Bruno Hauser

Characteristics of gastroesophageal reflux and potential risk of gastric content aspiration in children with cystic fibrosis.

Objectives: Increased gastroesophageal reflux (GER) is common in children with cystic fibrosis (CF). We studied the occurrence of acid, weakly acidic (WA), and weakly alkaline (WALK) reflux in children with CF and evaluated a possible surrogate marker for risk of gastric content aspiration. Patients and Methods: Twenty-four children with CF underwent impedance-pH monitoring for detection of acid (pH < 4), WA (pH 4-7), and WALK-GER (pH ≥ 7). In 11 children, cough was objectively recorded with esophageal manometry and the symptom association probability was calculated to determine the reflux-cough relation. Presence of bile acids (BA) was measured in the saliva of 65 patients with CF and 23 healthy children, respectively. Results: Sixteen of the 24 children had increased GER (esophageal acid exposure). The majority of reflux events were acidic in nature. WA reflux was less common and WALK reflux was rare. The sequence reflux-cough was found in 8 of the 11 children and 1 of 11 children had a positive symptom association probability for reflux-cough. The sequence cough-reflux was found in only 3 of the 11 children. Only a small fraction of the total esophageal acid and volume exposure was secondary to cough. Twenty-three of the 65 children with CF had BA in saliva compared with none of the healthy controls. Conclusions: Although WA-GER is uncommon, acid GER is prevalent in children with CF. It is a primary phenomenon and is not secondary to cough. One third of the children with CF have BA in saliva, which may indicate an increased risk for aspiration. However, the impact of salivary BA and potential aspiration on CF pulmonary disease needs further investigation.

The relationship between gastroesophageal reflux and cough in children with chronic unexplained cough using combined impedance–pH–manometry recordings

Assessment of the reflux–cough association in children is challenging. Esophageal (impedance) pH recording is sensitive to recognize reflux. However, cough recorded by an event marker, possibly lacks accuracy. We aimed to study the exact time relationship between reflux and cough in children with chronic cough.

A preliminary report on the efficacy of the Multicare AR-Bed in 3-week–3-month-old infants on regurgitation, associated symptoms and acid reflux

Objectives: The aim of this preliminary study was to evaluate the efficacy of a 40° supine body position on infant regurgitation, reflux-associated symptoms and acid reflux. Intervention: Thirty of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding were evaluated in the Multicare AR-Bed (Peos, Ninove, Belgium). The Infant-Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) and an oesophageal pH monitoring were performed at inclusion and after 1 week. Results: Eight out of 30 (27%) infants did not tolerate the 40° positioning, and had to be taken out of the study within the first 2 days. However, in 22/30 (73%) infants the I-GERQ-R and acid reflux decreased significantly with the Multicare AR-Bed. The mean duration of use of the Multicare AR-Bed was 3.2 months. Conclusion: The results of this pilot study suggest that a specially made bed that nurses the infant at 40° supine body position reduces regurgitation, acid reflux and reflux-associated symptoms. However, the intervention was open, the sample size small and the withdrawal rate was substantial. Larger trials are needed.

Gastrointestinal manifestations of cow's milk protein allergy and gastrointestinal motility.

Cow’s milk protein allergy (CMPA) may cause gastrointestinal motility disorders. Symptoms of both conditions overlap and diagnostic tests do not reliably differentiate between both. A decrease of symptoms with an extensive hydrolysate and relapse during challenge is not a proof of allergy, because hydrolysates enhance gastric emptying, a pathophysiologic mechanism of gastro‐oesophageal reflux (GER). Thickened formula reduces regurgitation, and failure to do so suggests CMPA. A thickened extensive hydrolysate may induce more rapid improvement, but does not always differentiate between CMPA and GER. Different hypotheses are discussed: is the overlap between CMPA and functional disorders coincidence, or do both entities present with identical symptoms, or does the fact that symptoms are identical indicates that there is only one entity involved? Studies on the prevention of CMPA focused on ‘at‐risk families’, and resulted in a decrease of CMPA and atopic dermatitis, but did not provide data on the incidence of GER.

The natural course of gastro-oesophageal reflux.

Gastro‐oesophageal reflux disease is a common phenomenon usually consistent with a benign prognosis. But alarm symptoms and complications occur at any age, and may be difficult to recognize clinically although requiring prompt and adequate intervention. Many unsettled issues in gastro‐oesophageal reflux (disease) are encountered in its natural course and clinical presentation. Severity of reflux is much more related to complications than to the amount of reflux. Current medical reflux treatment with H2‐receptor antagonists and preferably with proton pump inhibitors is efficient in controlling symptoms and healing oesophagitis. Whether early treatment of mild reflux significantly changes the incidence or severity of symptoms and complications in adulthood is uncertain. Atopic disease is now recognized to cause reflux‐like symptoms. Paediatricians should adequately consider the impact on the quality of life of repetitive regurgitation.

Esophageal impedance and esophagitis in children: any correlation?

Aim: The aim of this study was to correlate the data obtained with multiple intraluminal esophageal impedance and pH (MII-pH) recordings in infants and children referred for suspected gastroesophageal reflux disease with esophageal histology. Materials and Methods: In a prospective study, results of esophageal biopsies and MII-pH recording obtained in 45 children (mean age ± SD: 69 ± 55 months) were analyzed. Regarding the MII-pH data, an automatic (Autoscan Bioview Analysis Software, version 5.3.4, Sandhill Scientific Inc, Highlands Ranch, CO) and a manual reading were performed; an automatic pH analysis (meal included) was also performed. Results: Acidic, weakly acidic, and alkaline reflux episodes accounted, respectively, for 48.7%, 49.5%, and 1.8% of the total number of reflux episodes detected by MII-pH. Esophagitis was present in 25 (56%) children. Concordance between classic pH-study analysis (alone) and esophageal histology was found in 19 of 45 (42%) children. According to the MII-pH analysis, the mean and median value of the pH were significantly higher in the group with esophagitis than in the group with normal esophageal histology. A longer clearance time was found in the group with esophagitis than in subjects with normal histology. Gas reflux episodes represented 21% of the total reflux episodes and were comparable in both groups. Conclusions: Multiple intraluminal esophageal impedance and pH analysis does not provide a distinct parameter to predict esophageal mucosal injury in children. In our population, MII-pH shows comparable acidic, weakly acidic, alkaline, and gas reflux in children with and without esophagitis. Further research is needed to analyze clearance parameters.

Variability of the 13C‐octanoic acid breath test for gastric emptying of solids in healthy children

To assess the intra‐individual variability of the 13C‐octanoic acid breath test using non‐dispersive infrared spectrometry for gastric emptying of solids in healthy children.

Algorithms for managing infant constipation, colic, regurgitation and cow's milk allergy in formula-fed infants

Gastrointestinal symptoms, such as constipation, regurgitation and infant colic, occur in about half of infants. These symptoms are often functional, but they may also be caused by cows milk protein allergy. We developed three algorithms for formula‐fed infants, which are consensus rather than evidence‐based due to the limited research available in the existing literature.

Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children

BackgroundThe effect of proton pump inhibitors on the characteristics of gastroesophageal reflux (GER) in children and adolescents was evaluated.MethodsTwenty-one children and adolescents with symptoms suggesting GER disease (GERD) underwent upper endoscopy and a 24-hour multichannel intraluminal impedance/pH (MII-pH) monitoring before and at the end of 2 months of therapy with proton pump inhibitors (PPIs).ResultsFourteen (67%) patients reported clinically relevant symptom improvement after 2 months of PPIs intake. At the first endoscopy, 8 (38%) patients had macroscopic signs of reflux esophagitis; after two months of therapy, 6/8 (75%) patients had a complete mucosal recovery. There was a significant reduction in the total percentage of mean acid reflux time (from 13.1% to 3.8%), and the De Meester score dropped to normal (from 46.4 to 13.1). The mean number of acid refluxes decreased significantly from 48 to 15 per 24 hours, while inversely, the mean number of weakly acid refluxes increased significantly from 26 to 64 per 24 hours. PPI therapy did not affect the total number of reflux episodes, the number of liquid and mixed refluxes, the duration of esophageal bolus exposure and proximal extent of the reflux.ConclusionsIn children and adolescents with GERD, PPIs do not affect the total number of reflux episodes. PPIs only decrease the acidity of refluxate. Nevertheless, the majority of patients with typical reflux symptoms may report symptom improvement. Esophagitis can be healed after PPI treatment. The treatment of weakly acid and weakly alkaline reflux remains a challenge for physicians in the future.

Oral ranitidine and duration of gastric pH >4.0 in infants with persisting reflux symptoms.

BACKGROUND Ranitidine is a drug commonly used in pathological gastro-oesophageal reflux (GOR) in infants. Non-responsiveness has been reported. Data regarding the effect of ranitidine on oesophageal acid exposure and reduction of gastric acid secretion are limited in this age group. OBJECTIVE To evaluate oesophageal acid exposure, reduction of gastric acid secretion and histology of oesophageal biopsies in infants who clinically do not respond to oral ranitidine. PATIENTS AND DESIGN 103 infants (mean age 3.3 +/- 1.8 mo) with persisting symptoms of reflux despite administration of ranitidine, prescribed previously by a referring physician, at a mean (SD) dose of 9.4 (+/- 3.3) mg/kg/d for at least 2 wk (mean 30 d), were submitted to a 24-h pH study and oesophageal biopsy (90/103 patients). RESULTS Histological oesophagitis was present in 21/90 (23%). The oesophageal reflux index (RI) was >5% and >10% in 21/103 (20%) and 6/103 (6%) infants, respectively. Gastric pH was >4.0 during <50%, >50%, >75% and >90% of the duration of pH monitoring in 33/103 (32%), 70/103 (68%), 22/103 (21%) and 7/103 (7%), respectively. By simple regression analysis, the dosage of ranitidine correlated with the oesophageal RI (r = 0.21; p = 0.05), but not with the duration of time gastric pH was >4.0 (r = 0.09; p = 0.39). Histological oesophagitis did not correlate with ranitidine dosage, duration of treatment, duration gastric pH was >4.0 and oesophageal reflux index. CONCLUSION Some infants presenting with symptoms assumed to be GOR and acid related fail to respond to acid suppression with ranitidine, either because they need better acid suppression or because the symptoms are not acid related.