How Bad is Reflux in Children with Esophageal Atresia?

A recent retrospective study (FWT Vergouwe et al. JPGN 2019; 69: 515-22) with 57 children with esophageal atresia (EA) found most children have a normal reflux index.

This study, analyzing data between 2012-2017, reviewed all 24-hour pH-impedance (MII) studies in children at ≤18 months and 8 year olds with EA.  “All children with EA born in our hospital are offered a 24-hour pH-MII study at the age of 0.5 years and 8 years.”  In this institution, PPI treatment is given for at least 6 months after surgery. Of the 57 in the cohort, 20 had completed pH-MII at <18 months of age and 32 at age 8 years.

Key findings:

  • In children ≤18 months of age, median reflux index was 2.6% (abnormal in 2), median number of retrograde boluses was 61 (62% nonacid, 58% mixed)
  • In the older cohort (~8 years of age), median reflux index was 0.3% (abnormal in 4) and median number of retrograde boluses was 21 (64% nonacid, 75% mixed)
  • Overall, 10 of 57 children (17.5%) had GERD with reflux index >7% (n=6) or positive SI/SAP (n=4).  The authors note that much higher rates of GERD have been found in prior studies.  If they included children with fundoplication who were considered as having GERD (prior to fundoplication), then the GERD rate was 32%.

My take: This study showed that reflux in this cohort of children with EA was similar to the general population and likely indicates that a substantial portion of patients with EA do not need indefinite PPI therapy.  In children with more complex EA, PPI therapy is likely to be more beneficial.

Related blog posts:

Recent (November 4th) GI-Related Tweets:

How to Make a Study Look Favorable for Reflux Surgery Compared to Medical Treatment

A recent study (SJ Spechler et al. NEJM 2019; 381: 1513-23) on first glance appears to support surgery as more effective than medical treatment for refractory heartburn.

Only ~20% of enrolled patients were included in the reported outcomes!

Here’s what happened.  Among a cohort of VA patients (n=360, mean age 48 years) who were reportedly refractory to PPI-treatment:

  • 78 were excluded during prerandomization
  • 42 had relief of their heartburn during a 2-week omeprazole lead-in (20 mg BID)
  • 70 did not complete trial procedures
  • 23 had non-GERD disorders
  • 99 had functional heartburn

This left 78 patients who underwent randomization.  All patients in this highly-selected group had undergone endoscopy with biopsy, impedance-pH testing, and esophageal manometry.  18 of 27 (67%) had treatment success with surgery compared to 7 of 25 patients treated with baclofen/PPI and 3 of 26 with control medical treatment (PPI alone).

Key points:

  • Careful evaluation is needed in any patient with refractory heartburn, especially if contemplating surgery.  Most will either respond to PPI treatment or have a disorder other than reflux; the authors note that 122 patients (out of 360 patients) did NOT have reflux –99 had functional heartburn.
  • Careful instruction in PPI use can be helpful.  Omeprazole and similar agents should be taken 30 minutes before meals.
  • The authors noted that in addition to reflux, that reflux hypersensitivity can “respond to fundoplication…treatment success was 71% among the 14 with reflux hypersensitivity and 62% among the 13 with abnormal acid reflux.”

Limitations: The VA population is not representative of the general population; this trial had a predominance of white males. Also, it is hard to exclude that some of the ‘success’ of the procedure could relate to a powerful placebo response.

My take: This trial reinforces the notion that reflux surgery is helpful in very few highly-selected patients.

Related blog posts:

Are There Any Babies with a Normal GI Tract?

A recent study (S Salvatore et al. J Pediatr 2019; 212: 44-51) examines the role of neonatal antibiotics and prematurity on the development of functional gastrointestinal disorders in the first year of life.

What is most striking, though, in this study is how many of these infants have a GI disorder.

Background: Prospective cohort multicenter study with 934 infants who completed study; n=302 premature, n=320 antibiotic recipients

Key findings:

  • 718 (77%) had at least one functional GI disorder (FGID) based on Rome III criteria, including 47% with colic, 40% with regurgitation, 32% with dyschezia, 27% with constipation, and 4% with functional diarrhea
  • Preterm infants had FGID rate of 86% compared with 73% of full term infants (P=.0001)
  • Use of antibiotics was associated with FGIDs as well, with aRR of 1.16 (P=.001)
  • The prevalence of FGIDs was highest in the first three months of life and then improved markedly by 6 months of age; by 12 months of age, each of the FGIDs was well below 10%.

Limitation: This study relied on parental reports which could overestimate infant’s symptoms.

My take: More than 75% of infants had at least one FGID.

Related blog posts:

#NASPGHAN18 Highlights and Tweets (part 1)

I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course

 

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Top Posts 2016

The following posts are the ones that I think are most useful from 2016.

Gastroenterology:

Liver:

General:

Doctoring:

IBD:

Nutrition:

truth-johnpohl

Does Reflux Lead to Increased Aspiration Pneumonia?

This post’s title question turns out to be quite tricky.  According to a recent study (RL Rosen et al. JPGN 2016; 63: 210-17), reflux burden, even in children that aspirate did not correlate with increased hospitalization.

Here are the details:

Methods: Prospectively recruited cohort of 116 children who had both pH-impedance testing along with modified barium swallow. The authors considered pathologic reflux to have at least 73 episodes on pH-impedance or if pH<4 for >6% of study period.

Key findings:

  • There was no statistical correlation between pH-impedance study results and total number of admissions even with or without adjusting for aspiration status (and neurologic complications).

When the authors tried to reconcile these findings, they offered three competing potential explanations for these results:

  • Reflux has little impact on hospitalziations
  • Our methods for measuring reflux are not good
  • Even “normal” reflux can be a problem for those prone to complications; therefore, reflux burden is not consequential.

What is clear is that pH-impedance studies cannot predict which patients are at risk for increased complications.  This is supported by data showing that ‘reflux-related’ hospitalizations may not improve after fundoplication (Pediatrics 2006; 118: 2326-33; J Pediatr Surg 2008; 43: 59-63).  One particularly important limitation was that the cause of hospitalizations was determined by medical record review.

My take: A simple algorithm for preventing aspiration pneumonia does not exist.  Even the role of reflux testing is uncertain.

Related blog posts:

The accompanying article guaranteed that the pizza would pass through the body within 30 minutes.

The accompanying article guaranteed that the pizza would pass through the body within 30 minutes!!!

 

Linking Reflux and Tooth Erosion

Every now and then a dentist sends a kid to our GI practice due to eroded teeth because of concerns about reflux damaging the enamel.  While it is recognized that reflux may damage teeth, the exact frequency is unclear.  Other questions:

  • Which asymptomatic kids with poor dentition require GI evaluation?
  • What is the best way to evaluate these children?
  • If reflux is identified, how long should they remain on treatment? Forever?
  • How effective is reflux treatment in reducing tooth damage?

While none of these questions have been definitely answered, Rosen et al (JPGN 2016; 62: 309-13) show that acid reflux rather than nonacid reflux is predictive of tooth erosion. In this study, the authors used a prospective cohort of 27 children (age ≥3 years)–ALL of them were ON acid suppression (for >1 year) at the time of pH-MII testing.  Key findings:

  • Prevalence of tooth erosion was 10 or 27 (37%)
  • There was correlation with acid reflux episodes (& time in reflux) and tooth erosion, r=0.44, P=0.02
  • There was correlation with reflux index as well, r=0.54, P=0.004,  In the tooth erosion group, the mean reflux index was 7.3% compared with 1.6% in no dental erosion group.
  • There was no correlation with nonacid reflux with tooth erosion

The authors’ discussion highlights many prior relevant studies and indicates that a pH-metry study alone (rather than pH-MII) “may be adequate.” They note some of the limitations of this study which included a small number of patients and potential referral bias, as these children had suspected GERD.  In the methods section, the authors state that their standard practice, at the time of the study, was to maintain patients on prior acid suppression medication.  It would be useful to acknowledge that many experts, at this time, recommend doing pH-MII studies as well as standard pH studies off all acid suppression due to improved sensitivity/accuracy.

My take: This study shows that in the 10 children with tooth erosion who had suspected GERD, there was correlation with acid reflux but not with nonacid reflux.

Related blog post: Notes from PPI Webinar GutsandGrowth

Unrelated but interesting: Are medical errors really the 3rd leading cause of death in U.S.? Here’s NPR’s summary of a recent BMJ article which makes that claim: Only Heart Disease and Cancer Exceed Medical Errors As Cause of U.S. Death

Gibbs Gardens

Gibbs Gardens