Paolo Quitadamo

European pediatricians' approach to children with GER symptoms: survey of the implementation of 2009 NASPGHAN-ESPGHAN guidelines.

Objective: The aim of this study was to evaluate the current implementation of the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines, and to assess proton pump inhibitors’ (PPIs) prescribing patterns among pediatricians from different European countries. Methods: A randomly identified sample of general pediatricians distributed across 11 European countries. They were asked to complete a case report–structured questionnaire investigating their approaches to infants, children, and adolescents with symptoms suggestive of gastroesophageal reflux. Results: A total of 567 European general pediatricians completed the study questionnaire. Only 1.8% of them showed complete adherence to the guidelines. Forty-six percent of them reported that they diagnose gastroesophageal reflux disease based on clinical symptoms irrespective of the age of the child; 39% prescribe PPIs in infants with unexplained crying and/or distressed behavior and 36% prescribe PPIs in infants with uncomplicated recurrent regurgitation and vomiting; 48% prescribed PPIs in children younger than 8 to 12 years with vomiting and heartburn, without specific testing; 45% discontinue PPI therapy abruptly rather than tapering the dose. The overall rate of pediatricians overprescribing PPIs was 82%. Conclusions: The overall results of our survey show that the majority of pediatricians are unaware of 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition reflux guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. The overdiagnosis of gastroesophageal reflux disease places undue burden on both families and national health systems, which has not been affected by the publication of international guidelines.

The association of coeliac disease in childhood with functional gastrointestinal disorders: a prospective study in patients fulfilling Rome III criteria

Aliment Pharmacol Ther 2011; 34: 783–789

A randomized, prospective, comparison study of a mixture of acacia fiber, psyllium fiber, and fructose vs polyethylene glycol 3350 with electrolytes for the treatment of chronic functional constipation in childhood.

OBJECTIVES To compare the effectiveness of a mixture of acacia fiber, psyllium fiber, and fructose (AFPFF) with polyethylene glycol 3350 combined with electrolytes (PEG+E) in the treatment of children with chronic functional constipation (CFC); and to evaluate the safety and effectiveness of AFPFF in the treatment of children with CFC. STUDY DESIGN This was a randomized, open label, prospective, controlled, parallel-group study involving 100 children (M/F: 38/62; mean age ± SD: 6.5 ± 2.7 years) who were diagnosed with CFC according to the Rome III Criteria. Children were randomly divided into 2 groups: 50 children received AFPFF (16.8 g daily) and 50 children received PEG+E (0.5 g/kg daily) for 8 weeks. Primary outcome measures were frequency of bowel movements, stool consistency, fecal incontinence, and improvement of other associated gastrointestinal symptoms. Safety was assessed with evaluation of clinical adverse effects and growth measurements. RESULTS Compliance rates were 72% for AFPFF and 96% for PEG+E. A significant improvement of constipation was seen in both groups. After 8 weeks, 77.8% of children treated with AFPFF and 83% of children treated with PEG+E had improved (P = .788). Neither PEG+E nor AFPFF caused any clinically significant side effects during the entire course of the study period. CONCLUSIONS In this randomized study, we did not find any significant difference between the efficacy of AFPFF and PEG+E in the treatment of children with CFC. Both medications were proved to be safe for CFC treatment, but PEG+E was better accepted by children.

Total and abdominal obesity are risk factors for gastroesophageal reflux symptoms in children.

Objectives: The association between GERD and obesity has been frequently reported in adults. Data in children are scarce and inconclusive, evaluating only general obesity. Central adiposity has never been investigated in children as a possible risk factor for GERD. The aims of the present study were to evaluate the prevalence of gastroesophageal reflux disease (GERD) symptoms in overweight and obese children in comparison with a general normal-weight population and whether the GERD symptoms are associated with waist circumference (WC). Methods: The study population consisted of 153 healthy children. A detailed clinical history and a physical examination were obtained from each patient. A questionnaire on reflux symptoms was completed by caregivers. Results: The reflux symptomatic score resulted significantly higher in obese than in normal-weight children and in children with WC >90th percentile compared with those with WC <75th percentile. Conclusions: These preliminary data show that both total and abdominal obesity are risk factors for the development of GERD symptoms in children. The risk of GERD symptoms rises progressively with the increase in both body mass index and waist circumference, even in normal-weight children.

Novel and alternative therapies for childhood constipation.

Constipation is a common and distressing pediatric problem. Even if prevalence of this disorder has increased, treatment of constipation in children is still largely based on clinical experience rather than on evidence-based studies. The currently recommended treatment includes education, disimpaction, and maintenance therapy, consisting of dietary changes, behavioral modification, and use of laxatives. Among osmotic agents, polyethylene glycol solutions appear to be the first-line drug to use in pediatrics. Although these measures are effective in the majority of children, a sizable proportion needs long-term therapy. Chronicity may significantly interfere with the childs emotional growth and development. Advances in the understanding of the gastrointestinal enteric nervous system and epithelial function have led to the development of new classes of drugs. These include substances that bind to serotonin receptors or are chloride channel activators. Further studies are needed to assess the benefits and the risks of these new drugs.

Do pediatricians apply the 2009 NASPGHAN-ESPGHAN guidelines for the diagnosis and management of gastroesophageal reflux after being trained?

Background: According to a recent survey, the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition–European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines are poorly adhered to by European primary care pediatricians. The main issue raised from the survey was the prescription of unnecessary acid suppressive medications, especially in infants. No inquiry into the reasons was made. The primary objective of the present study was to assess the applicability of the guidelines in European primary care pediatricians undergoing specific trainings. Methods: One hundred pediatricians involved in the previous survey agreed to participate and were randomly divided into 2 groups: one group was trained in the guidelines through an online podcast and the other group was trained through a synopsis. During the following 3 months, each involved pediatrician was asked to enroll every consecutive infant, child, or adolescent with suggestive reflux symptoms. For every enrolled patient, pediatricians filled in a report concerning their diagnostic and therapeutic choices. Results: A total of 382 patients (boys/girls 186/196, infants/children/adolescents 194/123/65) were enrolled by pediatricians. Infants with unexplained crying and/or distressed behavior who were prescribed proton-pump inhibitors were 3.7% compared with 45.2% of the survey data obtained before the training (P < 0.05). Infants with uncomplicated recurrent regurgitation and vomiting who were prescribed proton-pump inhibitors were 4.5% against 37.1% of the baseline survey data (P < 0.05). The overall rate of children managed in full compliance with the guidelines was 46.1% after the training compared with 1.8% before the training (P < 0.05). No significant differences were seen between pediatricians from podcast and synopsis group. Conclusions: The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition–European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines have good applicability, despite that they are presently poorly adhered to by European primary care pediatricians. Simple, inexpensive trainings were proven to be effective in increasing adherence by pediatricians. The increase in compliance clearly favors the role of continuous medical education through simple educational tools and subsequent assessment of practice.

Clinical relevance of esophageal baseline impedance measurement: just an innocent bystander.

Objective: The clinical relevance of esophageal baseline impedance (BI) remains to be determined. In the present study, we explored the impact of gastroesophageal reflux disease (GERD) and esophageal dysmotility on BI. Methods: A total of 18 children with esophageal atresia, 26 children with GERD, and 17 controls prospectively underwent esophagogastroduodenoscopy and pH–impedance monitoring. BI was measured in both proximal and distal esophagus. Gastroesophageal reflux (GER) and bolus transit indicators were defined according to published criteria. Results: Patients with esophageal atresia showed significantly lower proximal and distal BI values (952 [716–1811] &OHgr;; 895 [284–1189] &OHgr;; respectively) compared with those with GERD (3015 [2368–3975] &OHgr;; 2231 [1770–3032] &OHgr;, P < 0.001 and <0.001, respectively) and controls (3699 [3194–4358] &OHgr;; 3522 [2927–3994] &OHgr;, P < 0.001 and <0.001, respectively). Using linear regression, proximal BI strongly correlated with total bolus transit time (r2 = 0.61, P < 0.001) and bolus presence time (BPT; r2 = 0.63, P < 0.001). Distal BI weakly correlated with acid exposure time (r2 = 0.16, P < 0.01) and longstanding reflux episodes (r2 = 0.17, P < 0.01), and strongly correlated with total bolus transit time (r2 = 0.53, P < 0.001) and BPT (r2 = 0.58, P < 0.001). By logistic regression, BPT predicted low proximal BI values (odds ratio [OR] 1.052; P < 0.05), whereas both GER indicators (acid exposure time: OR 1.56, P < 0.05; longstanding reflux episodes: OR 2.8, P < 0.05) and BPT (OR 1.66, P < 0.01) predicted low distal BI values. Conclusions: Along the length of esophagus, both bolus transit variables and GER significantly affect BI. This suggests that BI may merely mirror phenomena occurring within the esophageal lumen or wall, limiting its value as a discrete clinical entity to replace variables already used for assessing both GERD and esophageal dysmotility.

Functional Gastrointestinal Disorders in Children: A Survey on Clinical Approach in the Mediterranean Area

Objectives: Childhood functional gastrointestinal disorders (FGIDs) are common conditions associated with significant morbidity and high healthcare costs. This multicenter study aimed at assessing the clinical approach to infants (0–6 months) and children/adolescents (4–18 years) with suspected FGIDs by pediatricians from the Mediterranean Area. Methods: A survey evaluating the diagnostic approach, including the use of Rome II and III criteria, and the therapeutic management of some of the most prevalent FGIDs, such as irritable bowel syndrome (IBS), functional constipation (FC), and functional regurgitation (FR), was distributed to a sample of pediatricians. Results: We collected 278 questionnaires from 9 countries (Croatia, Greece, Israel, Italy, Lebanon, Montenegro, Serbia, Slovenia, and Spain). Rome III criteria are used to diagnose FC by 28.8%. Treatment of FC is based on dietary modifications (97.5%) and osmotic laxatives (93.5%). Rome III criteria are used to diagnose FR by 22.3% of the responders, in contrast to 79.5% who rely on personal experience for diagnosis. Reported treatments mainly consist of reassurance (96.8%) and thickened feedings (77.3%). Nevertheless, 21.2% prescribe proton pump inhibitors or H2-blockers to infants with FR. Rome III criteria are used to diagnose IBS by only 25.9%. Moreover, 86% of the pediatricians base IBS therapy on the predominant symptom. The most prescribed treatments are analgesics (36.6%) for pain control, dietary advice (41.5%) for diarrhea-predominant IBS, and dietary advice (47.8%) for constipation-predominant IBS. Conclusions: Our data show that the use of Rome III diagnostic criteria is not sufficiently widespread among pediatricians, and that large variability remains in the management of FGIDs within the different Mediterranean countries surveyed.

Gastroesophageal reflux in young children and adolescents: Is there a relation between symptom severity and esophageal histological grade?

Background: The pediatric literature about the correlation between symptoms and histological lesions in patients investigated for gastroesophageal reflux disease is scarce and inconclusive. The primary aim of the present study was to assess the relation between the complained symptom severity and the esophageal histological grade, through the use of validated and reliable scores. Methods: All children ages between 2 and 17 years referred to perform upper gastrointestinal endoscopy because of gastroesophageal reflux disease symptoms were asked to complete the Pediatric Gastroesophageal Symptom and Quality of Life validated questionnaire, investigating the main symptoms complained and their impact on daily life and school activities. Esophageal mucosal samples taken during the procedure were analyzed and scored according to the Yerian‐Fiocca classification. Results: A total of 164 children were included in the study. No significant association was found between symptomatic score and histological score (rs: 0.05, P: 0.49). Even when focusing only on adolescents with heartburn or chest pain, no correlation between symptom severity and esophageal lesions was found (rs: −0.18, P: 0.264). Intercellular space diameter values did not mirror symptom severity. Conclusions: The main finding of this study on children with reflux symptoms is the lack of correlation between symptom severity and esophageal histological grade. The magnitude of intercellular spaces was found not to be related with the clinical score as well.

Role of non-acid gastro-esophageal reflux in children with respiratory symptoms

Respiratory symptoms are a possible atypical clinical picture of gastro‐esophageal reflux disease (GERD). However, a significant number of patients with GERD‐related respiratory symptoms do not report improvement despite aggressive acid‐suppressive therapy. Some of these refractory cases may be due to the recently appreciated entity of non‐acid or weakly acidic reflux. The aim of our study is to assess the pH‐impedance features of GER inducing airway symptoms, compared with GER inducing typical gastro‐intestinal (GI) symptoms.