Diagnostic Accuracy of Tests in Pediatric Gastroesophageal Reflux Disease

doi:10.1016/j.jpeds.2012.10.041

The Journal of Pediatrics

Volume 162, Issue 5, May 2013, Pages 983-987.e4

https://doi.org/10.1016/j.jpeds.2012.10.041 Get rights and content

Objective

To systematically review the literature evaluating the diagnostic accuracy of commonly used diagnostic tests over conventional history taking and physical examination in children ≤18 months and >18 months suspected of gastroesophageal reflux disease (GERD).

Study design

We searched Medline, Embase, and the Cochrane database for studies assessing the diagnostic accuracy of pH-metry, pH-impedance, esophagogastroscopy, barium contrast study, scintigraphy, and empirical treatment as diagnostic tools. Quality was assessed according to Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews criteria.

Results

Of the 2178 studies found, 6 studies were included, containing 408 participants (age 1 month-13.6 years) and 145 controls (age 1 month-16.9 years). Studies included children with GERD symptoms; 1 included an atypical presentation. In all the studies, the diagnostic accuracy of pH-metry was investigated, and in 2 studies esophagogastroscopy was investigated as well. Sensitivity and specificity were calculated in 3 studies. The range of reported sensitivity and specificity was broad and unreliable because of poor methodological quality according to Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews criteria and inadequate study design.

Conclusion

Diagnostic accuracy of tests in children suspected of GERD remains unclear and implications for practice are hard to give. There is an urgent need of well-designed randomized controlled trials where the effect of treatment according to specific signs and symptoms will be compared with the effect of treatment based on the results of additional diagnostic tests, for patient relevant outcomes.

Section snippets

Methods

A clinical librarian searched Medline, Embase, and the Cochrane Database of systematic reviews (SR) electronic database for SRs, and clinical studies from inception to May 2012. The key words used to describe the study population were “esophagogastroscopy,” “pH-metry,” “pH-impedance,” “gastric emptying scintigraphy,” “barium radiography,” “GER,” “GERD,” “heartburn,” “extraesophageal symptoms,” “reflux esophagitis,” “infant,” “child,” and “adolescent” (medical subject headings and all fields).

Results

The search generated 2178 studies, of which 106 met our inclusion criteria (Figure; available at www.jpeds.com). No valid SR was encountered. After retrieving the full-text articles, 100 articles were excluded because of the lack of a control group, comparison between 2 diagnostic tests, and, therefore, no comparison with history and physical examination, use of antireflux medication during the study, and/or 1 of the other inclusion and/or exclusion criteria (Figure).

The 6 studies included were

Discussion

This systematic review clearly shows that, despite a large number of publications, there is a lack of high quality studies of the diagnostic accuracy compared with the current definition of GERD, which is based on history and physical examination. Therefore, the accuracy of tests in children ≤18 months and >18 months suspected of GERD remains unclear.

Nearly all studies investigating the accuracy of pH-metry used glass electrode catheters, 18, 19, 20, 21, 23 but ion sensitive field effect

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When did gastro-esophageal reflux become a disease? A historical perspective on GER(D) nomenclature
2020, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
It is estimated that more than a quarter of the North American adult population is afflicted by GERD, and the prevalence of the condition is on a constant rise [1]. In pediatrics, epidemiological studies of GERD continue to be limited by the absence of a consensus over GERD basic definition and of a validated diagnostic tool [2]. Prevalence estimates of pediatric GERD are primarily based on patient or parental symptom survey, and vary markedly depending on the age group and population studied, ranging from 2% to 15% worldwide [3–7].
Within the span of a few decades, gastro-esophageal reflux (GER) evolved from a rare entity to the most commonly diagnosed upper gastro-intestinal disease, i.e. gastro-esophageal reflux disease (GERD). The boundaries of GERD remain matter of controversy and appear to be ever expanding in both children and adults. Our aim is to answer the questions: when did GER become a disease? And when did it become specifically a pediatric disease?
We performed a comprehensive historical review of the original medical literature using Medline and Google, along with a compilation of original and secondary texts in English, French and German.
Our finding is that those actively involved in treating the reflux, first surgeons in the 1960s and then gastroenterologists in the 1970s, initiated naming it a disease. In pediatrics, the possible correlation between reflux events and sudden infant death syndrome accelerated the management of reflux associated with respiratory symptoms with surgery in the 1970s. Surgeons were also the first specialists to formulate the term pediatric GERD in 1982.
Understanding the genesis of GERD may shed light upon its expansion as a disease category and its persistent controversial nature in pediatrics.
Gastroesophageal reflux disease in children
2016, Seminars in Pediatric Surgery
Citation Excerpt :
There is no symptom or constellation of symptoms that are diagnostic of GERD or that predict response to therapy in infants and toddlers. Although apnea and sudden infant death syndrome are a significant cause of neonatal mortality, there is little evidence of a cause and effect relationship between GER/GERD and infant apnea.7 Effortless vomiting, epigastric pain and dyspepsia, anemia, failure to thrive, and strictures may be the presentation of GERD in older children.
Despite the frequency with which antireflux procedures are performed, decisions about gastroesophageal reflux disease treatment remain challenging. Several factors contribute to the difficulties in managing gastroesophageal reflux. First, the distinction between physiologic and pathologic gastroesophageal reflux (gastroesophageal reflux disease—GERD) is not always clear. Second, measures of the extent of gastroesophageal reflux often poorly correlate to symptoms or other complications attributed to reflux in infants and children. A third challenge is that the outcome of antireflux procedures, predominately fundoplications, are relatively poorly characterized. All of these factors contribute to difficulty in knowing when to recommend antireflux surgery. One of the manifestations of the uncertainties surrounding GERD is the high degree of variability in the utilization of pediatric antireflux procedures throughout the United States.
Pediatric surgeons are frequently consulted for GERD and fundoplication, uncertainties notwithstanding. Although retrospective series and anecdotal observations support fundoplication in some patients, there are many important questions for which sufficient high-quality data to provide a clear answer is lacking. In spite of this, surgeons need to provide guidance to patients and families while awaiting the development of improved evidence to aid in these recommendations. The purpose of this article is to define what is known and what is uncertain, with an emphasis on the most recent evidence.
Misdiagnosis of gastroesophageal reflux disease as epileptic seizures in children
2016, Brain and Development
Citation Excerpt :
The purposes of GERD therapy in children are relief of symptoms, the healing of tissue injuries and the prevention of growth retardation. The main treatment options are lifestyle changes including postural and nutritional suggestions, drug therapy such as proton pump inhibitors and histamine H2-receptor antagonists, and reflux surgery [7–10]. In this study, we evaluated the clinical features, definite diagnoses and treatment approaches of the children with clinically suspected GERD who were referred to our division of pediatric neurology with a suspected diagnosis of epileptic seizure.
Gastroesophageal reflux disease (GERD) can mimic epileptic seizure, and may be misdiagnosed as epilepsy. On the other hand, GERD can be more commonly seen in children with neurological disorders such as cerebral palsy (CP); this co-incidence may complicate the management of patients by mimicking refractory seizures.
The purpose of our study was to evaluate the clinical features, definite diagnoses and treatment approaches of the patients with clinically suspected GERD who were referred to the division of pediatric neurology with a suspected diagnosis of epileptic seizure. We also aimed to investigate the occurrence of GERD in children with epilepsy and/or CP.
Fifty-seven children who had a final diagnosis of GERD but were initially suspected of having epileptic seizures were assessed prospectively.
All patients were assigned to 3 groups according to definite diagnoses as follows: patients with only GERD who were misdiagnosed as having epileptic seizure (group 1: n = 16; 28.1%), those with comorbidity of epilepsy and GERD (group 2: n = 21; 36.8%), and those with the coexistence of GERD with epilepsy and CP (group 3: n = 20; 35.1%). Five patients (8.8%) did not respond to anti-reflux treatment and laparoscopic reflux surgery was performed. The positive effect of GERD therapy on paroxysmal nonepileptic events was observed in 51/57 (89.5%) patients.
GERD is one of the important causes of paroxysmal nonepileptic events. In addition, GERD must be kept in mind at the initial diagnosis and also in the long-term management of patients with neurological disorders such as epilepsy and CP.
Characteristics and surgical outcome of 98 infants and children surgically treated for a laryngotracheal stenosis after endotracheal intubation: Excellent outcome for higher grades of stenosis after SS-LTR
2014, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
This is especially true for the assessment of GERD. This is not routinely measure through pH-metry in our patients, partly due to the ongoing controversy surrounding this investigation and because we feel that all tracheotomised patients and patients with LTS benefit from PPI treatment [23–25]. Patients are only scheduled for reconstructive surgery when the stenotic area shows no sign of active inflammation or oedema.
To describe the characteristics and surgical outcome of 98 infants and children treated for an acquired laryngeal stenosis after intubation for respiratory support.
We retrospectively reviewed our data from the last 18 years (1994–2013) concerning infants and children with an acquired laryngotracheal stenosis who were treated in our hospital with a laryngotracheal reconstruction or a cricotracheal resection. Outcome was defined by decannulation ratio.
Of the 98 infants and children who were studied, 54% were preterm, 18% neonates, 13% infants and 14% children. Ninety-one SS-LTR’s, two DS-LTR’s and five CTR’s were performed as primary surgery; three revision operations were performed (DS-LTR). Seventy-seven children had a tracheostomy prior to surgery; decannulation ratio was 93% after primary surgery and 95% after inclusion of revision surgery. For SS-LTR, the decannulation ratio was 93%, including grade III stenosis with comorbidities. Male sex and glottic involvement of the stenosis are correlated to failure of decannulation. Intubation in the term neonatal period is correlated to complicated post-operative course after SS-LTR.
Excellent results of surgery for acquired laryngotracheal stenosis can be obtained with a high decannulation rate. Even for higher grades of stenosis with comorbidities and glottic involvement, an SS-LTR is an effective surgical treatment for acquired laryngeal stenosis.
Diagnosis and treatment of gastroesophageal reflux in infants and children
2015, American Family Physician
Citation Excerpt :
Multiple intraluminal impedance plus pH monitoring is considered superior to pH monitoring alone because it can differentiate acidic, weakly acidic, or nonacidic reflux; identify solid, liquid, or gas reflux; and better determine the temporal correlation between reflux and atypical symptoms. The high cost, high interobserver variability, and the lack of well-designed studies supporting its diagnostic accuracy limit its use.2,27,63 A barium study (upper gastrointestinal series) is useful for evaluating for anatomic causes of symptoms, particularly dysphagia and odynophagia, and bilious vomiting.
Gastroesophageal reflux is defined as the passage of stomach contents into the esophagus with or without accompanied regurgitation (spitting up) and vomiting. It is a normal physiologic process that occurs throughout the day in infants and less often in children and adolescents. Gastroesophageal reflux disease (GERD) is reflux that causes troublesome symptoms or leads to medical complications. The diagnoses of gastroesophageal reflux and GERD are based on the history and physical examination. Diagnostic tests, such as endoscopy, barium study, multiple intraluminal impedance, and pH monitoring, are reserved for when there are atypical symptoms, warning signs, doubts about the diagnosis, or suspected complications or treatment failure. In infants, most regurgitation resolves by 12 months of age and does not require treatment. Reflux in infants may be treated with body position changes while awake, lower-volume feedings, thickening agents (i.e., rice cereal), antiregurgitant formula, extensively hydrolyzed or amino acid formulas, and, in breastfed infants, eliminating cow's milk and eggs from the mother's diet. Lifestyle changes to treat reflux in children and adolescents include sleeping position changes; weight loss; and avoiding smoking, alcohol, and late evening meals. Histamine H₂ receptor antagonists and proton pump inhibitors are the principal medical therapies for GERD. They are effective in infants, based on low-quality evidence, and in children and adolescents, based on low- to moderate-quality evidence. Surgical treatment is available, but should be considered only when medical therapy is unsuccessful or is not tolerated.
Gastroesophageal Reflux Disease and Hiatal Hernia
2022, Fundamentals of Pediatric Surgery, Third Edition

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: The authors declare no conflicts of interest.

^∗: Contributed equally.

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Original ArticleDiagnostic Accuracy of Tests in Pediatric Gastroesophageal Reflux Disease

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Pediatr Surg

J Pediatr

Dig Liver Dis

One-year follow-up of symptoms of gastroesophageal reflux during infancy

Pediatrics

Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group

Arch Pediatr Adolesc Med

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

Healthcare costs of GERD and acid-related conditions in pediatric patients, with comparison between histamine-2 receptor antagonists and proton pump inhibitors

Curr Medical Res Opin

Is gastroesophageal reflux disease really a life-long disease: do babies who regurgitate grow up to be adults with GERD complications?

Am J Gastroenterol

A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population

Am J Gastroenterol

Over-prescription of acid-suppressing medications in infants: how it came about, why it's wrong, and what to do about it

J Pediatr

Symptoms and reflux in infants: Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R)–utility for symptom tracking and diagnosis

Curr Gastroenterol Rep

Eosinophilic esophagitis: updated consensus recommendations for children and adults

J All Clin Immunol

Simultaneous monitoring of gastric and oesophageal pH reveals limitations of conventional oesophageal pH monitoring in milk fed infants

Arch Dis Child

Gastroesophageal reflux in infants: evaluation of a new intraluminal impedance technique

J Pediatr Gastroenterol Nutr

Detection of small bolus volumes using multiple intraluminal impedance in preterm infants

J Pediatr Gastroenterol Nutr

Investigating esophageal reflux with the intraluminal impedance technique

J Pediatr Gastroenterol Nutr

The infant with chronic vomiting: the value of the upper GI series

Pediatr Radiol

Reflux esophagitis: sequelae and differential diagnosis in infants and children including eosinophilic esophagitis

Pediatr Dev Pathol

The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews

BMC Med Res Methodol

QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies

Ann Intern Med

Diagnostic accuracy of pH monitoring in gastro-oesophageal reflux

Arch Dis Child

Original Article
Diagnostic Accuracy of Tests in Pediatric Gastroesophageal Reflux Disease