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Rosen R.,Aerodigestive Center
JAMA Pediatrics | Year: 2014

Importance: Rarely have the best methods of diagnosis or the treatment of a disease engendered more controversy than gastroesophageal reflux (GER), a highly prevalent condition in infants. Objective: To discuss the latest controversies in the diagnosis and treatment of GER in infants. Evidence review: All articles related to the diagnosis and treatment of GER were reviewed and, whenever possible, literature about infants was weighted with greater Importance: than literature about older children and adults. Findings: Although as many as 60%of infants have signs of GER, the role of GER in causing disease is difficult to elucidate. Despite new diagnostic tools to detect acid and nonacid reflux, our understanding of the relationship between reflux events and symptoms is complex. Furthermore, acid suppression, the mainstay of therapy for GER, increases the burden of nonacid reflux, which is already much higher in infants than in older children and which mayworsen symptoms. Therefore, more conservative therapies are recommended for symptomatic infants. Conclusions and relevance: Although GER is a common reason for visits to primary care providers and specialists, few data suggest that GER Results: in many of the symptoms to which it has been attributed. A strong shift away from acid-suppression therapy in infants has occurred because of the adverse effects, lack of efficacy, and increase of nonacid reflux burden relative to acid burden. Nonpharmacologic measures should be used whenever possible because most infant GER will resolve without intervention. Copyright © 2014 American Medical Association. Source


Mahoney L.,Aerodigestive Center | Rosen R.,Aerodigestive Center
Paediatric Respiratory Reviews | Year: 2016

The current available literature evaluating feeding difficulties in children with esophageal atresia was reviewed. The published literature was searched through PubMed using a pre-defined search strategy. Feeding difficulties are commonly encountered in children and adults with repaired esophageal atresia [EA]. The mechanism for abnormal feeding includes both esophageal and oropharyngeal dysphagia. Esophageal dysphagia is commonly reported in patients with EA and causes include dysmotility, anatomic lesions, esophageal outlet obstruction and esophageal inflammation. Endoscopic evaluation, esophageal manometry and esophograms can be useful studies to evaluate for causes of esophageal dysphagia. Oropharyngeal dysfunction and aspiration are also important mechanisms for feeding difficulties in patients with EA. These patients often present with respiratory symptoms. Videofluoroscopic swallow study, salivagram, fiberoptic endoscopic evaluation of swallowing and high-resolution manometry can all be helpful tools to identify aspiration. Once diagnosed, management goals include reduction of aspiration during swallowing, reducing full column reflux into the oropharynx and continuation of oral feeding to maintain skills. We review specific strategies which can be used to reduce aspiration of gastric contents, including thickening feeds, changing feeding schedule, switching formula, trialing transpyloric feeds and fundoplication. © 2015 Elsevier Ltd. Source


Duncan D.R.,Aerodigestive Center | Rosen R.L.,Aerodigestive Center
NeoReviews | Year: 2016

Gastroesophageal reflux is common and, in most cases, is a self-limited and physiologic process in infants. However, the role of diagnostic testing and pharmacologic interventions in reflux remains controversial among providers. Various diagnostic modalities exist, but most infants do not require invasive testing and many symptoms traditionally attributed to reflux show no correlation on further testing. There are many strategies for managing reflux in infants. Nonpharmacologic approaches include positioning, thickening, changing formulas, and changing the frequency of feedings, with the benefits of these methods shown to be inconsistent. Many medications now exist to address reflux, particularly by way of acid suppression, but these pharmacologic interventions have risks, especially in young infants, andmany of these therapies have shown limited success in truly reducing reflux symptoms. In conclusion, nonpharmacologic approaches should be used, because most symptoms of gastroesophageal reflux will ultimately resolve without any intervention. © 2016 by the American Academy of Pediatrics. Source


Duncan D.R.,Aerodigestive Center | Amirault J.,Aerodigestive Center | Johnston N.,Medical College of Wisconsin | Mitchell P.,Clinical Research Program | And 2 more authors.
Journal of Pediatric Gastroenterology and Nutrition | Year: 2016

Objectives: Gastroesophageal reflux is common but remains a controversial disease to diagnose and treat and little is known about the role of reflux testing in predicting clinical outcomes, particularly in children at risk for extraesophageal reflux complications. The aim of this study was to determine if rates of hospitalization were affected by reflux burden even after adjusting for aspiration risk. Methods: We prospectively recruited, between 2009 and 2014, a cohort of pediatric patients with suspected extraesophageal reflux disease who were referred for reflux testing and underwent both multichannel intraluminal impedance with pH (pH-MII) and modified barium swallow studies. A subset of patients also underwent bronchoalveolar lavage with pepsin analysis. We determined their rates of hospitalization for a minimum of 1 year following pH-MII testing. Results: We prospectively enrolled 116 pediatric patients who presented for care at Boston Children's Hospital and underwent both pH-MII and modified barium swallow studies. There was no statistically significant relationship between reflux burden measured by pH-MII or bronchoalveolar pepsin and total number of admissions or number of admission nights even after adjusting for aspiration status (P>0.2). There were no statistically significant relationships between reflux burden by any method and the number or nights of urgent pulmonary admissions before or after adjusting for aspiration risk (P>0.08). Conclusions: Even in aspirating children, reflux burden did not increase the risk of hospitalization. Based on these results, routine reflux testing cannot be recommended even in aspirating children, because the results do not impact clinically significant outcomes. Copyright © 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Source


Rosen R.,Aerodigestive Center | Amirault J.,Aerodigestive Center | Liu H.,Clinical Research Center | Mitchell P.,Clinical Research Center | And 3 more authors.
JAMA Pediatrics | Year: 2014

IMPORTANCE: The use of acid suppression has been associated with an increased risk of upper and lower respiratory tract infections in the outpatient setting but the mechanism behind this increased risk is unknown.We hypothesize that this infection risk results from gastric bacterial overgrowth with subsequent seeding of the lungs.OBJECTIVES: To determine if acid-suppression use results in gastric bacterial overgrowth, if there are changes in lung microflora associated with the use of acid suppression, and if changes in lung microflora are related to full-column nonacid gastroesophageal reflux.DESIGN, SETTING, AND PARTICIPANTS: A 5-year prospective cohort study at a tertiary care center where children ages 1 to 18 years were undergoing bronchoscopy and endoscopy for the evaluation of chronic cough. Acid-suppression use was assessed through questionnaires with confirmation using an electronic medical record review.MAIN OUTCOMES AND MEASURES: Our primary outcomewas to compare differences in concentration and prevalence of gastric and lung bacteria between patients who were and were not receiving acid-suppression therapy.We compared medians using the Wilcoxon signed rank test and determined prevalence ratios using asymptotic standard errors and 95% confidence intervals.We determined correlations between continuous variables using Pearson correlation coefficients and compared categorical variables using the Fisher exact test.RESULTS: Forty-six percent of patients taking acid-suppression medication had gastric bacterial growth compared with 18%of untreated patients (P = .003). Staphylococcus (prevalence ratio, 12.75 [95%CI, 1.72-94.36]), Streptococcus (prevalence ratio, 6.91 [95%CI, 1.64-29.02]), Veillonella (prevalence ratio, 9.56 [95%CI, 1.26-72.67]), Dermabacter (prevalence ratio, 4.78 [95%CI, 1.09-21.02]), and Rothia (prevalence ratio, 6.38 [95%CI, 1.50-27.02]) were found more commonly in the gastric fluid of treated patients. The median bacterial concentration was higher in treated patients than in untreated patients (P = .001). There was no difference in the prevalence (P > .23) of different bacterial genera or the median concentration of total bacteria (P = .85) in the lungs between treated and untreated patients. There were significant positive correlations between proximal nonacid reflux burden and lung concentrations of Bacillus (r = 0.47, P = .005), Dermabacter (r = 0.37, P = .008), Lactobacillus (r = 0.45, P = .001), Peptostreptococcus (r = 0.37, P = .008), and Capnocytophagia (r = 0.37, P = .008).CONCLUSIONS AND RELEVANCE: Acid-suppression use results in gastric bacterial overgrowth of genera including Staphylococcus and Streptococcus. Full-column nonacid reflux is associated with greater concentrations of bacteria in the lung. Additional studies are needed to determine if acid suppression-related microflora changes predict clinical infection risk; these results suggest that acid suppression use may need to be limited in patients at risk for infections. Copyright © 2014 American Medical Association. All rights reserved. Source

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