, information is lacking on these trends and often does not control for other comorbidities that can serve as indicators for anti-reflux procedures. In JAMA Surgery, Dr. LaRiviere and colleagues published work that examined infants and children with GERD who required inpatient hospitalization and a subpopulation that progressed to anti-reflux procedures. The analysis included 141,190 children with GERD, 8.2% of whom underwent anti-reflux procedures during the 9-year study period. More than half of patients undergoing these procedures were 6 months of age or younger. Although about two-thirds of children receiving anti-reflux procedures had preoperative upper gastrointestinal tract fluoroscopy, the study found that these patients did not undergo a uniform workup.

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