Top 5 Pediatric Viewpoints of 2011

William T. Basco, Jr., MD


January 05, 2012

In This Article

The Top 5 Pediatric Viewpoint Topics of 2011

For the Year End 2011 Viewpoints, I offer a brief summary of each of the "Top 5" Viewpoints for 2011 (on the basis of readership). In addition, I will post a new Viewpoint about an article that is sure to be referenced often in the coming years. If you missed the original Viewpoints, I hope you'll take the time to review the studies that your colleagues found most compelling in 2011.

Diagnosing Gastroesophageal Reflux

Detection of Gastroesophageal Reflux in Children Using Combined Multi-Channel Intraluminal Impedance and pH Measurement: Data From the German Pediatric Impedance Group

Pilic D, Fröhlich T, Nöh F, et al
J Pediatr. 2011;158:650-654

Study Summary

This study compared the diagnostic sensitivity of a combined pH and impedance (changes in esophageal pressure) monitoring for diagnosis. The device used had 7 impedance nodes and 1 pH node. The study was completed at 4 German referral centers with > 700 subjects. Overall, 38.6% of the subjects had an abnormal study. Among children with abnormal test results, 18% had only abnormal pH monitoring results, 45% had only abnormal impedance results, and 37% had abnormal results from both monitoring modalities. When stratified by symptom, 35% of the children with gastrointestinal symptoms had abnormal test results, 40% of those with pulmonary symptoms had abnormal results, and 50% of the children who presented with neurologic symptoms had abnormal results. The authors concluded that combination monitoring with impedance and pH is superior to pH monitoring alone and suggest that combined testing should be considered to gold standard.

Year-End Viewpoint

Reflux, or at least reflux-like symptoms or reflux-related concerns, is a daily challenge for pediatric providers. I suspect, therefore, that many providers are hungry for data that might inform their approach to and treatment of the problem. When viewing these results, one should remember that this was a referral population that had severe enough reported symptoms to be referred to a pediatric specialist. I do think that the study shows very well that the 2 diagnostic modalities provide different information, and pH monitoring alone does not appear to perform as well as either impedance alone or combined monitoring.

The study also reminds me of an "oldie-but-goodie" study that I still periodically refer to on rounds, discussed in Medscape Pediatric Journal Scan in 2008. In that study, the investigators conducted a 2-week nonmedical intervention run-in period for infants that had previously qualified for a gastroesophageal reflux trial.[1] However, the run-in implemented a very aggressive nonmedical regimen, including changing the infants' formulas to hydrolyzed formula, thickening the formula, limiting volume, and upright positioning after feeds. With that comprehensive, nonmedical approach, 24% of the subjects who initially qualified improved enough to no longer qualify for a reflux study.

I've always been impressed by how much can be gained with either the passage of time and/or the combination of non-medical approaches, suggesting that we should try those first before starting any medication for gastroesophageal reflux.



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