Pediatric Gastroesophageal Reflux Clinical Practice Guidelines

Abstract

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

Aerodigestive Approach to Chronic Cough in Children

“…Nevertheless, there has not been significant correlation between pepsin obtained during a BAL and extra-esophageal reflux (41). The short term use of PPI therapy as a diagnostic test for cough is not recommended (46). …”

“…Transpyloric feeds can be considered in patients who are dependent on gastrostomy feeds. Laparoscopic Nissen fundoplication is usually reserved for patients with no response to the above treatment options (46). Neuromodulation with amitriptyline or gabapentin has demonstrated success in modifying the cough response in adults (47).…”

Exposure to acid-suppressing medications in the first 6 months of life is associated with an increased risk of allergic disease diagnosis

“…There is minimal evidence that these medications are even effective to reduce symptoms, with some evidence of increased infections and other side effects 2. The 2018 ESPGHAN/NASPGHAN guideline2 has taken the step of not recommending the use of PPIs or H 2 RA for well infants with crying or distress or visible regurgitation.…”

“…The 2018 ESPGHAN/NASPGHAN guideline2 has taken the step of not recommending the use of PPIs or H 2 RA for well infants with crying or distress or visible regurgitation. It advises PPIs only in those infants with ‘reflux-related erosive esophagitis’.…”

Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review

“…UK national guidelines on the management of GORD in children recommend preoperative endoscopy at the very least, with consideration of an oesophageal pH study and upper GI foregut contrast series too. Conversely, joint North American and European gastroenterological guidelines do not make explicit recommendations on the precise role of preoperative investigations, but imply that many will require ‘a workup’. In the majority of paediatric series, including some of the largest reported studies, many patients underwent ARS without key investigations.…”