Pediatric Gastroesophageal Reflux Surgery Guidelines: NASPGHAN/ESPGHAN Guidelines for Treatment of 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The most well-known prokinetic drug is cisapride, widely prescribed until 2000, when it was withdrawn due to cardiac toxicity which increased the risk of sudden death [97]. 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) [101].

In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique.

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 [35]. Some authors consider histology as non-mandatory and others recommend biopsies only to rule out other pathology [31]. 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.

The aim of this study was to compare the different diagnostic approaches in detection of gastroesophageal reflux disease in children presented with symptoms suggesting gastroesophageal reflux disease. Although their pharmacological mechanisms differ, both PPIs and H2RAs are acid-suppressing agents and thus similar outcomes can be expected. Although the studies are imperfect, symptom control between H2RA and PPIs is comparable. Rates of healing of erosive or histologic esophagitis are higher after 12 weeks of therapy with a PPI in contrast to H2RA.(1) Although evidence in children is very low, evidence in adults with erosive esophagitis shows that PPIs are superior to any other pharmacological treatments.(51, 219-221) Limited data are available on rates of esophagitis relapse seen after discontinuation of therapy.

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.

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3.3 Based on expert opinion, the working group suggests not to use ultrasonography for the diagnosis of GERD in infants and children. In conclusion, there is no evidence to support ultrasonography for the diagnosis of GERD in infants and children. 3.1 Based on expert opinion, the working group suggests not to use barium contrast studies for the diagnosis of GERD in infants and children.

receptor antagonists and proton pump inhibitors are the principal medical therapies for GERD. They are effective in infants, based on low-quality evidence, and in children and adolescents, based on low- to moderate-quality evidence. Surgical treatment is available, but should be considered only when medical therapy is unsuccessful or is not tolerated.

As already reported, all the above-mentioned signs and symptoms are variously prevalent and relevant in the different pediatric age groups. Therefore, GERD clinical pictures of infants, children, and adolescents will be treated in separate paragraphs.

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes.

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 ].

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].

Moreover, likewise infants and younger children, even older children and adolescents, may experience respiratory symptoms as the only manifestation of GERD [3]. Although reflux does occur physiologically in most infants, clinicians should be aware that there is a continuum between physiologic GER and GERD leading to significant symptoms, signs, and complications. Therefore, a small proportion of symptomatic infants may deserve an instrumental diagnostic assessment for GERD or other GERD-mimicking diseases. To help identify this subgroup of infants, the latest international GER guidelines drafted a list of warning signals requiring investigations in infants with regurgitation or vomiting (Table 1).

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.

Effectiveness and safety of proton pump inhibitors in infantile gastroesophageal reflux disease. Infantile gastroesophageal reflux may present with frequent regurgitation or vomiting, postprandial irritability, prolonged feeding or feeding refusal, or back arching.

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