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2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines

The number of PPI prescriptions for infants has increased manifold over the last years, despite the absence of evidence for acid-related disorders in the majority [66, 67]. This dramatic increase in PPIs’ prescribing patterns has raised concerns related to their appropriate use and associated costs [68]. Although irritable infants are frequently empirically treated with PPIs as the reflux esophagitis is believed to be the cause of crying, there is no evidence supporting the usefulness of PPIs, neither as a diagnostic test nor as a treatment strategy in this age group. 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].

The term “happy spitter” has been used to identify these patients, in order to highlight the benignity of such condition. Infants regurgitate more frequently than adults due to the large liquid volume intake, the prolonged horizontal position of infants, and the limited capacity of both the stomach and esophagus [6]. Irritability and excessive crying are also very frequent in infants and may present along with regurgitation and vomiting. Therefore, neither regurgitation and vomiting nor irritability and excessive crying, regardless of their severity extent and their extent, are sufficient to diagnose GERD.

The reflux can damage the esophagus, so we try to help parents prevent and reduce GERD symptoms and promote healing through lifestyle changes, but if that doesn’t work, medications that reduce the production of stomach acid are also helpful options,” DiLorenzo explained. 23. DiMarino MC. Drug treatment of gastric acidity. Merck Manual Professional Version.

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.

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).

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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.

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.

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.

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However, in Joint recommendation of NASPGHAN and ESPGHAN from 2009 was stated that in rare occasions in which a relation between symptoms and GER is suspected or in those with recurrent symptoms, MII/pH monitoring in combination with polysomnographic recording and precise, synchronous symptom recording may aid in establishing potential causal relationship [2]. In the same recommendations apnea spells are included in signs that may be associated with gastroesophageal reflux [2]. A relation between GER and short, physiologic apnea has been shown [19]. One recently published study demonstrated that pathologic apnea can occur as a consequence of GER [20].

For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a three-day consensus meeting, all recommendations were discussed and finalized.

6. Management of physiologic GER

The rate of erosive esophagitis in children presenting with solely extraesophageal symptoms is not known and is complicated by the widespread use of PPIs. Up to 32% of children presenting solely with extraesophageal symptoms have microscopic esophagitis, and up to 8% of children with these symptoms have eosinophilic esophagitis, only presenting with cough or other respiratory symptoms.(47-49) Therefore, the main reason for endoscopy in this population with extraesophageal symptoms is to uncover reflux masqueraders such as eosinophilic esophagitis.

Large epidemiologic studies in children also are needed to determine the role of extraesophageal symptoms and concomitant conditions (e.g., asthma) in GERD. In newborns and infants, TLESRs are physiological events. Further considering the physiologic poorer tone of the lower esophageal sphincter, the frequency of GER events is commonly much higher compared to the other ages of life. Thus, uncomplicated GER in otherwise healthy infants is classified as physiologic or functional GER. This condition tends to resolve spontaneously in 95% of infants within 12-14 months of life [37, 38].

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.

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