Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events. Sankaran Janani,Qureshi Aslam H,Woodley Frederick,Splaingard Mark,Jadcherla Sudarshan R The Journal of pediatrics OBJECTIVES:To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state. STUDY DESIGN:Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state. RESULTS:Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups. CONCLUSIONS:Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms. 10.1016/j.jpeds.2016.08.066

Diagnostic utility of impedance-pH monitoring in infants of diabetic mothers with oral feeding difficulties. Journal of perinatology : official journal of the California Perinatal Association OBJECTIVE:To determine the diagnostic utility of impedance-pH monitoring in infants of diabetic mothers (IDM) with oral feeding difficulties. STUDY DESIGN:Retrospective review of a consecutive sample of 50 IDM who had impedance-pH monitoring for objective gastroesophageal reflux disease (GERD) diagnosis. Acid reflux index (ARI) ≥ 7 was considered pathological (ARI+). RESULTS:Impedance-pH monitoring was performed at 42.1-week postmenstrual age. Twenty infants (40%) with ARI+ compared to 30 with ARI < 7 (ARI-). ARI+ had lower weight at study vs. ARI- (p < 0.05). ARI+ had significantly higher reflux parameters but had similar symptom burden and symptom-association scores vs. ARI-. All ARI+ received proton-pump inhibitors (PPI) vs. 7 (23.3%) in ARI- (p < 0.05), but oral feeding outcomes, gastrostomy rate, growth, and hospital length of stay were similar in both groups. CONCLUSIONS:The diagnostic yield of impedance-pH monitoring in IDM is about 40%. However, GERD diagnosis or treatment with PPI did not modify short-term clinical outcomes. 10.1038/s41372-020-00832-7

Distress in Infants and Young Children: Don't Blame Acid Reflux. Salvatore Silvia,Pagliarin Federica,Huysentruyt Koen,Bosco Annalisa,Fumagalli Letizia,Van De Maele Kristel,Agosti Massimo,Vandenplas Yvan Journal of pediatric gastroenterology and nutrition OBJECTIVE:The role of gastroesophageal reflux (GER) causing distress in infants is controversial but acid inhibitors are often empirically prescribed. We evaluated the relation between distress assessed by the Face, Legs, Activity, Cry, Consolability (FLACC) scale and GER in infants. METHODS:We analyzed multiple intraluminal impedance-pH (MII-pH) monitoring tracings of infants with persistent unexplained fussiness or distress. Symptoms occurring during investigation were scored by parents using the FLACC scale and were grouped as "distress" episodes. RESULTS:We recruited 62 children (ages 15 days to 23 months, median age 3.5 months). During MII-pH, 452 episodes of distress were registered: 217 (48%) were temporally associated with GER and 235 (52%) were not, with no difference in the median value of FLACC between the 2 groups. Infants with abnormal acid exposure index had a significantly lower FLACC compared with the group with acid reflux index <7% (P < 0.001). When associated with symptoms, GER occurred significantly more often before than simultaneously or after an episode of distress (P = 0.001). Age, proximal extension, and duration of GER did not correlate with FLACC scores. Episodes of distress associated with nonacid reflux presented a significant higher FLACC compared with the ones with acid content (FLACC 6 vs 5, P = 0.011). In infants, episodes of distress do not significantly correlate with GER. CONCLUSIONS:No difference in infant distress was noted between proximal and distal GER. Non-acid reflux is perceived at least as painful than acid GER. Our results stress that acid inhibitors should not be started in infants presenting distress unless a clear association with acid GER is demonstrated. 10.1097/MPG.0000000000002841

Ambulatory Reflux Monitoring Guides Proton Pump Inhibitor Discontinuation in Patients With Gastroesophageal Reflux Symptoms: A Clinical Trial. Gastroenterology BACKGROUND AND AIMS:Proton pump inhibitor (PPI) therapy fails to provide adequate symptom control in up to 50% of patients with gastroesophageal reflux symptoms. Although a proportion do not require ongoing PPI therapy, a diagnostic approach to identify candidates appropriate for PPI cessation is not available. This study aimed to examine the clinical utility of prolonged wireless reflux monitoring to predict the ability to discontinue PPIs. METHODS:This double-blinded clinical trial performed over 3 years at 2 centers enrolled adults with troublesome esophageal symptoms of heartburn, regurgitation, and/or chest pain and inadequate PPI response. Participants underwent prolonged wireless reflux monitoring (off PPIs for ≥7 days) and a 3-week PPI cessation intervention. Primary outcome was tolerance of PPI cessation (discontinued or resumed PPIs). Symptom burden was quantified using the Reflux Symptom Questionnaire electronic Diary (RESQ-eD). RESULTS:Of 128 enrolled, 100 participants met inclusion criteria (mean age, 48.6 years; 41 men). Thirty-four participants (34%) discontinued PPIs. The strongest predictor of PPI discontinuation was number of days with acid exposure time (AET) > 4.0% (odds ratio, 1.82; P < .001). Participants with 0 days of AET > 4.0% had a 10 times increased odds of discontinuing PPI than participants with 4 days of AET > 4.0%. Reduction in symptom burden was greater among the discontinued versus resumed PPI group (RESQ-eD, -43.7% vs -5.3%; P = .04). CONCLUSIONS:Among patients with typical reflux symptoms, inadequate PPI response, and absence of severe esophagitis, acid exposure on reflux monitoring predicted the ability to discontinue PPIs without symptom escalation. Upfront reflux monitoring off acid suppression can limit unnecessary PPI use and guide personalized management. (ClinicalTrials.gov, Number: NCT03202537). 10.1053/j.gastro.2020.09.013

Characterization of intragastric pressure waveform in endoscopic pressure study integrated system: Novel diagnostic device for gastroesophageal reflux disease. Shimamura Yuto,Inoue Haruhiro,Rodriguez de Santiago Enrique,Abad Mary Raina Angeli,Fujiyoshi Yusuke,Toshimori Akiko,Tanabe Mayo,Sumi Kazuya,Iwaya Yugo,Ikeda Haruo,Onimaru Manabu Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society OBJECTIVES:Endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool for gastroesophageal reflux disease (GERD). EPSIS has been developed to evaluate lower esophageal sphincter function by monitoring the intragastric pressure (IGP) while insufflating the stomach during gastroscopy. Based on previous data, EPSIS could diagnose GERD with good accuracy by assessing IGP waveform pattern. This study aimed to further characterize the waveform to improve the diagnostic yield of EPSIS. METHODS:We conducted a retrospective analysis of patients with typical GERD symptoms who underwent both EPSIS and 24-h impedance-pH monitoring (MII-pH) at a single tertiary referral center from October 2018 to May 2020. EPSIS was performed by using a through-the-scope catheter connected to the pressure measuring system (TR-W550, TR-TeH08, AP-C35; Keyence, Osaka, Japan) to monitor IGP. Abnormal acid reflux was defined as acid exposure time (AET) over 6.0%. Pressure waveform was characterized as follows: (i) Basal IGP, (ii) Maximum IGP, (iii) Pressure difference, (iv) Gradient of the waveform. RESULTS:A total of 57 patients with GERD symptoms were analyzed. Twenty-one patients presented abnormal AET on MII-pH. Among EPSIS parameters, pressure difference during insufflation correlated with AET (ρ = -0.66, P < 0.01) and showed the best diagnostic accuracy for AET with the cutoff value of 4.7 mmHg (area under the curve [AUC], 0.87). The gradient of EPSIS waveform also revealed good diagnostic accuracy for abnormal AET with the cutoff value of 0.07 mmHg/s (AUC, 0.81). CONCLUSIONS:Endoscopic pressure study integrated system waveform parameters, especially pressure difference, presented high diagnostic accuracy for the presence of abnormal acid reflux. 10.1111/den.13867