Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition — Indiana University School of Medicine

Other diagnostic interventions may be utilized to rule out conditions other than GERD in the presence of specific diagnostic clues. In the absence of a single ‘gold standard’ investigation to diagnose GERD in infants or children, the diagnostic tests discussed in this section should be seen in this light.

In conclusion, there is insufficient evidence to support the use of a barium contrast study for the primary diagnosis of GERD in infants and children. It should be noted that a general concern is that the reported definitions of GERD and outcome measures used to assess treatment efficacy vary widely among studies with outcomes ranging from symptom resolution to reduction in the number of reflux events or healing of esophagitis. This heterogeneity makes comparisons among studies difficult. For this purpose, the working group critically reviewed evidence from existing guidelines, systematic reviews and consensus documents to establish a comprehensive list of symptoms and signs indicative of GERD (Question 2, Table 1).(1, 3, 20, 21) Additionally, the working group highlighted a number of clinical manifestations and features, including gastrointestinal and systemic manifestations, which they considered to be recognized as ‘red flags’ suggesting possible other disorders apart from GERD in the infant or child presenting with regurgitation and/or vomiting (Question 2, Table 2).

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).

This study had several limitations dominantly related to its retrospective nature and the lack of healthy control group due to ethical reasons. Although we enrolled all consecutive patients with suspected GERD referred to our hospital, we could not completely eliminate selection bias. No validated parent- or patient- reported gastroesophageal reflux questionnaires have been used prior to monitoring. Both questionnaires for infants (Infant Gastroesophageal Reflux Questionnaire (I-GERQ) [31] and Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) [4]) as well as 5-item questionnaire for children 7 to 16 years of age [32] have been shown to be valid and reliable for documentation and monitoring of reported symptoms. All questionnaires were validated using abnormal pH probe studies and/or abnormal esophageal biopsies as gold standards, and none by using abnormal pH-MII monitoring.

In conclusion, it is uncertain whether the use of cimetidine improves histology/macroscopy in infants and children with GERD when compared to sucralfate. It is uncertain whether the use of cimetidine leads to more side-effects in infants and children with GERD compared with sucralfate. In conclusion, it is uncertain whether the use of lansoprazole improves signs and symptoms based on the I-GERQ-R questionnaire in infants with GERD compared with hydrolyzed formula.

A catheter is placed in the nose with the sensor lying immediately above the uvula. In a single pediatric study by Chiou et al, 15 patients underwent simultaneous oropharyngeal pH monitoring and pH-MII testing.(97) The authors failed to show any relationship between changes in the oropharyngeal pH and esophageal reflux events detected by pH-MII suggesting that oropharyngeal monitoring does not represent GER events.

Question 1: What is the definition of pediatric gastroesophageal reflux disease?

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].

Physiologic regurgitation and episodic vomiting are frequent in infants. Onset of GERD symptoms after the age of 6 months or persistence of symptoms beyond 12 months raises the possibility of alternative diagnoses to infant GER. Because these symptoms are not unique to GERD, referral to a pediatric gastroenterologist for evaluation to diagnose possible GERD and to rule out other diagnoses is recommended based on expert opinion. The goal of additional testing is to rule out mimickers or complications of GERD.

Late onset as well as symptoms increasing or persisting after infancy, based on natural course of the disease, may indicate a diagnosis other than GERD.

Adult studies have since shown similar results.(113, 114) Therefore, because of this inadequate sensitivity, oropharyngeal monitoring is not recommended. The search identified one study comparing rates of gastroesophageal reflux events seen during barium imaging in symptomatic and asymptomatic infants and children ages 3 month old to 17 years old.(28) In this study, there were no definitions of how a positive test was defined so calculation of specificity or sensitivity was not possible. While most reflux in infants is benign, some infants merit additional testing. 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.

Therefore, a clinical diagnosis based on a history of heartburn cannot be inferred since these individuals cannot reliably communicate the quality and quantity of their symptoms [12, 13, 14, 15, 16]. GERD testing mainly include esophageal pH/MII, upper GI endoscopy, and barium upper GI series. The diagnosis of GERD has to be inferred when tests show excessive frequency or duration of reflux episodes, esophagitis, or a clear association of symptoms and signs with reflux episodes in the absence of alternative diagnose (Table 2). GER is a normal physiologic process occurring in the healthy pediatric population and adults alike.

Visible breaks in the esophageal mucosa are the endoscopic sign of greatest inter-observer reliability based on adult studies.(11) However, no studies in adults or in children support that microscopic esophagitis without evidence of erosive esophagitis is adequate to diagnose GERD defined as the presence of troublesome symptoms though microscopic esophagitis may, in some contexts, signify the presence of pathologic acid reflux defined by pH-metry.(43) The primary role for esophageal histology is to rule out other conditions in the differential diagnosis, such as eosinophilic esophagitis, Crohn’s disease, Barrett esophagus, infection and others. Compared with the results of 24-hour esophageal pH testing as a diagnostic test for GERD, the sensitivity of color Doppler ultrasound performed for 15 minutes post-prandially is about 95% with a specificity of only 11%, and reflux frequency detected by ultrasound does not correlate with reflux index (RI) detected by pH monitoring.(40, 41) At present, ultrasound has no role as a routine diagnostic tool for GERD in children, but this test may be of use to evaluate for other conditions that might mimic GERD including, most importantly in the infant population, pyloric stenosis. Abdominal ultrasound may also pick up other diagnoses which may trigger symptoms of discomfort and vomiting including diagnoses such as hydronephrosis, uretero-pelvic obstruction, gallstones and ovarian torsion.

The diagnostic approach of infants with frequent regurgitation or vomiting is presented in Algorithm 2. Definitions of GER and GERD are therefore blurred for the pediatric population, making it difficult to identify infants and children who genuinely suffer from GERD and to estimate the true prevalence and burden of the problem. Moreover, to date no gold standard diagnostic tool exists for the diagnosis of GERD in infants and children. Despite these limitations, and given the need for definitions, the working group decided to adapt the definition of pediatric GERD as formulated in the 2009 consensus statements for all age groups.

However, for the large number of U.S. children with acid reflux or gastroesophageal reflux disease (GERD), holiday dining isn’t always a happy occasion. Obesity and gastroesophageal reflux disease and gastroesophageal reflux symptoms in children. Increased prevalence of gastroesophageal reflux symptoms in obese children evaluated in an academic medical center. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population.

Up to 77% infants compared to 24% children above 8 years of age would be undiagnosed with pH-metry alone. The sensitivity of pH-metry (using pH-MII monitoring as gold standard) in children with isolated EE symptoms is 38.1%, whereas in children with GI symptoms with or without concomitant EE symptoms it is almost 2-fold higher. However, even in the group with GI symptoms more than 35% of children with an abnormal finding on pH-MII would not be diagnosed by pH-metry alone.

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