Significance of Extra-Esophageal Symptoms in Pediatric Gastroesophageal Reflux Disease

THIEME 472 Original Research Significance of Extra-Esophageal Symptoms in Pediatric Gastroesophageal Reflux Disease Andro Košec1 Orjena Žaja2 Filip Matovinović1 1 Department of Otorhinolarygology and Head and Neck Surgery, University Clinical Hospital Centre Sestre Milosrdnice, Zagreb University School of Medicine, Zagreb, Croatia 2 Department of Pediatrics, University Clinical Hospital Centre Sestre Milosrdnice, Zagreb University School of Medicine, Zagreb, Croatia 3 Department of Otorhinolaryngology, Mostar University Hospital, Mostar, Bosnia and Herzegovina Boris Jelavić3 Tomislav Baudoin1 Address for correspondence Andro Košec, MD, PhD, FEBORL-HNS, Department of Otorhinolarygology and Head and Neck Surgery, University Clinical Hospital Centre Sestre Milosrdnice, Zagreb University School of Medicine, Vinogradska cesta 29, 10000 Zagreb, Croatia (e-mail: ). Int Arch Otorhinolaryngol 2020;24(4):e472–e476. Abstract Keywords ► diagnostics ► obesity ► pediatric gastroesophageal reflux disease ► screening Introduction Current practice guidelines in gastroesophageal reflux disease (GERD) often require invasive diagnostic testing. Objective The aim of the present study was to evaluate the significance of extraesophageal symptoms and reliability of a screening risk score that is simple to use. Methods A longitudinal retrospective single-institution cohort study. Setting: A university clinical hospital tertiary referral center. The present study enrolled pediatric patients with symptoms suggestive of GERD: epigastric pain, occasional nausea, regurgitation, tasting acid in the oral cavity, chronic cough, hoarseness of voice, frequent throat clearing. The patients underwent 24-hour esophageal pH monitoring and fiber-optic laryngoscopy. The correlations between the local findings, anamnestic and objective measurement data were analyzed. Results The present study evaluated 89 pediatric patients. Patients with asthma presented significantly more often with adjoining gastrointestinal symptoms (p ¼ 0.0472). Patients that were obese were linked to a higher rate of reports of gastrointestinal symptoms (p ¼ 0.0495). After the patients had been assigned to newly developed risk groups, obesity showed to be significantly more frequent in patients placed in higher risk groups (p < 0.0001) for a positive GERD diagnosis. Conclusion Patients with leading symptoms of asthma presented significantly more often with adjoining gastrointestinal symptoms. Obesity showed to be significantly more frequent in patients placed in higher risk groups for a positive GERD diagnosis. Introduction Pediatric gastroesophageal reflux disease (GERD) is characterized by backflow of gastric contents into the esophagus, with acid-induced and pepsin-mediated injury to the mucosa causing troublesome symptoms, affecting up to 3.3% of the pediatric population.1 The manifestations of GERD have been labeled as either esophageal or extra-esophageal syndromes (EESs). received June 8, 2019 accepted October 20, 2019 DOI https://doi.org/ 10.1055/s-0039-3402437. ISSN 1809-9777. Among the latter, atypical manifestations of GERD, including chronic cough and pediatric laryngopharyngeal reflux (PLPR) have been considered significant by general physicians, pediatricians and otorhinolaryngologists.2 In particular, there are increasing evidence linking the growing prevalence of PLPR among GERD patients.3 There is evidence that PLPR is associated with rhinosinusitis, laryngitis, pneumonia, and asthma in children, but the comorbidities are still frequently overlooked Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil Screening for Pediatric GERD Made Simpler by otorhinolaryngologists and pediatricians.4 Children with GERD often experience extra-esophageal symptoms that can be intermittent.5 Controversies remain regarding the confirmation of the diagnosis of extra-esophageal GERD manifestations in general. At present, insufficient data are available on the assessment of GERD symptoms and on the characteristics of the symptom complex in these patients. In October 2009, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) published new clinical practice guidelines for the diagnosis and management of reflux in the pediatric population, updating and unifying their previous guidelines as a means of improving uniformity of practice and quality of patient care. One of the most frequent deviations from the NASPGHAN/ESPGHAN recommendations concerned the use of diagnostic modalities. Previously published studies show symptom description to be unreliable and nonspecific.6 Current practice guidelines in GERD often require invasive diagnostic testing. The aim of the present study was to evaluate the prevalence of extra-esophageal symptoms and the reliability of a novel screening score that is simple to use. Košec et al. lasting > 5 minutes. The measurements were performed by the same pediatric gastroenterologist. The otorhinolaryngologic examination was performed by the same otorhinolaryngologist to reduce interobserver variability, through fiber-optic laryngoscopy (4-mm flexible optic fiber, Karl Storz, Tuttlingen, Germany) that assessed the upper airway from the nasal vestibule to the infraglottic area. The patients’ parents gave written informed consent for the diagnostic testing. Obesity was factored in as an independent predictive factor if the patient’s body mass index (BMI) was at least two standard deviations (SDs) above the World Health Organization (WHO) growth reference median. The diagnosis of asthma was established through spirometry examinations (reduced forced expiratory flow higher than 25–75% of the Forced Vital Capacity [FVC]). The statistical analysis was performed using the MedCalc software ( MedCalc Software, Ostend, Belgium), version 11.2.1. The data for the cohort were expressed as ratios due to the fact that it was composed of less than 100 patients (n ¼ 89). The associations between variables were assessed using the Fisher exact test, Mann–Whitney test and Kruskal–Wallis test for nonparametric paired samples. All of the tests of statistical significance were performed using a two-sided 5% type-I error rate. Methods The present study was conducted as a retrospective longitudinal cohort study. It encompassed pediatric patients who presented with extra-esophageal GERD symptoms (epigastric pain, nausea, regurgitation, acid in the oral cavity, chronic cough, dysphonia, frequent throat clearing) to the pediatric gastroenterologist first, who were then evaluated by an otorhinolaryngologist. The 24-hour dual-probe monitoring procedure was performed in all pediatric patients with extra-esophageal symptoms clearly present in their patient history as part of a department diagnostic protocol. Initially, data from 121 pediatric patients who underwent 24-hour esophageal pH monitori (...truncated)