Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children

We prospectively evaluated bronchial washings from 45 patients aged 1 month to 25 years (mean 3.3 years) for the presence of lipid-laden macrophages. By grading the amount of intracellular oil-red-O-positive material, we determined a semiquantitative lipid-laden macrophage index for each patient. All patients observed to be definite aspirators (n = 22) had indexes greater than or equal to 86 (mean +/- SD, 139 +/- 46). All patients with no clinical suspicion of aspiration (n = 23) had indexes less than or equal to 72 (mean +/- SD, 21 +/- 20). Our results suggest that simply sighting lipid-laden macrophages in a nonspecific finding, but quantitation of these cells may be a very good test for recurrent aspiration of food substances in children. This test appears to be more sensitive than radiographic studies.

Recurrent aspiration in children: lipid-laden alveolar macrophage quantitation.

Sudden infant death syndrome: 1987 perspective.

Pneumograms in infants who subsequently died of sudden infant death syndrome

Respiratory observations made during nutritive feeding and a complete daytime nap within the first week of life on ten newborns who subsequently were victims of sudden infant death syndrome (SIDS) were compared with normative data based on 1,301 infants of comparable ages. Measurements were obtained of all apneic pauses and/or transient respiratory obstructive events at least two seconds in duration. A statistically significant increased number of future SIDS victims were found to have an unusual amount of apnea/obstruction episodes during nutritive feeding when compared with the normative group. Future SIDS victims, as a group, also had an increased frequency of apneic pauses during sleep. Furthermore, all SIDS victims demonstrated either an unusual amount of apnea/obstruction during nutritive feeding or apneic pauses during sleep. None of the airway obstruction measures during sleep differentiated the SIDS infants from the normative group. These results are consistent with the general hypothesis that prolonged apnea or airway obstruction is part of the pathophysiologic process resulting in SIDS and those hypotheses implicating unstable respiratory activity during sleep as well as apnea and pharyngeal/laryngeal dysfunction induced by liquid stimulation of the upper airway. They are also compatible with the growing body of evidence indicating that factors that predispose an infant to SIDS originate in the perinatal period.

The Sudden Infant Death Syndrome and Apnea/Obstruction During Neonatal Sleep and Feeding

• Electrocardiograms obtained during sleep within the first and/or fourth week postnatally were available on eight infants who subsequently died of the sudden infant death syndrome (SIDS). The corrected QT (QTc) and R-R intervals were compared with controls for the purpose of evaluating their relevance for SIDS. The QTc interval in controls increased with age and tended to be longer during sleep without rapid eye movements. The R-R interval decreased with age. None of the SIDS victims was found to have a prolonged QTc interval. However, the R-R interval during rapid eye movement epochs was significantly shorter in future SIDS victims compared with controls. These data were interpreted as being inconsistent with the congenital variants of the long-QT hypothesis but compatible with the growing conviction that infants who die of SIDS have a chronic underlying abnormality that has subtle manifestations within the immediate postnatal period. (AJDC1985;139:987-990)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=peds&articleId=512419&pdfFileName=archpedi_139_10_023.pdf

QTc and R-R intervals in victims of the sudden infant death syndrome.

The purpose of this study was to examine the influence of neonatal age, sex, type of feeding, and rapid eye movements on the occurrence of apneic pauses during sleep in a hyperthermic environment. One hundred and twenty fullterm infants (equally divided by sex and type of feeding) were observed during a complete nap within the first and approximately fourth wk of life. Each sleep session was characterized by twenty-one measures including the longest apneic pause, mean apnea duration, relative frequency of apnea, apnea periodicity, respiratory rate, and relative frequency of REM epochs. The relative frequency of REM epochs decreased with age and was greater in formula-fed (versus breast-fed) infants. The longest apneic pauses were greater in the first wk of life and in breast-fed infants. In addition, the average Longest Duration:REM was greater than the average Longest Duration:NREM. Of potential importance was the demonstration that this latter effect was greater in the first wk than in the fourth wk of life. Breast-fed infants and females had larger apnea Mean Duration scores. The relative frequency of apneic pauses (greater than or equal to 2 sec in duration), periodicity, and the relative amount of apnea were greater in the fourth-wk study and in breast-fed infants. The relative frequency of apneic pauses greater than or equal to 6 sec in duration (Apnea6%) and the A6/D% measure were greater in breast-fed infants. Numerous interactions were observed between age, sex, and type of feeding. Respiratory rate decreased with age and was greater during NREM epochs and in formula-fed infants.

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Sleep respiratory instability in term neonates under hyperthermic conditions: age, sex, type of feeding, and rapid eye movements.

Sudden infant death syndrome (SIDS), apnea, and near miss for SIDS.

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Alfred Steinschneider

Papers

The Sudden Infant Death Syndrome and Apnea/Obstruction During Neonatal Sleep and Feeding

QTc and R-R intervals in victims of the sudden infant death syndrome.

Sleep respiratory instability in term neonates under hyperthermic conditions: age, sex, type of feeding, and rapid eye movements.

Sudden infant death syndrome (SIDS), apnea, and near miss for SIDS.

The Prevalence of Central Apnea in High Risk Sids Infants