Effect of metoclopramide on prolonged intraesophageal pH testing in infants with gastroesophageal reflux

The effect of metoclopramide (MCP) on prolonged intraesophageal pH testing was evaluated in 42 infants with gastroesophageal reflux (GER). Following a baseline period of intraesophageal pH monitoring, MCP was administered by injection at 0.1 mg/kg/dose (10 patients), 0.2 mg/kg/dose (11 patients), or 0.3 mg/kg/dose (21 patients). The percentage of time of intraesophageal pH less than 4, reflux frequency, and acid clearance time were calculated for each subject before and after MCP for both 5% dextrose and formula feedings. These parameters were further separated into 2-hour or shorter and more than 2-hour postprandial periods. No significant differences with either type of feeding were noted at either 0.1 or 0.2 mg/kg/dose. Significant decreases in the percentage of time the intraesophageal pH was less than 4 (30.0 +/- 2.9 versus 15.6 +/- 3.1, p = 0.001), the reflux frequency (episodes/hour; 6.5 +/- 0.9 versus 4.0 +/- 0.6, p = 0.004), and the acid clearance time (minutes/episode; 3.8 +/- 0.7 versus 2.2 +/- 0.3, p = 0.047) were noted in the 2-hour or shorter period following 5% dextrose feedings but not following the formula feedings in the subjects receiving 0.3 mg/kg/dose. Three of the 42 study patients developed increased irritability, and one developed dystonia following MCP. These data suggest that if a clinical trial of MCP in infants with GER is performed, a larger dose of the medication than previously appreciated might be required.     

新生儿胃食管返流的24小时食管内pH监测

目的探讨新生儿胃食管返流食管内pH的变化及其临床意义。方法疑诊为新生儿胃食管返流36例，以无症状新生儿15例作对照。用便携式24小时食管、胃pH自动记录仪（Digitrapper型）在常态下作24小时食管内pH监测。食管pH降至4以下持续15秒钟以上定义为一次返流。结果疑诊为新生儿胃食管近流的36例中14例Boix－Ochoa评分＞11．99为病理性返流，22例为生理性返流。15例对照组中2例为生理性返流，13例为正常。结论24小时新生儿食管内pH监测为早期诊断新生儿胃食管返流提供客观依据。     

Evaluation of reflux episodes during simultaneous esophageal pH monitoring and gastroesophageal reflux scintigraphy in children.

Gastroesophageal pH monitoring and reflux scintigraphy were simultaneously performed in 65 children, who were being investigated for suspected gastroesophageal reflux disease. The aim of the study was to compare, peak per peak, the information provided by the two techniques during a 1-h simultaneous-recording period. During this period, 123 reflux episodes were recorded with both techniques, but only six occurred simultaneously. Significantly more reflux episodes were recorded on scintigraphy (n = 88; p less than 0.05), particularly during the first half-hour period (n = 62), if compared with the number of pH drops greater than 1 unit, even at pH levels higher than 4 (n = 41; p less than 0.05). It is concluded that the two techniques explore differently the reflux phenomenon.     

Gastric emptying using three different formulas in infants with gastroesophageal reflux.

The role of delayed gastric emptying (GE) in the pathogenesis of gastroesophageal reflux (GER) in infants is controversial at present. GE has been shown to be altered by the composition and osmolality of the feedings. This prospective study was undertaken to assess the changes in the GE and the percentage of time GER was detected by scintigraphy using three different formulas on consecutive days in infants with GER. Twenty-eight infants under 1 year of age diagnosed to have GER by extended intraesophageal pH monitoring (pH being less than 4.0 for greater than 5% of the duration of the test), underwent scintigraphy on three consecutive days using the same volume per single feeding of a casein-predominant, soy, or a whey-hydrolysate formula in a randomized order. The formulas were isocaloric. Gastric emptying and percentage of GER into the esophagus were estimated for 60 min following these feedings. Mean GER percent during the study was 20.39, 17.68, and 16.34 on casein-predominant, soy, and whey-hydrolysate formulas, respectively, and was not significantly different. Mean values of GE were 39.7%, 44.6%, and 48.5% on casein, soy, and whey formula, respectively. No significant difference in GE was also observed between casein-predominant and soy formula. However, a significant difference was observed (p less than 0.05) on GE between casein-predominant and whey-hydrolysate feedings. Our data suggest that formula selection may be important in the treatment of conditions associated with delayed gastric emptying.     

Thickening of infant feedings for therapy of gastroesophageal reflux

To assess the effect of thickening of feedings on gastroesophageal reflux and gastric emptying, 20 infants were examined with technetium scintigraphy and detailed behavioral observation after each of a pair of feedings, one with radiolabeled infant formula alone and the other with radiolabeled formula thickened with dry rice cereal. The thickened and unthickened meals were followed by similar amounts of scintigraphically demonstrated gastroesophageal reflux. However, the number of episodes of emesis (1.2 +/- 0.7 vs 3.9 +/- 0.9 per 90 minutes postprandial), the percent of gastric emptying at 30 minutes (17.8% +/- 2.7% vs 22.4% +/- 2.4%), the time spent crying (11.7 +/- 3.1 minutes vs 17.6 +/- 3.8 minutes per 90 minutes), and the total time spent awake (45.2 +/- 5.9 minutes vs 53.1 +/- 4.9 minutes per 90 minutes) were significantly less after the thickened feedings. Because thickening of infant feedings increases the caloric density, decreases emesis, decreases crying time, and increases sleep time in the postprandial period, it is likely to be beneficial in the treatment of infants with gastroesophageal reflux associated with failure to thrive.     

Prolonged esophageal pH monitoring in the evaluation of gastroesophageal reflux in children with chronic tubotympanal disorders

BACKGROUND: Children with ear, nose and throat disorders are believed to have a high incidence of pathologic gastroesophageal reflux (GER). This study was designed to establish the frequency and ratio of pathologic GER in the development of chronic tubotympanal disorders. METHODS: Twenty-seven children with chronic tubotympanal disorders (mean age, 2 to 13 years; average age, 6.8 years) underwent 24-hour continuous pH monitoring. Fourteen of the examined patients had secretory otitis, whereas 13 patients had recurrent otitis. From each 24-hour pH monitoring, 12-hour daytime and nighttime periods were selected. Eleven patients were tested using simultaneous dual pH monitoring (distal and proximal pH monitoring). RESULTS: Fifteen (55.6%) of 27 patients had pathologic GER. The authors did not find a relation between pathologic GER and different types of ear disorders. Daytime pH monitoring yielded significantly more episodes of reflux than did nighttime monitoring. The reflux index was substantially higher during the day. In the current study, distal pH monitoring showed that 6 of 11 patients had pathologic GER, whereas proximal pH monitoring showed that only only 3 of 11 patients had pathologic GER. CONCLUSIONS: The authors recommend that a pH study be performed in children with chronic tubotympanal disorders when standard treatment is ineffective. The method of choice for the diagnosis of pathologic GER in patients with chronic tubotympanal disorders should be pH monitoring of the esophagus and throat.     

动态24小时食管pH值监测小儿胃食管返流

为了解２４小时食管ｐＨ值监测在小儿胃食管返流（ＧＥＲ）诊治中的作用，研究小儿病理性ＧＥＲ的特点及其诊断标准，对５０例经钡餐造影诊为ＧＥＲ的患儿进行动态２４小时食管内ｐＨ值监测，３０例健康小儿为对照组，复查１３例病理性ＧＥＲ患儿治疗后（９例为手术治疗）的食管ｐＨ值。结果表明，ＧＥＲ组各项返流指标显著高于对照组。对照组中１例为病理性ＧＥＲ，ＧＥＲ组３１例为病理性，另１９例则为生理性。１３例食管裂孔疝（ＨＨ）患儿均有明显的病理性返流，其各项返流指标除ｐＨ值＜４次数外均显著高于单纯病理性ＧＥＲ；ＨＨ组卧位时返流≥５分钟次数、最长返流时间、总ｐＨ值＜４的时间占总观察时间的百分比和平均返流周期均显著大于立位时；单纯病理性ＧＥＲ组卧位时返流≥５分钟次数、最长返流时间和平均返流周期显著大于立位时，而返流次数则小于立位时。提示小儿病理性ＧＥＲ以卧位时明显，伴有食管裂孔疝者返流更为严重。动态２４小时食管内ｐＨ值监测可用于小儿ＧＥＲ的诊断、分析和疗效评定。     

Oesophageal pH monitoring and reflux oesophagitis in irritable infants

Acid reflux and/or oesophagitis may be responsible for inconsolable crying in infants. We evaluated prospectively the presence of acid reflux disease, oesophagitis and the accuracy of pH monitoring in the prediction of oesophagitis in a population of irritable infants. A 24-h oesophageal pH monitoring with a glass electrode and an upper gastro-intestinal tract endoscopy with grasp biopsies were performed in 60 irritable infants, aged 1 to 6 months, not responding to cows milk elimination. The 24-h oesophageal pH monitoring was considered abnormal in 40/60 (66%) babies and histological oesophagitis was present in 26/60 (43%). In the infants with histological oesophagitis, the reflux index (% of the investigation time with a pH <4.0) was >5% in 18/26 (69%). Histology of the oesophagus was normal in 22 of the 40 (55%) infants with an abnormal pH monitoring. The mean reflux index in the group with oesophagitis (12.20%) was significantly higher than in the group with normal histology (8.74) ( P =0.036), although there was an important overlap. The sensitivity and specificity to predict oesophagitis with a reflux index of 5.0% or more was 69.2 and 35.3, respectively. There was not a reflux index which could be related to a clinically useful sensitivity and specificity to predict oesophagitis. Conclusion:acid gastro-oesophageal reflux disease and/or histological oesophagitis were diagnosed in 66% and 43% of irritable infants, respectively. There was no relation between symptoms and abnormal pH metry or oesophagitis; however, the reflux index does not accurately predict oesophagitis and normal histology does not accurately exclude acid gastro-oesophageal reflux disease. Oesophageal pH monitoring and endoscopy provide additional information.Abbreviations GOR gastro-oesophageal reflux - RI reflux index     

Evaluation of infantile acid and nonacid gastroesophageal reflux using combined pH monitoring and impedance measurement

OBJECTIVE: Characterize the proportion of acid and nonacid esophageal reflux events in young infants with suspected gastroesophageal reflux (GER) using combined pH-multichannel intraluminal impedance (MII) monitoring. Determine the symptom index correlation with nonacid reflux and acid reflux events. STUDY DESIGN: Prospective study of children, aged 2 weeks to 1 year, referred to The Children's Hospital of Denver Gastroenterology Clinic for evaluation of GER. Exclusion criteria were congenital anomalies or syndromes, cerebral palsy, mental retardation, and pulmonary or cardiac disease. The children were admitted to The Children's Hospital General Clinical Research Center for a 20 hour pH-MII study. Acid suppression was either never used or discontinued 2 weeks before testing. RESULTS: Thirty-four infants were enrolled from February 2004 to February 2005. Ages ranged from 2 months to 11 months, median = 7 (20 females/14 males). One thousand eight hundred ninety reflux events were detected by MII, and 588 reflux events were detected by pH probe alone. The percent of reflux that was acid was 47% (888 events) versus 53% of (1,002 events) nonacid reflux events. The proportion of nonacid reflux decreased with age (P < 0.0001 by Pearson chi test) and with increasing time elapsed from last meal. There were 958 total symptoms evaluated. The most frequently reported symptom was fussiness/pain, which correlated with nonacid reflux events 24.6% and acid reflux 25.2%. The proximal height of a reflux was predictive for symptoms of fussiness/pain, arching, and burping. CONCLUSION: MII detects more reflux events than pH monitoring alone. The proportion of nonacid reflux to acid reflux events in infants is more similar to adults than previously reported. Combined pH-MII esophageal monitoring identifies more reflux events and improves clinical correlation with symptoms.     

Thickened feedings as a cause of increased coughing when used as therapy for gastroesophageal reflux in infants.

To determine whether thickening of infant formula feedings with rice cereal increases coughing, we studied 25 infants from birth to 6 months of age, referred for evaluation of gastroesophageal reflux. Coughing was blindly quantified after each of a pair of isocaloric meals (one thickened and one unthickened). Coughing was more frequent after thickened feedings than after unthickened feedings.     

Stridor and gastroesophageal reflux in infants

A relation was found between persistent stridor and gastroesophageal reflux in seven infants, aged 6 weeks to 6 months. Stridor began at 11 days to 2 months of age, and four of the seven infants had transient hypercarbia on at least one occasion before study. Only one had a history of frequent vomiting; three had recurrent pneumonia. Midesophageal pH, chest and abdominal movement, exhaled carbon dioxide partial pressure, and heart rate of six of the infants were recorded for 4 to 12 hours as they slept. Esophageal pH of the seventh infant was recorded for 24 hours. In the six completely studied infants, there were persistent increases of greater than 10 mm Hg in exhaled carbon dioxide level (three infants), of greater than 10 breaths per minute in respiratory rate (four infants), and in retractions and stridor (six infants) 5 to 20 minutes after onset of reflux. Stridor improved with medical management in 48 hours (five of five infants) and disappeared in 3 weeks (three of five infants) to 2 months (one of five infants). One of these medically treated infants subsequently was treated by Nissen gastric fundoplication because of a recurrence of persistent and severe stridor. Three infants had antireflux surgery, and in two of these stridor disappeared in 48 hours. In the third infant stridor disappeared 3 weeks after surgery. Based on this experience, reflux occasionally causes stridor, probably because of acute inflammation of the upper airway. If structural anomalies are ruled out, infants with severe stridor should be examined for gastroesophageal reflux.     

Frequency of gastroesophageal reflux in neonates as assessed by 24-hour pH monitoring

The purpose of the present study was to determine the frequency and the other characteristics of gastroesophageal reflux (GER) in 46 asymptomatic neonates during the first weeks of life. The GER were assessed by 24-hour continuous esophageal pH monitoring (CPR). The frequency of all the GER was 0.66 +/- 0.54/h (0 to 2.21). Half of the GER were determined as acid (pH less than 4 during at least 15 sec), 23% as highly acid (pH less than 3 during at least 15 sec), 39% as weakly acid (abrupt fall of the pH higher than 1 unit pH), and 11% as non acid (abrupt increase of pH higher than 1 unit pH). According to these results, a CPR should be considered as pathologic in neonates when the following criteria are fulfilled (upper limits fixed at means + 2 S.D.): 1. frequency of acid GER longer than 5 min above 0.35/h; 2. time ratio at pH below 4 exceeding 10.4%; or 3. frequency of very acid GER greater than 0.53/h.     

Diagnosis of gastroesophageal reflux disease in infants

Gastroesophageal reflux is commonly encountered in the infant population. Most children will outgrow their reflux but some develop pervasive disease and require medical or surgical treatment. Many tools exist for use in the workup of pediatric gastroesophageal reflux disease; however, the most effective method of diagnosis is not clear. Delineating which patients will benefit from more definitive therapy is a remarkable challenge in this group, often borrowing tools and principles from the adult patient population. Therefore, we reviewed the available literature to critically evaluate the merits and limitations of the current diagnostic modalities available for the evaluation of infantile gastroesophageal reflux.