Vikram Khoshoo

Impact of nutritional rehabilitation on gastroesophageal reflux in neurologically impaired children

The impact of nutritional rehabilitation on gastroesophageal reflux (GER) in 10 malnourished neurologically impaired children (NIC) was studied (mean age, 9.1 +/- 3.1 years). None of the children had an antireflux procedure (ARP), and all were fed exclusively through a percutaneous endoscopic gastrostomy (PEG). Malnutrition was defined as triceps skin fold thickness (TSF) below the fifth percentile for age and sex. GER was established using standard criteria for a 24-hour pH probe study. All children were treated with an H2 antagonist and a prokinetic agent, along with aggressive nutritional rehabilitation. When TSF was > or = 50th percentile, medications were stopped, and the 24-hour pH probe study was repeated. The mean weight gain was 8.8 +/- 3.7 kg over 8.4 +/- 2.3 months. The 24-hour pH probe study showed marked improvement after nutritional rehabilitation in six of 10 children. These children remained asymptomatic throughout long-term follow-up, without the use of medications. Two children had abnormal pH probe results and worsening clinical symptoms when taken off medications after nutritional rehabilitation. They were reexamined after reinstituting the prokinetic drug; results of the pH probe study were normal, and there was no clinical symptomatology. The patients were then given long-term medication. Two children (one with erosive esophagitis and one with persistent symptoms) underwent ARP. We conclude that despite accompanying GER, successful nutritional rehabilitation can be achieved in malnourished NIC, using PEG feeding and antireflux medication. Although some NIC with GER may need an ARP or long-term medication, in most malnourished NIC nutritional rehabilitation is associated with resolution of GER.

Reduced long-term respiratory morbidity after treatment of respiratory syncytial virus bronchiolitis with ribavirin in previously healthy infants: A preliminary report

Previously healthy infants less than 6 months of age with severe respiratory syncytial virus bronchiolitis who required hospitalization were identified from hospital records. Infants had been treated either conservatively (control group, n = 19) or with ribavirin added to conservative management (study group, n = 22). All infants underwent a 1‐year follow‐up after the initial illness. There was a significant reduction in the prevalence of reactive airway disease in the group treated with ribavirin (P < 0.05) compared with the control group, both in terms of the proportion of patients developing airway reactivity (59% vs. 89%) and the number of episodes of reactive airway disease (31 vs. 70). Our data suggest that ribavirin reduces the prevalence of airway reactivity. Pediatr. Pulmonol. 1998; 25:154–158.

Smaller volume, thickened formulas in the management of gastroesophageal reflux in thriving infants.

Background The effect of smaller volume, thickened formulas on gastroesophageal reflux is not clear. Methods The frequency of gastroesophageal reflux and duration of acid pH in the esophagus were determined in six thriving infants using extended esophageal pH monitoring. Results There was a significant reduction in frequency of emesis and gastroesophageal reflux but not the duration of acid pH in the esophagus with the use of infant formula thickened with rice cereal to provide a nutritionally appropriate intake in a smaller volume. Conclusions Thickening of formula with rice cereal in a nutritionally balanced form and smaller volume may be an appropriate strategy for reducing frequency of emesis and gastroesophageal reflux in thriving infants.

Associated Factors in Children With Chronic Cough

BACKGROUND Children presenting with chronic cough are common to the primary care physicians, but data on the etiology are scant. METHODS We evaluated 40 children (age range, 5 to 12 years) with chronic cough (> 8 weeks duration) with no obvious cause who were referred by their primary care physicians. All patients underwent an extensive multispecialty workup that included pulmonary, GI, allergy, immunology, and otorhinolaryngology testing. Response to treatment was quantified pretreatment and 8 weeks after treatment by using a visual analog scale. RESULTS Positive diagnostic test results were noted for gastroesophageal reflux disease (27.5%), allergy (22.5%), asthma (12.5%), infection (5%), aspiration (2.5%), and multiple etiologies (20%). Appropriate treatment for these factors resulted in a significant improvement in cough. CONCLUSION Reflux, allergy, and asthma accounted for > 80% of the likely etiologic factors of chronic cough in children and responded to appropriate treatment.

Propofol versus midazolam plus meperidine for sedation during ambulatory esophagogastroduodenoscopy

Objective To evaluate the efficacy and safety of propofol and meperidine plus midazolam for sedation during esophagogastroduodenoscopy (EGD) in children. Methods Data were collected prospectively and retrospectively from neurologically intact children (0.2–17.7 years of age) who underwent ambulatory diagnostic EGD during a 4-year period. Data were included from 155 consecutive patients receiving propofol with or without premedication with midazolam (PM group). One hundred five consecutive patients who received sedation with a midazolam plus meperidine combination served as a comparison (MM group). Outcome variables were: time required for induction of sedation, length of procedure, time for recovery, need for additional supportive measures, and need for physical restraint. Results The onset of sedation was faster and the length of procedure and recovery were significantly shorter in the PM group as compared with the MM group (P < 0.01). Patients in the MM group required restraint more often than in the PM group. A higher dose of meperidine and midazolam was used in the prospective study. This led to deeper sedation but increased need for additional support. Conclusions Propofol is safe and effective for facilitating EGD in children.

Are We Overprescribing Antireflux Medications for Infants With Regurgitation

OBJECTIVE. Our goal was to evaluate the diagnosis and treatment of infants with persistent regurgitation who were referred to a pediatric gastroenterology service. METHODS. The records of 64 infants with persistent regurgitation and without any neurodevelopmental abnormalities, underlying illness, or cigarette smoke exposure were evaluated for diagnostic workup and treatment. Forty-four infants underwent extended esophageal pH monitoring. RESULTS. Only 8 of 44 pH studies showed abnormal acid reflux. Forty-two of these 44 infants were already on antireflux medications. Other etiologies included hypertrophic pyloric stenosis (4) and renal tubular acidosis (1). Discontinuation of medication did not result in worsening of symptoms in most infants with normal pH studies. CONCLUSIONS. The majority of infants who were prescribed antireflux drugs did not meet diagnostic criteria for gastroesophageal reflux disease.

Effect of antireflux treatment on asthma exacerbations in nonatopic children.

Objective: To evaluate the asthma outcome of treatment with ranitidine or esomeprazole plus metoclopramide in older children with moderate-persistent asthma and gastroesophageal reflux disease (GERD). Patients and Methods: The study patients included 44 patients with asthma and GERD who had received 1 year of treatment with a proton pump inhibitor/prokinetic combination and had shown significant clinical improvement in asthma symptoms and no exacerbations for more than 3 months. For further treatment, 30 of the 44 patients continued treatment with esomeprazole/metoclopramide (group A), and 14 switched to ranitidine (group B). Nine patients with GERD and asthma who had previously undergone fundoplication were used as control individuals (group C). All patients were followed up closely for exacerbation of asthma symptoms and treated according to a standardized protocol. Results: During the 6-month follow-up, group B patients experienced significantly more exacerbations per patient (2.2) than did those in group A (0.33) or group C (0.77) (P < 0.05). Conclusions: Fundoplication or continued treatment with esomeprazole and metoclopramide is associated with significantly fewer exacerbations of asthma symptoms in children with moderate-persistent asthma and concomitant GERD in comparison with treatment with ranitidine.

Clinical response to 2 dosing regimens of lansoprazole in infants with gastroesophageal reflux.

Proton pump inhibitors such as lansoprazole are used in the treatment of gastroesophageal reflux disease (GERD), but dosing guidelines for infants have not been determined. The objective of this study was to assess the clinical efficacy of 2 dosing regimens of lansoprazole in infants with GERD using the revised infant gastroesophageal reflux questionnaire scores (I-GERQ-R). Thirty consecutive infants (3–7 months) with GERD, whose conditions were diagnosed by I-GERQ-R scores of ≥16, were randomly assigned to receive 1 of 2 lansoprazole dosing regimens: 15 mg given once per day (group A) or approximately 7.5 mg given 2 times per day (group B). Matched infants in a control group were treated with an extensively hydrolyzed formula (group C). Daily I-GERQ-R scores were gathered, and the scores after 1 and 2 weeks of treatment were used for analysis. The mean pretreatment scores were similar in groups A, B, and C (26.6, 26.9, and 25.9, respectively). After treatment there was a similar drop in the mean scores in groups A and B (20.6 and 20.0, respectively), but not in group C (25.8). At the end of the first week of treatment, in group A, 5 of 15 infants (33%) had a significant reduction in their I-GERQ-R scores, whereas in group B, 10 of 15 infants (67%) had a significant reduction in their I-GERQ-R scores (P < 0.05). At the end of the second week of treatment, groups A and B had similar numbers of patients with significant improvement (60% and 67%), which was higher than in group C (3/15, 20%). Overall, there was no difference in the symptom response, as measured by I-GERQ-R scores, between 15 mg of lansoprazole given once per day and 7.5 mg given twice per day in infants with GERD, but the twice-daily regimen produced a faster symptom response. Both regimens were significantly better than treatment of infants with an extensively hydrolyzed formula.

Nutritional manipulation in the management of dumping syndrome.

Two children with Nissens fundoplication and either gastrocystoplasty or pyloroplasty developed dumping syndrome. Correction of their blood glucose abnormalities, resolution of symptoms, and weight gain were effectively achieved by addition of fats and uncooked corn starch (50 g/l) to their feeds.

Bronchial hyperreactivity in non-atopic children with asthma and reflux: effect of anti-reflux treatment.

The prevalence of bronchial hyperreactivity (BHR) or the effect of anti‐reflux treatment on BHR in children with asthma and gastroesophageal reflux disease (GERD) is not known.