2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
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 . 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 .
GERD symptoms may occur as a complication associated with GER, and it is important for clinicians to accurately diagnose and assess how best to manage the patient to improve symptoms and facilitate healing of the esophagus. Pediatric patients with GER who experience uncomplicated recurrent regurgitation should be managed conservatively with minimal testing and lifestyle modifications.
The diagnosis and treatment of GERD in adults are fairly well established because the symptoms are clear and easily communicated by most patients, according to Dr. LaRiviere. â€œHowever,â€ she says, â€œthis approach is more difficult in children-especially in infants-because they canâ€™t communicate symptoms.â€ In addition, the lack of clearly established objective diagnostic criteria in children makes diagnosis and treatment less well-understood. Some studies have suggested that infants with GERD are more likely than older children to undergo anti-reflux procedures.
Physician Survey Shows Need For Education About Acid Reflux
Regurgitation and vomiting are very frequent in healthy infants, mostly during the first months of life. About 70% of healthy infants physiologically regurgitate several times per day, and in about 95% of them, symptoms disappear without intervention by 12-14 months of age [4, 5].
- A relation between GER and short, physiologic apnea has been shown .
- Prevalence of symptoms of gastroesophageal reflux during infancy.
- Currently, other prokinetics such as domperidone and metoclopramide are still commonly prescribed.
- 3.5 The working group suggests not to use esophago-gastro-duodenoscopy to diagnose GERD in infants and children.
- Moreover, most surgical series include children with underlying conditions predisposing to the most severe GERD, such as neurological impairment, thereby confounding efforts to determine the benefits versus risks of surgical anti-reflux procedures in specific patient populations.
Thanks to pH-impedance studies, several authors have recently highlighted the role of weakly acid and non-acid reflux [28, 29, 30, 31, 32, 33, 34, 35]. Furthermore, a recent review reported that a significant percentage of patients with GERD-related respiratory symptoms do not improve despite an aggressive acid-suppressive therapy , thus supporting the hypothesis that respiratory symptoms are less related to acidity than GI symptoms. AXID(R) Oral Solution is a treatment for endoscopically diagnosed esophagitis, including erosive and ulcerative esophagitis, and associated heartburn due to gastroesophageal reflux disease (GERD) for up to 8 weeks. It is an alcohol-free, bubblegum-flavored, formulation of nizatidine approved by the United States Food and Drug Administration for use in pediatric patients aged 12 years and up in May 2004. IPEG guidelines for the surgical treatment of pediatric gastroesophageal reflux disease (GERD).
The study design was cross sectional. The study retrospectively included all children who underwent combined multiple intraluminal impedance and pH (pH-MII) monitoring due to gastrointestinal and/or extraesophageal symptoms suggesting gastroesophageal reflux disease at University Children’s Hospital in Belgrade, from July 2012 to July 2016.
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.
On the other hand, excellent correlation between endoscopy findings and histology in patients with erosive reflux disease lessens the importance of histopathology in these patients . Some authors consider histology as non-mandatory and others recommend biopsies only to rule out other pathology . Due to cross-sectional design of the study we did not provide information on the follow-up of patients and treatment effects. A definition of gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) specific to the pediatric population was developed in 2009 as an international consensus document, based on evidence reviewed from pediatric studies.(10) This document was developed in recognition of the special clinical and scientific needs of the pediatric population, not fully addressed by the Montreal consensus document on the adult definition and classification of GERD).(11) Both documents define GER as the passage of gastri contents into the esophagus with or without regurgitation and/or vomiting. GER is considered to be pathologic and referred to as GERD when the reflux leads to troublesome symptoms and/or complications, such as esophagitis or stricturing.