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[Anonymous]

Symptoms Arising from Non-Acid Reflux in Children

By: Rachel Rosen, M.D., Children’s Hospital Boston, Boston, MA

Dr. Rosen is the recipient of the IFFGD 2005 Research Award to Pediatric Investigator, Clinical Science.
Her current research focuses on the role of non-acid reflux in symptom
development in children. In the studies that she and her colleagues
have conducted at the motility unit at Children’s Hospital Boston, they
found that non-acid reflux is common in pediatrics.

Children
under the age of 18 have the highest rates of acute respiratory
diseases of any age group; more than 30,000,000 visits are made to
pediatricians and family practitioners each year because of pediatric
respiratory conditions. Many of these acute illnesses progress to
chronic respiratory diseases such as asthma, which result in
significant morbidity and mortality. Despite excellent medical therapy,
the prevalence rates of chronic respiratory disease remain high; the
prevalence rates for asthma, for example, have increased steadily to
126 children per 1,000 who have a diagnosis of asthma. [Affairs,
A.M.A.Council of Scientific Affairs., Childhood asthma: emerging
patterns and prospects for novel therapies (A-02). 2000.]

Because
of the large public health impact of chronic respiratory disease,
pulmonologists (doctors who specialize in lung disorders) and
otolaryngologists (doctors who specialize in ear, nose, and throat
disorders) have been actively searching for a cause for these high
rates of disease. One factor implicated as a cause for respiratory
disease is gastroesophageal reflux (GER). Prior literature has focused
on the role that acid reflux plays in the genesis of respiratory
disease. The current “gold standard” diagnostic tool used to evaluate
for GER is the pH probe which measures the amount of acid reflux
entering the esophagus over a 24-hour period. Despite acid blocking
medications, some patients continue to experience severe respiratory
symptoms that resolve after patients undergo anti-reflux surgery. One
explanation for this is that patients are experiencing reflux that is
missed by our currently available tests and that is not effectively
treated by acid suppression medications.

This reflux has
recently been termed “non-acid reflux” and is defined as reflux with a
pH greater than 4. Prior pediatric studies have shown that between
30-88% of reflux in children is non-acid. Non-acid reflux is a
particular problem in pediatrics because children are fed more
frequently than adults and the majority of non-acid reflux occurs in
the period after mealtime (post-prandial) when stomach contents are
neutralized. Additionally, there are many children that are
continuously fed through gastrostomy tubes such that the pH of the
stomach is neutral for the majority of the day.

Non-acid
reflux is measured using a new tool called multi-channel intra-luminal
impedance (pH-MII). The pH-MII catheter is a small tube that is
inserted through the nose into the esophagus and is identical in size
to the standard pH probe. The catheter remains in place for 24 hours
during which it continuously measures the amount of both acid and
non-acid reflux that is entering the esophagus from the stomach.
Another significant advantage to pH-MII is the ability of the catheter
to measure the height of the refluxed stomach contents; impedance
sensors are positioned throughout the esophagus so clinicians can
determine if reflux extends along the entire length of the esophagus
and even up into the mouth and potentially the airway. Pediatric
studies have suggested that the pH-MII catheter is as sensitive as the
pH probe in the detection of reflux.

This tool has been very
useful in the evaluation of patients with atypical reflux symptoms
(such as asthma, chronic cough, laryngitis, chest pain) and in patients
who continue to have symptoms while taking acid blocking medicines.
Studies in adults and children have shown that the addition of pH-MII
monitoring significantly improves the physicians’ ability to diagnose
reflux-related disease. In studies of infants, the use of pH-MII has
been particularly important in clarifying the relationship between
respiratory diseases. While the association between apnea (a pause in
breathing) and reflux in infants has been debated, there is some
evidence that non-acid reflux may be associated with breathing problems
in these young patients. In a study of 22 infants with primarily
respiratory symptoms who underwent pH-MII testing, the standard pH
probe failed to detect 88% of reflux episodes that were associated with
breathing problems. There is also literature that suggests that
non-acid reflux in children may be associated with other respiratory
symptoms. In a study of 28 older children with severe respiratory
disease who were taking acid blocking medicine, non-acid reflux was
more likely to be associated with respiratory symptoms than acid
reflux. Adult data supports this pediatric evidence that non-acid
reflux may be associated with respiratory symptoms.

Because
the understanding of the role of non-acid reflux is in its infancy,
very few studies have addressed the treatment options for patients with
pathologic non-acid reflux. Adult and pediatric studies suggest that
proton pump inhibitors such as omeprazole and lansoprazole do not
decrease the total amount of reflux in patients. Instead, they convert
the reflux from acid to non-acid reflux which may explain why some
patients continue to have symptoms despite therapy with proton pump
inhibitors. Adult studies have suggested that therapy with the drug
baclofen (a GABA agonist), which decreases the amount of esophageal
sphincter relaxations (the main cause of reflux), or anti-reflux
surgery may effectively treat non-acid reflux. In pediatrics, pH-MII
has been used to evaluate other reflux therapies such as body
positioning, tube feeding, and thickening of feeds. All of the
therapeutic studies have involved a small number of patients and
additional data on the treatment of non-acid reflux is needed.

Because of the newly available pH-MII technology, many new studies are
underway to clarify the role of non-acid reflux in disease and the
possible therapies to treat non-acid reflux. Additionally, pH-MII
technology has been paired with manometry, a method of measuring
pressures in the esophagus, so that physicians will have a greater
understanding of the relationship between acid and non-acid reflux and
reflux clearance in the esophagus.

Last updated September 23, 2006

[Anonymous]

Very interesting. Thanks for posting.

[Anonymous]

Thanks for posting. We are quite possibly headed for a ph probe (we never had one when she was younger) and so this may be an option if it is available here.

[Anonymous]

Here’s another article related to this topic…bit on the heavy side. It seems the consensus is these Ph probes aren’t that good at dx reflux (we all knew that). So when the Drs say no to PPIs on basis of ph probes…maybe now we can print some of this stuff out and show them!!

http://gut.bmj.com/cgi/content/full/53/7/1024

I’m still trying to work out why non-acid reflux would hurt???

[Anonymous]

Thanks for the very interesting information. It will be helpful to have it here on the board.

[hellbennt]

therese,

I think non acid reflux would hurt bcse the actual act of refluxing is probably uncomfortable?

also w/ the non-acid reflux, there’s still reflux occuring, so liquid (I don’t know what it’s made of? presumably stomach contents of some sort? w/ acid-reflux babies on meds, the reflux is non-acidic reflux?) gets all up into the upper respiratory system & can wreak havoc…

[Anonymous]

Thanks for posting this Sarah. We have this going on with Hailey and she is very bothered by it, especially at night. We know (think?) that her acid is controlled on her PPI b/c her scope came back clear, but she’s still refluxing stuff up anyhow. It wakes her, and often goes up her nose- you hear it come up, and then she’s all snory afterwards.

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