Pediatric Gastroesophageal Reflux Surgery Guidelines: NASPGHAN/ESPGHAN Guidelines for Treatment of Pediatric GERD

The results of the present study parallel the results from those of previous studies of PPIs in adults with EE and provide additional support for the use of esomeprazole treatment for EE in young children. Acid suppression with a proton pump inhibitor is standard treatment for gastroesophageal reflux disease and erosive esophagitis in adults and increasingly is becoming first-line therapy for children aged 1-17 years.

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.

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).

Clinicians should carefully monitor pediatric patients with GERD to ensure their symptoms are improving with medication management. It is also important to avoid any unnecessary diagnostic procedures or pharmacologic therapy as best practice in the pediatric population. Gastroesophageal reflux disease (GERD) results in food and stomach acid backing up into the esophagus from the stomach.

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).

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Surgical treatment represents the last option for GERD management. When and which children could likely benefit from anti-reflux surgery (ARS) has never yet been elucidated. Currently, surgery should be considered for children with confirmed GERD who have failed optimal medical therapy, who are dependent on medical therapy over a long period of time, who are significantly nonadherent with medical therapy, or who have life-threatening complications [2]. Medical literature on surgical therapy in children with GERD mainly consists of retrospective case series in which details on GERD diagnosis and on previous medical therapy are partially lacking, making it difficult to evaluate the indications for and the outcomes of surgery [117, 118, 119]. 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.

It has been well recognized that endoscopy has high specificity (90%-95%) for GERD [26]. However, a poor sensitivity of around 50% has been reported [27]. 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 [8], 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 [21].

  • Although biopsy specimens were not evaluated by a central reader and therefore were not standardized, the histopathologic data obtained contribute to the existing sparse literature in this patient population.
  • It is uncertain whether the use of cimetidine leads to more side-effects in infants and children with GERD compared with sucralfate.
  • Therefore, most studies investigating effectiveness and safety of GERD drugs have been performed in adults, and their applicability to children of all ages is uncertain.

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%.

Our aim is to review current management practices of GER/GERD in HGH, in view of NASPGHAN/ESPGHAN guideline. 3.13 We suggest not to use a trial of PPIs as a diagnostic test for GERD in infants. 3.5 We suggest not to use esophago-gastro-duodenoscopy to diagnose GERD in infants and children.

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].

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].

Alginates and antacids are commonly combined in the same product and are widely used by adult patients to treat reflux symptoms. Antacids act by directly buffering gastric contents, thereby reducing heartburn. There is little evidence for the use of antacids in pediatric age [105, 106]. Conversely, alginates have been studied to a greater extent in children.

Our results highlight the fact that the addition of MII to conventional pH monitoring significantly increases sensitivity of the test in infants and children with suspected GERD. This study showed that the sensitivity of pH-metry alone is especially low in infants, and that it increases with age. Moreover, our findings indicate that 40% of infants and children with an abnormal finding on pH-MII would not be identified by pH-metry alone.

Several pathogenetic mechanisms have been proposed to explain the link between GERD and respiratory symptoms, including aspiration of acid gastric contents into the upper airways, vagal reflex induced by the presence of acid in the esophageal lumen, and sensitization of the central cough reflex [2, 25]. In older children and adolescents’ heartburn, regurgitation and chest pain are the specific symptoms of GERD. According to experts’ opinions, in this age group, the description and localization of these symptoms are a reliable indicator for GERD, and an acid suppressive trial may be empirically started, regardless of an objective evaluation of reflux. This approach is mainly driven from adult studies [17, 18]. Along with heartburn and chest pain, other symptoms and signs may occur in older children and adolescents, such as regurgitation, epigastric pain, food refusal, dysphagia, impaired quality of life, sleeping disturbances, anorexia, and dental erosions.

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