Reflux and Respiratory Diseases


Study


Usefulness


Observations


Esophageal pH-metry


Evaluates the presence of acidic fluid


Useful to evaluate anti-GER treatment


Does not detect mildly acidic or non-acidic fluids


Esophageal pH-metry multichannel intraluminal impedance


Evaluates the presence of acid, mildly acidic, and non-acid reflux


Useful to evaluate the effectiveness of anti-GER treatment and its association with extradigestive symptoms (cough, difficult-to-control asthma, chest pain)


Impedance normal values for pediatric age are missing


Esophagus-duodenum-stomach x ray


Anatomical evaluation when malformations are suspected


Should not be used to diagnose GER or quantity of


Gastric endoscopy


Evaluation of macroscopic signs of esophagitis and taking of histological samples for differential diagnosis of other pathologies (eosinophilic esophagitis)


If no macroscopic alterations are found it may not diagnose GER


Flexible laryngoscopy


Evaluates the anatomy of the aerodigestive way and macroscopic signs of laryngopharyngealreflux


Findings are not necessarily related to GER


Gastroesophageal scintigraphy


Evaluation of postprandial and aspiration GER


Lack standardization technique and normal values for each age




Treatment


There are pharmacological and non-pharmacological measures for patients with confirmed disease caused by gastroesophageal reflux. For pediatric patients, the strategy of “empirical treatment” with no clear symptoms of GER has not been confirmed as sensitive or specific for the diagnosis of this disease, and therefore it is not recommended as a diagnosis method.


Use of thick or “anti-regurgitation” formulas, although they reduce the number of regurgitations observed by the caregivers, is not translated in pH-metry improvement. Formula thickened at home with rice cereal increases weight in infants, considering the caloric density it involves.


In older children and adolescents, weight reduction is recommended in children with excess malnutrition. Although suspending certain foods a priori is a commonly used strategy, it has not been confirmed that it actually reduces GER episodes. Instead, it is recommended to reduce certain foods according to each case.


It has been shown that prone and lateral decubitus position reduces GER episodes. Nevertheless, these positions have been associated with an increased rate in sudden death syndrome, and therefore supine position is recommended for those patients who are under 1 year of life and also have GER. Prone position can be kept when they are awake and always supervised.


In relation to pharmacological measures, there are medications that have a buffer effect on the acid, a barrier effect on the mucosa, anti-acid secretors, and prokinetics.


Evidence about pediatric use of antacids is limited, and special care must be taken with those drugs containing aluminum, in relation to milk-alkali syndrome. They are generally not recommended for the treatment of GER in children.


Acid secretion inhibitors are ion histamine type 2 receptor agonist (H2RA), such as ranitidine and famotidine, and the proton bomb inhibitors, such as omeprazole, esomeprazole, and lanzoprazole. Proton pump inhibitors are considered to be better than the H2RA in suppressing acid effects, which also present tachyphylaxis after 6 weeks of use, and even reactions like irritability, headache, and sleepiness may be wrongly interpreted as GER worsening. It has been confirmed that proton pump inhibitors are better than histamine receptor inhibitors in treating erosive esophagitis. Nevertheless, it has some difficulties in the dosage and administration, because there is no syrup presentation. In general, the use of costumed preparations is not recommended, as there are few studies supporting the stability and bioavailability of these substances. Besides this, the use of proton pump inhibitors is not risk free, because idiosyncratic reactions may occur, as well as diarrhea, constipation, nauseas, hypergastrinemia with its chronic use, hyperplasia of enterochromaffin-like cells, and in the long term, micronutrients malabsorption (iron and B12 vitamin). In premature babies an increased risk of necrotizing enterocolitis and candidemia was observed. Table 55.2 shows the recommended dosages for H2RA and proton pump inhibitors .
Nov 7, 2020 | Posted by in Uncategorized | Comments Off on Reflux and Respiratory Diseases
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