Pediatr Gastroenterol Hepatol Nutr.  2019 Nov;22(6):511-517. 10.5223/pghn.2019.22.6.511.

Is the Diagnostic Trial with Proton Pump Inhibitors Reasonable for School Age Children with Gastroesophageal Reflux Symptoms?

• Yang J
• Lee J
• Lee H
• Lee J
• Youn YM
• Choi JH
• Kim YJ
• Kang HS
• Han KH
• Kim SH
• Kang KS

• KMID: 2462090
• DOI: http://doi.org/10.5223/pghn.2019.22.6.511

Abstract

PURPOSE
On the basis of evidence, we aimed to reevaluate the necessity of the empirical proton pump inhibitor (PPI) trial for children with suspected gastroesophageal reflux disease (GERD).
METHODS
We analyzed the frequency of GERD in 85 school-age children with gastroesophageal reflux (GER) symptoms, who received 24-hour esophageal pH monitoring and/or upper endoscopy. According to the reflux index (RI), the children were classified into normal (RI <5%), intermediate (5%≤ RI <10%), or abnormal (RI ≥10%) groups.
RESULTS
Fifty six were female and 29 were male. Their mean age was 12.6±0.5 (±standard deviation) years (range: 6.8-18.6). The RI analysis showed that the normal group included 76 patients (89.4%), the intermediate group included 6 patients (7.1%), and the abnormal group included 3 patients (3.5%). The DeMeester score was 5.93±4.65, 14.68±7.86 and 40.37±12.96 for the normal, intermediate and abnormal group, respectively (p=0.001). The longest reflux time was 5.56±6.00 minutes, 9.53±7.84 minutes, and 19.46±8.35 minutes in the normal, intermediate, and abnormal group, respectively (p=0.031). Endoscopic findings showed reflux esophagitis in 7 patients. On the basis of the Los Angeles Classification of Esophagitis, 5 of these patients were included in group A, 1 patient, in group B and 1 patient, in group C.
CONCLUSION
The incidence of GERD was very low in school-age children with GER symptoms. Therefore, injudicious diagnostic PPI trials would be postponed until the actual prevalence of GERD is verified in future prospective studies.

Keyword

Gastroesophageal reflux; Proton pump inhibitor; Child; Empirical

MeSH Terms

Child*
Classification
Endoscopy
Esophageal pH Monitoring
Esophagitis
Esophagitis, Peptic
Female
Gastroesophageal Reflux*
Humans
Incidence
Male
Prevalence
Prospective Studies
Proton Pump Inhibitors*
Proton Pumps*
Protons*
Proton Pump Inhibitors
Proton Pumps
Protons

Reference

1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the north american society for pediatric gastroenterology, hepatology, and nutrition and the european society for pediatric gastroenterology, hepatology, and nutrition. J Pediatr Gastroenterol Nutr. 2018; 63:516–554.

2. Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, et al. North American Society for Pediatric Gastroenterology Hepatology and Nutrition. European Society for Pediatric Gastroenterology Hepatology and Nutrition. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009; 49:498–547.

3. Fass R. Empirical trials in treatment of gastroesophageal reflux disease. Dig Dis. 2000; 18:20–26.

4. Bautista J, Fullerton H, Briseno M, Cui H, Fass R. The effect of an empirical trial of high-dose lansoprazole on symptom response of patients with non-cardiac chest pain--a randomized, double-blind, placebo-controlled, crossover trial. Aliment Pharmacol Ther. 2004; 19:1123–1130.

5. Fass R, Fennerty MB, Ofman JJ, Gralnek IM, Johnson C, Camargo E, et al. The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology. 1998; 115:42–49.

6. Stark CM, Nylund CM. Side effects and complications of proton pump inhibitors: a pediatric perspective. J Pediatr. 2016; 168:16–22.

7. De Bruyne P, Christiaens T, Vander Stichele R, Van Winckel M. Changes in prescription patterns of acid-suppressant medications by Belgian pediatricians: analysis of the national database, [1997-2009]. J Pediatr Gastroenterol Nutr. 2014; 58:220–225.

8. Kinoshita Y, Ishimura N, Ishihara S. Advantages and disadvantages of long-term proton pump inhibitor use. J Neurogastroenterol Motil. 2018; 24:182–196.

9. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999; 45:172–180.

10. Johnsson F, Joelsson B, Isberg PE. Ambulatory 24 hour intraesophageal pH-monitoring in the diagnosis of gastroesophageal reflux disease. Gut. 1987; 28:1145–1150.

11. Bagucka B, Badriul H, Vandemaele K, Troch E, Vandenplas Y. Normal ranges of continuous pH monitoring in the proximal esophagus. J Pediatr Gastroenterol Nutr. 2000; 31:244–247.

12. Neto RML, Herbella FAM, Schlottmann F, Patti MG. Does DeMeester score still define GERD? Dis Esophagus. 2019; 32:doy118.

13. MD save. Bravo 48 hour pH monitor [Internet]. San Francisco: MD saves;2019. cited 2019 May 7. Available from: https://www.mdsave.com/procedures/bravo-48-hour-ph-monitor/d784fecc.

14. MD save. Upper endoscopy [Internet]. San Francisco: MD saves;2019. cited 2019 May 7. Available from: https://www.mdsave.com/procedures/upper-endoscopy-egd/d782ffc5.

15. Benmassaoud A, McDonald EG, Lee TC. Potential harms of proton pump inhibitor therapy: rare adverse effects of commonly used drugs. CMAJ. 2016; 188:657–662.

16. Hassall E. Over-prescription of acid-suppressing medications in infants: how it came about, why it's wrong, and what to do about it. J Pediatr. 2012; 160:193–198.

17. Streets CG, DeMeester TR. Ambulatory 24-hour esophageal pH monitoring: why, when, and what to do. J Clin Gastroenterol. 2003; 37:14–22.

18. Lupu VV, Ignat A, Paduraru G, Ciubara A, Moscalu M, Marginean CO, et al. Correlation between the different pH-metry scores in gastroesophageal reflux disease in children. Medicine (Baltimore). 2016; 95:e3804.

19. Yang A, Kang B, Choe JY, Kim HS, Kim K, Choe YH. Prevalence and epidemiological characteristics of endoscopically proven reflux esophagitis in children in Korea. Pediatr Gastroenterol Hepatol Nutr. 2017; 20:160–166.

20. Jung HK, Choi MG, Baek MK, Wu JCY. Development and psychometric assessment of a self-evaluation questionnaire for gastroesophageal reflux disease. J Neurogastroenterol Motil. 2018; 24:584–592.

21. Gonzalez Ayerbe JI, Hauser B, Salvatore S, Vandenplas Y. Diagnosis and management of gastroesophageal reflux disease in infants and children: from guidelines to clinical practice. Pediatr Gastroenterol Hepatol Nutr. 2019; 22:107–121.

22. Vandenplas Y, Goyvaerts H, Helven R, Sacre L. Gastroesophageal reflux, as measured by 24-hour pH monitoring, in 509 healthy infants screened for risk of sudden infant death syndrome. Pediatrics. 1991; 88:834–840.

23. Taghavi SA, Ghasedi M, Saberi-Firoozi M, Alizadeh-Naeeni M, Bagheri-Lankarani K, Kaviani MJ, et al. Symptom association probability and symptom sensitivity index: preferable but still suboptimal predictors of response to high dose omeprazole. Gut. 2005; 54:1067–1071.