Updated Clinical Practice Guidelines for Pediatric GERD
The most well-known prokinetic drug is cisapride, widely prescribed until 2000, when it was withdrawn due to cardiac toxicity which increased the risk of sudden death . Currently, other prokinetics such as domperidone and metoclopramide are still commonly prescribed. Nevertheless, neither have robust evidence to support their use in children with GERD [98, 99, 100]. Baclofen is a gamma-amino-butyric-acid (GABA) receptor agonist which has been shown to reduce both acid and non-acid refluxes in adults, probably by inhibiting the transient relaxations of the lower esophageal sphincters (TLESRs) .
Bilious vomiting at any age, particularly in the first few months of life, is an emergency and suggests intestinal obstruction.21 Gastrointestinal bleeding also requires further workup. Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy.
Nevertheless, according to the available data, ARS in children shows a good overall success rate (median 86%) in terms of complete relief of symptoms, and its outcome does not seem to be significantly influenced by different surgical techniques . Gastric fundoplication is the most commonly performed intervention. Different types of fundoplication have been developed, according to Nissen (360Â° fundic wrap around the esophagus) and Thal and Toupet (both partial wraps). Traditionally, these procedures were performed open, whereas in most centers, laparoscopic fundoplications are now preferred. Nevertheless, a recent pediatric trial showed that open and laparoscopic fundoplications provide similar control of reflux and quality of life at follow-up, although the latter is associated with reduced incidence of retching persisting over a 4-year period [120, 121, 122].
According to the current international guidelines, infants with functional GER should not receive pharmacological treatment, despite symptoms may cause significant distress to both infants and parents . The most common symptoms associated with GER in the first year of life are regurgitation, vomiting, irritability, cough, and food refusal [39, 40, 41, 42].
Proton pump inhibitors are reasonable treatment options for GERD in older children and adolescents, but their use in infants is questionable because of a lack of proven effectiveness. receptor antagonists are an option for acid suppression therapy in infants and children with GERD. Conservative treatments are the first-line strategies for most infants, older children, and adolescents with reflux and GERD.
PPIs have greater efficacy than H 2 RAs. Young children may require higher per kilogram doses to obtain the same acid-blocking effect [93, 94, 95, 96]. Clinical history of disease and physical examination in the evaluation of GERD is important to distinguish GER from GERD, to identify possible complications of GERD and also to exclude more worrisome disorders requiring further investigation and management.
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.
- Recurrent nonprojectile vomiting or regurgitation beyond 18 months of age is uncommon and suggests GERD or more concerning pathology.2, 3, 20 Poor weight gain, parent-reported abdominal pain, and coughing or choking during feeding may also suggest GERD and warrant further workup.
- Conversely, alginates have been studied to a greater extent in children.
- IPEG guidelines for the surgical treatment of pediatric gastroesophageal reflux disease (GERD).
- Moreover, it has been suggested that the questionnaires are more useful for follow-up of patients than for diagnosing GERD .
- GERD diagnosis may remain, especially in young infants, until symptoms wane as part of the natural history of regurgitation or until an objective test disproves the presence of the disease.
- Double-blind randomized placebo-controlled trials of PPI efficacy in infants with GER symptoms showed that PPIs and placebo produced similar improvement in crying, despite the finding that acid suppression occurred only in the PPI group [6, 69].
5.2 Based on expert opinion, the working group recommends the use of PPIs as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD (Algorithm 2). One of the most controversial issues currently around the performance of endoscopy is whether it should be performed while the patient is on or off acid suppression. The field has evolved over time with a greater understanding of eosinophilic esophagitis and, more recently, proton-pump-inhibitor-responsive EoE.
In the present study, the prevalence of EE (49%) in children aged 1-11 years was higher than that reported previously in children (12.4%) [3 ]. Baseline endoscopic and histologic data showed that 18% of patients had esophageal nodules, which have been shown to be a possible predictor of EE in the PEDS-CORI [18 ]. Our results suggest that dilation of intercellular space may be a potential histologic diagnostic criterion for EE [6 ].
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.
Testing may include laboratory tests, contrast imaging, upper GI endoscopy and/or esophageal pH/MII, depending on presenting symptoms (Table 2 and â€‹and3).3). The diagnostic approach of children with frequent regurgitation or vomiting is presented in Algorithm 2.
GERD requires treatment to avoid complications like esophageal damage. Efficacy and safety of once-daily esomeprazole for the treatment of gastroesophageal reflux disease in neonatal patients.
pH-metry poorly identifies full column reflux (97, 98) and fails to correlate symptoms with esophageal acid events,(97) making it an inadequate tool for the diagnosis of extraesophageal symptoms. 1 year).(27) It should however be noted that for this population, although attempts have been made, no â€˜trueâ€™ normative values have been established because of the ethics of performing invasive studies in healthy infants and children.(75, 95) The authors found the RI measured by pH-metry had a sensitivity and specificity 50% and 82%, respectively, using history and physical examination as the gold standard method for diagnosing GERD. 3.6 Based on expert opinion, the working group suggests to use esophago-gastro-duodenoscopy with biopsies to assess complications of GERD, in case an underlying mucosal disease is suspected, or prior to escalation of therapy. 3.5 The working group suggests not to use esophago-gastro-duodenoscopy to diagnose GERD in infants and children. In conclusion, there is insufficient evidence to support the use of EGD with/without biopsy for the diagnosis of GERD in infants and children.
Gastroesophageal Reflux Disease Management in Pediatric Patients
It has been well recognized that endoscopy has high specificity (90%-95%) for GERD . However, a poor sensitivity of around 50% has been reported . In our study, using pH-MII monitoring as gold standard, we found low sensitivity of endoscopy (32.9%), which is in agreement with results from previous studies [8,11]. In contrast with some previous studies , our data showed higher number of total and acidic reflux episodes in older children. However, we found greater number of weakly acidic episodes in infants, as in previous reports .