TACTICA

Several guidelines have been published regarding the management of gastro-oesophageal reflux disease in children. Rudolph et al. (2001) conducted a systematic review to develop a

Chapter 4 | 108 guideline for management of suspected GOR in children on behalf of the North American Society for Pediatric Gastroenterology and Nutrition. The guideline summarised the diagnostic approaches to GOR, available treatments and recommended a management approach based on specific symptom presentations in children. Below I discuss the diagnostic and treatments for GOR in relation to the headings used in the guideline (Rudolph, 2001) in reference to children.

4.2.2.1 Diagnosis of GORD

(1) History and physical examination – History should include any previous reflux episodes, frequency and pattern of reflux, feeding, medical, exposure to smoke, sleeping position, etc. to relate to GOR symptoms. A significant relationship between maternal GOR and infant spilling was observed in a prospective cohort study of 693 infants and suggested that a genetic component may be involved (Martin, 2002).

Maternal history of GOR may be another variable to be collected when taking history.

Physical examination could identify any abnormal signs. Some experts thought that history and physical examination is sufficient to diagnose GOR, recognise any complications and to initiate management (Rudolph, 2001).

(2) Upper GI series – Upper GI series test (barium contrast radiography) is useful to detect anatomical abnormalities such as hiatus hernia, pyloric stenosis, malrotation and annular pancreas in vomiting infants. Sensitivity ranges from 31% to 86% and specificity ranges from 21% to 83% when compared to oesophageal pH monitoring (Rudolph, 2001). However, the test is neither sensitive nor specific to GOR, and therefore it is not a very useful test for diagnosis of GOR.

(3) Oesophageal pH monitoring is regarded as a first line of investigation for children regardless of age (Al Khawari, 2002). It is a valid and reliable way to measure acid reflux. This method involves transnasal placement of microelectrode into lower oesophagus to measure and record inter-oesophageal pH. Computerised devices are normally used to record pH every 4 to 8 seconds, which then calculates the frequency and episodes of reflux, usually within a 24-hour period. An episode is defined as pH<4 for a minimum of 15 to 30 seconds. A normal episode of acid reflux in normal infants is 31 (±21) per day with an upper limit of 73 episodes (Vandenplas, 1991). 24-hour pH monitoring can detect any abnormal acid reflux and could be used to

Chapter 4 | 109 determine whether the symptoms are temporally associated with GORD. On the other hand, non-acidic reflux episodes, for example post-prandial reflux in infants are not detected by pH monitoring. In some patients, pH monitoring is within normal range but the brief episodes of GOR may also cause complications. A study suggested that non-acidic reflux occurs more frequently than acid reflux in infants (Wenzl, 2002) thus oesophageal pH monitoring may not be able to detect reflux events in children (Condino, 2006).

(4) Impedance monitoring is a new technique to detect non-acid or weak acid reflux.

Impedance is defined as the ratio of voltage to current. It is used to detect bolus volume of the refluxate independently from its pH composition (Condino, 2006).

Condino et al. (2006) finds that impedance is better at detecting both non-acidic and acidic reflux, but a combined pH-impedance monitoring improves the correlation of reflux-type events even further (Condino, 2006). A combination of pH-impedance monitoring may become a standard test for GOR in the future (Bredenoord, 2008;

Zerbib, 2006).

(5) Endoscopy is used for diagnosis of complicated GORD for example when oesophagitis is suspected or the regurgitation has been persistent (Vandenplas, 2000).

Endoscopy and biopsy allow visualisation of the oesophageal epithelium for the presence and severity of oesophagitis, strictures or Barrett’s oesophagus (not common in children). This diagnosis is used to rule out other disorders e.g. Crohn’s disease. A normal appearance of oesophagus however does not exclude histopathological oesophagitis. The findings from endoscopy are then used to determine the appropriate management and/or treatment for the patient.

(6) Empiric medical therapy is an experimental procedure to test whether GOR is causing specific symptoms. In empiric medical therapy, a suspected GORD patient is put under a trial of GOR medical therapy for a limited time period. Depends on whether the symptoms resolve, continue or worsen, the clinician may then make a deduction whether GORD is the problem and whether the medication should continue.

Chapter 4 | 110 4.2.2.2 Treatment options

There is currently no medical treatment targeting the primary mechanism of GOR i.e.

transient relaxation of the lower oesophageal sphincter. All available treatments available are aiming at relieving patient’s symptoms, promoting normal weight gain, healing inflammation caused by GOR, and preventing respiratory or other complications associated with chronic reflux of gastric contents (Rudolph, 2001).

Diet changes such as use of thickened formulae should be regarded as the first step of treatment (Vandenplas, 2000) for infants with GORD symptoms. In children younger than 2 years, thickeners like starch and bean gum added to normal formulae help reduce symptoms of GORD (Craig, 2004). While it reduces the symptoms like vomiting, thickeners do not improve reflux index (Rudolph, 2001). Thickened formulae also increase sleep duration (Vandenplas, 1997; Vandenplas, 1998) and may also help underweight infants due to GORD to gain weight (Ferry, 1983). On the contrary, Huang et al. (2002) conducted a systematic review on the efficacy of thickeners for newborn infants with GOR but did not find any studies that met the inclusion criteria. She concluded that the use of thickeners should not be encouraged for GOR management in neonates in the absence of evidence from randomised controlled trials. The use of thickeners may increase coughing during feedings in infants (Orenstein, 1992; Rudolph, 2001) and in theory could delay gastric emptying (Huang, 2002).

Infants sleeping in prone position have less GORD symptoms as shown by a pH monitor compared to those sleeping in a supine position. However, the risk of sudden infant death syndrome (SIDS) is significantly increased when infants sleep in prone position. In the 0-12 month infant population, this is not advisable as the risk of SIDS outweighs the benefits of prone sleeping. It should only be considered if the fatal complications from GORD outweigh the risk of SIDS (Rudolph, 2001). Although the benefit of sleep positioning has not been studied in the older children population, it is suggested that left side positioning and elevation of head of the bed may have some likely benefits (Hamilton, 1988; Johnson, 1981; Stanciu, 1977).

Lifestyle changes include avoiding food that may cause allergy, caffeine, chocolates and spicy food that may provoke GORD symptoms (Chang, 1997; Murphy, 1988; Pehl, 1997;

Vandenplas, 1986). Obesity and exposure to tobacco and alcohol are also associated with

Chapter 4 | 111 GORD and should be avoided (Fisher, 1999; Locke, 1999). Lifestyle changes apply more to older children and adults but not to younger children and infants. However, parents’ lifestyle changes like avoiding smoking around children or giving up smoking completely will definitely help in avoiding children from exposure to second-hand smoke. In patients who already received pharmacological therapy, the benefit of lifestyle changes has not been established (Rudolph, 2001).

Acid-suppressant therapy is used to relief symptoms of GORD and promotes mucosal healing of the oesophagus. Many acid-suppressants are sold over-the-counter (OTC) in many countries. A meta-analysis of OTC drugs for GOR concluded that they are effective for symptomatic GORD when compared to placebo (Strickland, 2007) and reported a number-needed-to-treat (NNT) of four (95% CI, 2 – 9) for alginate-antacid. However, a trial concluded that Gaviscon alginates, which are available OTC, did not improve number of reflux events but only marginally improved reflux height up the oesophagus in infants when compared to placebo (Del Buono, 2005). Chronic antacids are not generally recommended for self-management of GORD as more convenient and safe alternatives are available (Rudolph, 2001). However, a BMJ review recognises that the efficacy studies of OTC drugs in GORD treatment may be bias as more severe symptoms may be masked or ignored when self-managing GORD symptoms (Strickland, 2007). Health professionals should be sought when GORD symptoms are observed in younger children and infants.

Pro-kinetic drugs treatment for GORD has initiated some debates of its efficacy and safety.

Many studies (Cucchiara, 1987; De Loore, 1979; Escobar Castro, 1994; Van Eygen, 1989) showed pro-kinetic drugs are effective when used to treat patients with GORD, whilst some other studies did not establish that relationship (Carroccio, 1994; Clara, 1979; Cohen, 1999;

Scott, 1997; Vandenplas, 1991). We shall look at the use of pro-kinetic drugs therapy in patients with GORD further in Section 4.2.3 below.

Surgery is the last treatment option to be considered when other medical treatments and management do not work. The diagnosis and particular cause of GORD must also be confirmed before performing surgery. Several surgical procedure were proposed for GORD treatment – Nissen fundoplication, Thal procedure, Toupet posterior wrap, Hill repair, Boerema procedure and the Boix-Ochoa balanced procedure (Ashcraft, 1993; Boix-Ochoa, 1989; Hill, 1967). The most popular surgical procedure for GORD in the paediatric patients is

Chapter 4 | 112 Nissen fundoplication (Dalla Vecchia, 1997; Rudolph, 2001) with 91% success rate (Dalla Vecchia, 1997). The procedure involves a construction of a new ‘valve’ between the oesophagus and the stomach by wrapping the upper portion of the stomach (fundus) to the lowest part on the oesophagus. In Nissen procedure, a short loose wrap is created by completely wrapping the fundus around the lower oesophagus. As the stomach becomes distended, e.g. during meals, the wrap then compresses the lower oesophagus preventing reflux. About 76% of Nissen fundoplication wrap failure in children attributed to vomiting has been reported (Dalla Vecchia, 1997). Common adverse effect attributed to surgery is raised intragastric pressure (“gas bloat syndrome”) which could disruption to the wrap or wrap slippage into the chest as a result of forceful vomiting or retching (Bush, 2005; Saedon, 2007). In rare situations, complications of surgery also include perforation of the stomach and wound infections (Iwanaka, 2004).