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

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).

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).

Moreover, it has been suggested that the questionnaires are more useful for follow-up of patients than for diagnosing GERD [33]. Furthermore, endoscopy was not performed in all patients from our study population.

Question 6: Which infants and children would benefit from surgical treatment (i.e. fundoplication) after (non)-pharmacological treatment and what are the efficacies of these surgical therapies?

GERD should be suspected in infants with these symptoms, but none of the symptoms are specific to GERD alone. The major role of history and physical examination in the evaluation of purported GERD is to rule out other more worrisome disorders that present with similar symptoms (especially vomiting) and to identify possible complications of GERD.

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.

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.

Keeping in mind the fact that in our sample more than one-third of children above 8 years with GI symptoms suspected for GERD were pH-MII negative, it is important to emphasize the high prevalence of functional dyspepsia in this age group, as previously reported [8]. Furthermore, this implicated low diagnostic value of GI symptoms in differential diagnosis between GERD and functional dyspepsia, even in older children, which is in agreement with Hojsak et al [8].

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.

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.

to provide guidance for primary care physicians, dietitians, and pediatric gastroenterologists. Despite the fact that none of the GRADE approved studies reported any serious adverse events in children taking H2RA or PPIs, case control studies show increased risk of infection in infants and children taking these medications compared to non-users. These infections include necrotizing enterocolitis, pneumonia, upper respiratory tract infections, sepsis, urinary tract infections, and Clostridium difficile infections.(51, 226, 227) Acid has a protective effect against bacterial gastrointestinal infections, and it is therefore important that widespread unnecessary usage of acid suppressive medications be avoided, and that when these drugs are used, unnecessarily long-term usage be avoided whenever possible. Thus, it is important to be able to identify those children and young people with reflux esophagitis and symptoms responsive to acid suppression therapy so that treatment is used appropriately.

In some infants, H 2 RA therapy causes irritability, head banging, headache, somnolence, and other side effects that, if interpreted as persistent symptoms of GERD, could result in an inappropriate increase in dosage [79]. H 2 RAs, particularly cimetidine, are associated with an increased risk of liver disease [86, 87] and cimetidine with gynecomastia [88].

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It is uncertain whether the use of lansoprazole leads to more side-effects in infants with GERD compared with hydrolyzed formula. Clarify the role of acid and non-acid reflux in the etiology of esophagitis and other signs and symptoms suggestive for GERD. In conclusion, there is insufficient evidence to support the use of pH-MII as a single technique for the diagnosis of GERD in infants and children. Clarify the role of acid reflux in the etiology of esophagitis and other signs and symptoms suggestive for GERD. In conclusion, there is insufficient evidence to support the routine use of pH-metry for the diagnosis of GERD in infants and children.

Are lifestyle measures effective in patients with gastroesophageal reflux disease?. An evidence-based approach. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Long-term acid suppression therapy for gastroesophageal reflux disease should be titrated to the lowest effective dose.

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