Incredible Review of GERD, BRUE, Aspiration, and Gastroparesis

Recently, Rachel Rosen gave a terrific review of reflux and reflux-related entities as part of our annual William (Billy) Meyers lectureship.  This lecture information would be helpful for every pediatric gastroenterologist as well as every pediatrician, pediatric ENT, pediatric pulmonologist, pediatric SLP and lactation specialist.  It puts to rest many obsolete ideas about reflux and its management. Some of her points have been covered by this blog previously (see links below) and by her bowel sounds podcast (see link below).   Some errors of omission and transcription may have occurred as I took notes during this lecture. 

Main points:


  1. Using the label “GERD” increases the likelihood that an infant will be prescribed acid blockers; this phenomenon is noted as well with SLP and lactation specialist team members.  Everyone needs to be careful about ascribing infant symptoms to “reflux disease”
  2. AR formulas need acid to increase their viscosity (don’t use PPIs in infants taking AR formulas). Also, AR formula viscosity is hindered when mixed with breastmilk (don’t mix with breastmilk)
  3. Most infants with reflux have nonacid reflux.  PPIs do not help nonacid reflux
  4. PPIs are associated with increased aspiration and infection risks.  Acid suppression has been associated with increased risk of allergic diseases
  5. Rumination can look a lot like reflux on pH probe studies
  6. Reflux hypersensitivity, and functional heartburn can result in similar symptoms as reflux (can be distinguished with pH testing)
  7. Pepsin can increase lung inflammation and can be increased by PPI use
  8. Red airway appearance is NOT indicative of reflux (poor specificity, poor sensitivity)
  9. If having symptoms with transpyloric feedings, this indicates that the symptoms are NOT due to reflux; transpyloritc feedings have similar efficacy as a fundoplication
  10. Avoid fundoplication.  It does not result in fewer hospitalizations or improve pulmonary outcomes.  It can result in a number of complications
  11. Consider genotyping for CYP2C19 pharmacogenetics in patients receiving chronic PPI.  Those with rapid metabolism could benefit from higher doses.  Those with slow metabolism could benefit from lower doses.  Higher doses of PPIs increase risk for infections
  12. Bolus feedings result in fewer problems than continuous feedings

Delayed Gastric Emptying (Gastroparesis)

  1. Delayed GE is associated with increased lung bile acids.  This is important in lung transplant recipients and increased lung bile acids is seen more commonly in those with frequent admissions for respiratory issues
  2. In Dr. Rosen’s experience, prucalopride is currently the most useful promotility agent in documented gastroparesis


  1.  Infants with BRUE need to be tested for aspiration, not prescribed PPIs.
  2.  VSS (aka OPMS) has the highest yield of any test in infants with BRUE (~72% abnormal testing in one study). 
  3. Silent aspiration is common -don’t rely on SLP bedside assessment.
  4. Even with this diagnosis, many infants are still prescribed PPIs which increase the risk of complications (more hospitalizations, more infections, possible increase in allergies)


  1. There are a number of potential etiologies, though most infants have aspiration due to neurological reasons (most transitory and improved by 7 months of age)
  2. In Boston, less than 5% with aspiration on VSS required GT placement
  3. Thickeners can be very helpful.  Practitioners need to know the differences (don’t use Simply Thick in 1st year of life due to NEC risk)

Chronic Cough:

  1. ~10% of kids with chronic cough have eosinophilic esophagitis (who have seen GI in Boston)

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Cacti at Tucson Botanical Gardens

Update on Chronic Cough

It is not uncommon for a pediatric gastroenterologist to see a patient with a chronic cough due to concerns about potential gastroesophageal reflux disease (GERD).  As such, a recent clinical practice article (JA Smith, A Woodcock. NEJM 2016; 375: 1544-51) by lung specialists was of interest, even though this article was not targeted to the pediatric population.

Key points:

  • The authors define a chronic cough as lasting more than 8 weeks and note that it common with respiratory conditions (eg. chronic obstructive pulmonary disease, asthma, and bronchiectasis) and some non-respiratory conditions (eg. gastroesophageal reflux and rhinosinusitis).  Medications, particularly ACE inhibitors, can trigger a chronic cough as well.
  • Steps in evaluation: 1. H&P, CXR, spirometry. 2. Consider metacholine challenge, ENT evaluation, consider empiric treatment (eg. inhaled glucocorticoids, PPI), and consider GERD evaluation. 3. High-resolution CT and bronchoscopy.
  • For many patients, there is likely to be an abnormality in neuronal pathways controlling cough and the term “cough hypersensitivity syndrome” has been coined.  Figure 2 (below) illustrates the neuronal pathways.
  • For refractory patients, potential therapies would include low-dose morphine, gabapentin or pregabalin, and speech language therapy.



  • Guidelines “suggest a trial of treatment with acid-suppression therapy” (eg. twice-daily PPIs for up to 3 months).
  • “Most randomized, controlled trials of reflux treatment for cough have not shown a significant improvement in association with this type of treatment.”
  • Subgroups of patients with heartburn, regurgitation, or excessive acid reflux on esophageal pH monitoring “appeared marginally more likely to have a response to PPI treatment.”  pH or impedance tests “are poorly predictive of a response of cough to acid suppression.”

My take: In the absence of clinical reflux, reflux therapy is unlikely to help with chronic cough.  However, in patients with an adequate workup, an empiric course of a PPI is likely more preferable than empiric morphine or gabapentin.

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Pet Peeves -Cough and Cold Medicines and Antibiotic Usage

Although upper respiratory illnesses are not a primary focus for pediatric gastroenterologists, due to their frequency, we see them quite a bit.  Even with my limited exposure, I frequently receive requests for medications to reduce the symptoms of cough and runny nose.

My approach has typically been to explain that I don’t believe that cough and cold medicines (CCMs) are effective and can be harmful, especially in young children.  This explanation is in agreement with efforts that both the pharmaceutical industry and the Food and Drug Administration (FDA) took in 2007 and 2008 to limit the use of over the counter (OTC) CCMs in young children.  The American Academy of Pediatrics has gone further and advised against their usage in children under age 6 years.  These recommendations came in part due to lack of efficacy of these agents but also due to the recognized potential for adverse effects, including fatalities.

Recently, a study (J Pediatr 2014; 165:1024-8) has shown that despite labeling changes on CCMs there has been virtually no impact on the use of OTC CCMs.  Using information from administrative databases, this study compared prescribing patterns 2005-2006 with 2009-2010 in children aged ≤ 12 years.  Results: There was an increase in use of OTC CCM used in ambulatory clinics (6.3% to 11.1%) but a decrease in the use of prescription CCMs 6.7% to 2.9%.  The OTC CCM use in children <2 years was essentially unchanged between the two timeframes (6.8% compared to 6.5%)

Bottomline: If parents and physicians want to do what is best for the children they care for, then more effort is needed to stop the widespread use of CCMs.  Prevention with influenza vaccination and proper hand hygiene are measures which can help.

A separate problem is the misuse of antibiotics for upper respiratory illnesses.  This is widespread as well.  While this blog has discussed antibiotic resistance and antimicrobial stewardship, a recent article (NEJM 2014; 371: 1761-63) provided a few new ideas on this subject.

  • First, the authors note that modern medicine is entirely dependent on antibiotics.  “Two major ways that modern medicine saves lives are through antibiotic treatment of severe infections and the performance of medical and surgical procedures under the protection of antibiotics.”
  • Second, the authors note that “as people in wealthier regions run out of effective antibiotics, they come to share the lot of people in poorer regions who can’t afford them to begin with.”
  • Third, the authors point out that antibiotic resistance was recognized in 1945 by Alexander Fleming and Howard Walter Florey when they accepted the Nobel Prize for the discovery of penicillin.

The authors then outline the areas that need to be addressed to diminish the prospects of ineffective antibiotics:

  • Prevention with vaccination and sanitation
  • Leadership to coordinate global surveillance and manage rewards for proper usage
  • Access to subsidized appropriate usage in poorer countries
  • Conservation of antibiotic usage –restrain use of antibiotics in agriculture/farming
  • Conservation through appropriate use of prescriptions

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