Background: Persistent crying in infancy is common and may be associated with gastroesophageal reflux disease (GERD) and/or non-IgE-mediated cow's milk protein allergy (CMPA). We aimed to document upper gastrointestinal motility events in infants with CMPA and compare these to findings in infants with functional GERD. Methods: Infants aged 2 to 26 weeks with persistent crying, GERD symptoms and possible CMPA were included. Symptoms were recorded by 48-hour cry-fuss chart and validated reflux questionnaire (infant GERD questionnaire [IGERDQ]). Infants underwent a blinded milk elimination-challenge sequence to diagnose CMPA. GERD parameters and mucosal integrity were assessed by 24-hour pH-impedance monitoring before and after cow's milk protein (CMP) elimination. 13C-octanoate breath testing for gastric emptying dynamics, dual-sugar intestinal permeability, fecal calprotectin, and serum vitamin D were also measured. Results: Fifty infants (mean age 13 ± 7 weeks; 27 boys) were enrolled. On the basis of CMP elimination-challenge outcomes, 14 (28%) were categorized as non-IgE-mediated CMPA, and 17 (34%) were not allergic to milk; 12 infants with equivocal findings, and 7 with incomplete data were excluded. There were no baseline differences in GERD parameters between infants with and without CMPA. In the CMPA group, CMP elimination resulted in a significant reduction in reflux symptoms, esophageal acid exposure (reflux index), acid clearance time, and an increase in esophageal mucosal impedance. Conclusions: In infants with persistent crying, upper gastrointestinal motility parameters did not reliably differentiate between non-IgE-mediated CMPA and functional GERD. In the group with non-IgE-mediated CMPA, elimination of CMP significantly improved GERD symptoms, esophageal peristaltic function, and mucosal integrity.

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BackgroundHigh‐resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children.MethodsFifty‐five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult‐derived upper limits were adjusted for length using the slopes of the identified linear equations.Key ResultsMean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4‐s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three.Conclusions & InferencesWe prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure‐impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.

Abstract:Background & Aims: The role of high resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary GER disease, for whom symptoms of dysphagia to solids were determined pre-and post-operatively and we examined for features that may predict post-operative dysphagia. Methods: Thirteen children (aged 6.8 -15.5 years) undergoing work up prior to 360o Nissen fundoplication were included. A dysphagia score assessed symptoms. A HRIM procedure recorded 5ml liquid, 5ml viscous and 2cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow-index score (PFI) was also derived. Results: Pre-operative PFI was positively correlated with post-operative dysphagia score (PFI viscous bolus r = 0.771, p<0.005 Abbreviations: HRIM, high resolution impedance manometry; GER, gastroesophageal reflux; EGJ, esophago-gastric junction; LES, lower esophageal sphincter; CD, crural diaphragm; TZ, transition zone; CDP, contractile deceleration point; pH-MII, pH with multichannel intraluminal impedance; PPI, proton pump inhibitor; EPT, esophageal pressure topography; IRP4s, 4s integrated relaxation pressure; CFV, contractile front velocity; DCI, distal contractile integral; DL, distal latency; EGJ-CI, EGJ contractile index; DPA, distension pressure during bolus accommodation; DPCT, distension pressure during compartmentalized transport; DPE, distension pressure during esophageal emptying; PFI, pressure-flow-index; IR, impedance ratio; SDL, swallow to distension latency; DCL, distension to contraction latency; RP, ramp pressure; IEM, ineffective esophageal motility; EoE, eosinophilic esophagitis. Acknowledgements:We thank Mrs G Seiboth, Mrs K Lowe and Ms S Kritas for assistance with performance of HRIM studies and Dr Junko Fujino for assistance with reviewing endoscopy images. • The ability to accurately predict post-operative dysphagia risk is of interest to gastroenterologists. 'Pressure-flow' anomalies may be predictors of dysphagia symptoms following anti-reflux surgery.• Past studies were performed using 'low-resolution' perfusion lower esophageal sphincter sleeve-manometry.2. What are the significant and/or new findings of this study?• Dysphagia symptoms were common in our pediatric GER disease patients who were receiving diagnostic work up for anti-reflux surgery.• Of all parameters evaluated, bolus 'clearing pressures' were most reliably associated with dysphagia symptoms. Results: Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p<0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p<0.005). Conclusions:In order to mitigate symptoms i...

Background The Chicago Classification (CC) facilitates interpretation of high‐resolution manometry (HRM) recordings. Application of this adult based algorithm to the pediatric population is unknown. We therefore assessed intra and interrater reliability of software‐based CC diagnosis in a pediatric cohort. Methods Thirty pediatric solid state HRM recordings (13M; mean age 12.1 ± 5.1 years) assessing 10 liquid swallows per patient were analyzed twice by 11 raters (six experts, five non‐experts). Software‐placed anatomical landmarks required manual adjustment or removal. Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and break size (BS), and an overall CC diagnosis were software‐generated. In addition, raters provided their subjective CC diagnosis. Reliability was calculated with Cohen's and Fleiss’ kappa (κ) and intraclass correlation coefficient (ICC). Key Results Intra‐ and interrater reliability of software‐generated CC diagnosis after manual adjustment of landmarks was substantial (mean κ = 0.69 and 0.77 respectively) and moderate‐substantial for subjective CC diagnosis (mean κ = 0.70 and 0.58 respectively). Reliability of both software‐generated and subjective diagnosis of normal motility was high (κ = 0.81 and κ = 0.79). Intra‐ and interrater reliability were excellent for IRP4s, DCI, and BS. Experts had higher interrater reliability than non‐experts for DL (ICC = 0.65 vs ICC = 0.36 respectively) and the software‐generated diagnosis diffuse esophageal spasm (DES, κ = 0.64 vs κ = 0.30). Among experts, the reliability for the subjective diagnosis of achalasia and esophageal gastric junction outflow obstruction was moderate‐substantial (κ = 0.45–0.82). Conclusions & Inferences Inter‐ and intrarater reliability of software‐based CC diagnosis of pediatric HRM recordings was high overall. However, experience was a factor influencing the diagnosis of some motility disorders, particularly DES and achalasia.

The current state-of-the-art diagnosis of esophageal motility disorders is based on esophageal pressure topography (EPT) using the Chicago classification (CCv3.0). 1 The proposed standardized approach is based on EPT reference values from adult cohorts.However, without adjusting for esophageal length, the adult reference values will overestimate the prevalence of major motility disorders in pediatric patients. [2][3][4] The optimal form of reference value adjustment for pediatric use remains to be determined as former studies examining age-and size-related trends have been limited by the inclusion of patients with known dysphagia-causing medical diagnoses such as achalasia and esophageal atresia. Furthermore, published datasets do not extend to the infant population for which the appropriate level of adjustment is currently unknown.As part of an ongoing research program, we have acquired esophageal high-resolution manometry (HRM) data in 12 healthy young infants (aged 31-65 days, 10 males). We have been able to compare these data with a cohort of 57 pediatric patients (aged 1-17.4 years, 27 males) referred for HRM. The cohort comprised 35 cases from a previous publication 4 and 22 new cases. Patients with esophageal atresia, neuromuscular disease, unequivocal achalasia subtypes, and past antireflux surgery were not included. The following EPT metrics were derived using the Web application Swallow Gateway (swallowgateway.com): 4-second integrated relaxation pressure (IRP4), distal latency (DL), and distal contractile integral (DCI).The esophageal length (from upper esophageal sphincter to esophagogastric junction) of otherwise healthy young infants ranged from 5.7 to 8.6 cm. By using the linear best fit for esophageal length trends seen in the pediatric patients, data derived from infants were found to lie within the predicted continuum ( Figure 1). Indeed, we found that after adjustment for esophageal length, the number of infants below the diagnostic cutoff values decreased. F I G U R E 1Esophageal pressure topography metrics in relation to esophageal length. Scatter plot of A, IRP4; B, DL; and C, DCI averaged per patient. Healthy infants (n = 12), as well as pediatric patients (n = 57), from our cohort are presented. Adult cutoff values described by Singendonk et al 4 and Bogte et al 5 and CCv3.0 1 are displayed (horizontal lines). Adjusted cutoff values are presented parallel to the trend line and projecting from the mean adult esophageal length of 20 cm 4 at diagnostic thresholds. DL and DCI decrease while IRP4 seem to increase related to shorter esophagus. The number of infants below the cutoff line decreased for all investigated metrics: IRP4 from 33% to 0%, DL from 100% to 17%, and DCI from 50% to 8%

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Gastrostomy site-related problems were more common than generally reported. There was a higher incidence of site infection and skin excoriation for gastrostomy placement with concurrent fundoplication. There was no significant difference in complications between the method of gastrostomy placement or neurological status. Balloon devices were changed 3 times more often than bolster retention devices.