Intra- and interobserver agreement of histopathological findings in pediatric patients with eosinophilic esophagitis

Abstract Objective: To assess intra- and interobserver agreement among non-expert pathologists in identifying features of the eosinophilic esophagitis histologic scoring system (EoEHSS) in pediatric patients. Patients and methods: The authors used 50 slides from patients (aged 1-15 years; 72% male) with EoE. EoEHSS evaluates eosinophilic inflammation and other features including epithelial basal zone hyperplasia, eosinophilic abscesses, eosinophil surface layering, dilated intercellular spaces, surface epithelial alteration, dyskeratotic epithelial cells, and lamina propria fibrosis. Grade and stage of abnormalities are scored using a 4-point scale (0 normal; 3 maximum change). Four pathologists determined EoEHSS findings on two occasions. Intra- and interobserver agreement was assessed using Kappa (κ) statistics and intra-class correlation coefficients. Results: Intra- and interobserver agreement for the identification of eosinophil counts ≥ 15/high power field (HPF) was excellent, however varied when assessing additional features of the EoEHSS. For the more experienced pathologist, agreement for most EoEHSS items and the composite scores was substantial to excellent. For the less experienced pathologists, intraobserver agreement ranged from absent to substantial for individual features and ranged from moderate to substantial for the composite scores. Conclusion: Most items of the EoEHSS had substantial to excellent reliability when assessed by a pathologist experienced in the diagnosis of EoE but presented lower repeatability among less experienced pathologists. These findings suggest that specific training of pathologists is required for the identification of EoEHSS characteristics beyond eosinophil count, as these features are considered useful in the evaluation of response to treatment and correlation with clinical manifestations and endoscopic findings.

Intra- and interobserver agreement of histopathological findings in pediatric patients with eosinophilic esophagitis.

OBJECTIVE: To assess intra- and interobserver agreement among non-expert pathologists in identifying features of the eosinophilic esophagitis histologic scoring system (EoEHSS) in pediatric patients. PATIENTS AND METHODS: The authors used 50 slides from patients (aged 1-15 years; 72% male) with EoE. EoEHSS evaluates eosinophilic inflammation and other features including epithelial basal zone hyperplasia, eosinophilic abscesses, eosinophil surface layering, dilated intercellular spaces, surface epithelial alteration, dyskeratotic epithelial cells, and lamina propria fibrosis. Grade and stage of abnormalities are scored using a 4-point scale (0 normal; 3 maximum change). Four pathologists determined EoEHSS findings on two occasions. Intra- and interobserver agreement was assessed using Kappa (κ) statistics and intra-class correlation coefficients. RESULTS: Intra- and interobserver agreement for the identification of eosinophil counts ≥ 15/high power field (HPF) was excellent, however varied when assessing additional features of the EoEHSS. For the more experienced pathologist, agreement for most EoEHSS items and the composite scores was substantial to excellent. For the less experienced pathologists, intraobserver agreement ranged from absent to substantial for individual features and ranged from moderate to substantial for the composite scores. CONCLUSION: Most items of the EoEHSS had substantial to excellent reliability when assessed by a pathologist experienced in the diagnosis of EoE but presented lower repeatability among less experienced pathologists. These findings suggest that specific training of pathologists is required for the identification of EoEHSS characteristics beyond eosinophil count, as these features are considered useful in the evaluation of response to treatment and correlation with clinical manifestations and endoscopic findings.

Endoscopic and histological characteristics in patients with eosinophilic esophagitis responsive and non-responsive to proton pump inhibitors / Características endoscópicas e histológicas em pacientes com esofagite eosinofílica responsiva e não responsiva aos inibidores de bomba de prótons

Abstract Objective: To compare endoscopic and histologic features of pediatric patients with eosinophilic esophagitis (EoE) responding to proton pump inhibitor (PPI) to those not responding to PPI. Methods: Endoscopic reports and photographs of patients with symptoms of esophageal dysfunction and ≥15 eosinophils per high-powered field (eos/hpf) in esophageal biopsies prior to PPI trial were reviewed. Patients were classified as responsive to PPI (PPIREoE) or non-responsive to PPI (PPINREoE) according to response totreatment (<15 eos/hpf) at second endoscopy after 8 weeks. Results: Of the 231 patients (72.3% male), 64 (27.7%) were responsive to the proton pump inhibitors. Edema (77.3% vs. 62.5%, p = 0.031) and vertical lines (69.5% vs. 51.6%, p = 0.014) were more frequent in PPINREoE patients. An eosinophil count in the mid-esophagus ≥ 35 eos/HPF (25.1% vs. 12.5%) was more frequent in these patients (p = 0.001). Those with eosinophil count < 15 eos/HPF in the mid-esophagus at the first endoscopy were more likely to respond to treatment with proton pump inhibitors compared to patients with 15-34 eos/HPF (p = 0.004, OR: 3.26, 95% CI: 1.46-7.24) and to patients with ≥ 35 eos/HPF (p = 0.006, OR: 3.20, 95% CI: 1.39-7.41). Conclusion: Edema and vertical lines at the endoscopy and a higher eosinophil count in the mid-esophagus were more frequent in patients who were non-responsive to proton pump inhibitors. As there were no significant differences in the other findings between the groups, it cannot be affirmed that these characteristics are sufficient to differentiate between PPINREoE and PPIREoE patients.

Resumo Objetivo: Comparar características endoscópicas e histológicas entre pacientes com esofagite eosinofílica responsiva (EoERIBP) e não responsiva (EoENRIBP) ao tratamento com inibidores de bomba de prótons. Métodos: Avaliados laudos e imagens endoscópicas de pacientes com sintomas de disfunção esofágica associados a contagem ≥ 15 eosinófilos por campo de grande aumento (eos/CGA) em biópsia do esôfago. Os pacientes foram classificados em responsivos (EoERIBP) ou não responsivos (EoENRIBP) aos inibidores de bomba de prótons conforme resposta ao tratamento na segunda endoscopia (< 15 eos/CGA) após 8 semanas. Resultados: Dos 231 pacientes (72,3% masculino), 64 (27,7%) foram responsivos aos inibidores de bomba de prótons. Edema (77,3% vs. 62,5%, p = 0,031) e linhas verticais (69,5% vs. 51,6%, p = 0,014) foram mais frequentes nos EoENRIBP. A contagem de eosinófilos em esôfago médio ≥ 35 eos/CGA (25,1% vs. 12,5%) foi mais frequente nesses pacientes (p = 0,001). Os que apresentaram contagem de eosinófilos < 15 eos/CGA no esôfago médio à primeira endoscopia apresentaram maior chance de responder ao tratamento com inibidores de bomba de prótons em comparação aos pacientes com 15-34 eos/CGA (p = 0,004; OR: 3,26; IC95%: 1,46-7,24) e aos pacientes com ≥ 35 eos/CGA (p = 0,006; OR: 3,20; IC95%: 1,39-7,41). Conclusão: Edema e linhas verticais à endoscopia e maior contagem de eosinófilos em esôfago médio foram mais frequentes nos pacientes não responsivos aos inibidores de bomba de prótons. Uma vez que não houve diferenças significativas nos outros achados entre os grupos, não se pode afirmar que essas características sejam suficientes para distinguir pacientes com EoENRIBP dos pacientes com EoERIBP.

Brazilian pediatricians' adherence to food allergy guidelines-A cross-sectional study.

Food allergy is an emerging clinical condition in pediatrics, so recommendations on its management have been widely published. Studying pediatricians' adherence to these clinical practice guidelines (CPG) and understanding the reasons for their non-compliance can help to promote better management of this condition. A cross-sectional study was conducted by a survey among Brazilian pediatricians, randomly selected during the 38th Brazilian Congress of Pediatrics, which took place in October, 2017. A validated questionnaire with 16 questions addressing knowledge and practice on food allergy, as well as self-reported adherence to international guidelines was applied. Of the total of 415 pediatricians from all regions of the country who were surveyed, only 69 (16.7%) had a satisfactory adherence rate (≥80%). Adequate adherence to the guidelines was associated with the variables: 'evaluating more than 10 children with suspected cow's milk allergy (CMA) per month'; 'having read the Brazilian consensus'; or 'being aware of any international food allergy guideline'. In 8 of the 10 questions that assessed conscious adherence, a minority of those surveyed (20.3-42.3% variation) stated that they knew that their response was in line with the guidelines. This finding was statistically significant (p<0.05) in 7 of these 8 questions. The self-reported adherence of Brazilian pediatricians to international food allergy guidelines was low. Pediatricians who evaluated a higher number of children with suspected CMA or who were aware of the recommendations, had a higher rate of adherence. The results of the survey found that lack of resource was the major reported barrier to guideline adherence but lack of awareness must be a relevant non perceived barrier. This study shows the pediatricians´ self-reported adherence to food allergy guidelines in a widely overview for the first time in Brazil. More studies are necessary to investigate adherence to guidelines by pediatricians in other countries and to develop strategies to improve adherence.

Endoscopic and histological characteristics in patients with eosinophilic esophagitis responsive and non-responsive to proton pump inhibitors.

OBJECTIVE: To compare endoscopic and histologic features of pediatric patients with eosinophilic esophagitis (EoE) responding to proton pump inhibitor (PPI) to those not responding to PPI. METHODS: Endoscopic reports and photographs of patients with symptoms of esophageal dysfunction and ≥15 eosinophils per high-powered field (eos/hpf) in esophageal biopsies prior to PPI trial were reviewed. Patients were classified as responsive to PPI (PPIREoE) or non-responsive to PPI (PPINREoE) according to response totreatment (<15 eos/hpf) at second endoscopy after 8 weeks. RESULTS: Of the 231 patients (72.3% male), 64 (27.7%) were responsive to the proton pump inhibitors. Edema (77.3% vs. 62.5%, p=0.031) and vertical lines (69.5% vs. 51.6%, p=0.014) were more frequent in PPINREoE patients. An eosinophil count in the mid-esophagus ≥ 35 eos/HPF (25.1% vs. 12.5%) was more frequent in these patients (p=0.001). Those with eosinophil count < 15 eos/HPF in the mid-esophagus at the first endoscopy were more likely to respond to treatment with proton pump inhibitors compared to patients with 15-34 eos/HPF (p=0.004, OR: 3.26, 95% CI: 1.46-7.24) and to patients with ≥ 35 eos/HPF (p=0.006, OR: 3.20, 95% CI: 1.39-7.41). CONCLUSION: Edema and vertical lines at the endoscopy and a higher eosinophil count in the mid-esophagus were more frequent in patients who were non-responsive to proton pump inhibitors. As there were no significant differences in the other findings between the groups, it cannot be affirmed that these characteristics are sufficient to differentiate between PPINREoE and PPIREoE patients.

Eosinophilic esophagitis-Where are we today? / Esofagite eosinofílica - Qual é a nossa posição atual?

Abstract Objective: The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. Sources: A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. Summary of the findings: The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. Conclusions: Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.

Resumo Objetivo: Fornecer uma visão geral do diagnóstico e do tratamento da esofagite eosinofílica na prática clínica e aumentar a visibilidade da doença entre os pediatras. Fontes dos dados: Foi feita uma busca na literatura relevante nos bancos de dados Medline, Embase, CINAHL e consensos e diretrizes recentes foram revisados. Síntese dos dados: A definição de esofagite eosinofílica é baseada nos sintomas e na histologia. É importante excluir outras doenças associadas com inflamação esofágica predominantemente eosinofílica. Ainda não está claro se o aumento na prevalência é devido a um real aumento da incidência ou se é o resultado da maior suspeição diagnóstica. Várias opções para tratamento, inclusive inibidores de bomba de prótons, restrições dietéticas, esteroides tópicos deglutidos e dilatações endoscópicas têm sido usadas em pacientes pediátricos. Mais recentemente a eosinofilia esofágica responsiva a inibidores de bomba de prótons e a esofagite eosinofílica têm sido contempladas no mesmo espectro e os inibidores de bomba de prótons devem ser considerados como opção inicial no tratamento desses pacientes. Conclusões: A esofagite eosinofílica é uma doença relativamente nova com uma notável progressão da incidência e prevalência nas últimas 2-3 décadas e critérios diagnósticos estão em evolução constante. É importante entender melhor a patogênese dessa doença, os fatores predisponentes, a história natural e a categorização dos diferentes fenótipos para desenvolver estratégias diagnósticas e terapêuticas que vão ao encontro das necessidades clínicas dos pacientes.

Eosinophilic esophagitis-Where are we today?

OBJECTIVE: The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. SOURCES: A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. SUMMARY OF THE FINDINGS: The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. CONCLUSIONS: Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.

Survey on the Adherence to the 2009 NASPGHAN-ESPGHAN Gastroesophageal Reflux Guidelines by Brazilian Paediatricians.

OBJECTIVE: The aim of the study was to evaluate the management of gastroesophageal reflux in children among Brazilian pediatricians and adherence to the 2009 North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Guideline in Brazil. METHODS: An observational cross-sectional study was conducted, applying a standard questionnaire with 12 questions about gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) management in infants, children, and adolescents to the pediatricians during the 37th Brazilian Pediatrics Congress in October, 2015. Adherence to the 2009 NASPGHAN-ESPGHAN Guideline was verified through analyses of interviewees' answers. Pediatricians' demographic and professional characteristics were screened. RESULTS: A total of 390 Brazilian pediatricians answered the questionnaire. None showed complete adherence to Guideline recommendations. GERD diagnosis by history alone was reported by 67%, irrespective of the child's age. The mean score for diagnostic adherence to the guidelines was 0.94 ±â€Š0.86 (range 0-4). Working in public health services (P = 0.026) was the only variable retained as a significant predictor of poor adherence for GER/GERD diagnosis after multivariate logistic regression analysis. No significant statistical differences were found between Brazilian regions on total score (P = 0.774). Proton pump inhibitors were prescribed by 28.4% of the pediatricians independent of child's age, and 59% use proton pump inhibitors to treat babies with unexplained crying and/or distressed behavior. CONCLUSIONS: 2009 NASPGHAN-ESPGHAN Guideline recommendations had poor adherence by Brazilian pediatricians. Studies evaluating the reasons for the poor adherence to NASPGHAN/ESPGHAN guidelines are urgently needed.

Amino acid formula as a new strategy for diagnosing cow's milk allergy in infants: is it cost-effective?

AIMS: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow's milk allergy (CMA). MATERIALS AND METHODS: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. RESULTS: The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation. LIMITATIONS: In the absence of information in the literature, some premises were defined by a panel of specialists. CONCLUSIONS: The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.

Pediatrician's knowledge on the management of the infant who cries excessively in the first months of life.

OBJECTIVE: To evaluate the attitude, the practice and the knowledge of pediatricians regarding the management of the infant who cries excessively in the first months of life. METHODS: Descriptive cross-sectional study that enrolled pediatricians (n=132) randomly interviewed at a Pediatric meeting in Brazil, in August 2012. The data were collected by a self-administered standardized form after reading the hypothetical case of an infant who cried excessively. RESULTS: The majority of the participants were females, the mean age was 39 years and the average mean time working in the specialty was 14 years; 52.2% were Board Certified by the Brazilian Society of Pediatrics. The diagnosis most often considered was gastroesophageal reflux disease (62.9%), followed by infant colic (23.5%) and cow's milk allergy (6.8%). The diagnostic test most frequently mentioned was 24-hour esophageal pH-monitoring (21.9%). The medications most frequently indicated were domperidone (30.3%), the combination of domperidone with ranitidine (12.1%) and paracetamol (6%). CONCLUSIONS: In the approach of the infant who cries excessively, diagnostic tests are frequently requested and unnecessary medical treatment is usually recommended.

Pediatrician's knowledge on the management of the infant who cries excessively in the first months of life / Actitud, práctica y conocimiento del pediatra sobre el lactante que llora excesivamente durante los primeros meses de vida / Conhecimentos do pediatra sobre o manejo do lactente que chora excessivamente nos primeiros meses de vida

To evaluate the attitude, the practice and the knowledge of pediatricians regarding the management of the infant who cries excessively in the first months of life. METHODS: Descriptive cross-sectional study that enrolled pediatricians (n=132) randomly interviewed at a Pediatric meeting in Brazil, in August 2012. The data were collected by a self-administered standardized form after reading the hypothetical case of an infant who cried excessively. RESULTS: The majority of the participants were females, the mean age was 39 years and the average mean time working in the specialty was 14 years; 52.2% were Board Certified by the Brazilian Society of Pediatrics. The diagnosis most often considered was gastroesophageal reflux disease (62.9%), followed by infant colic (23.5%) and cow's milk allergy (6.8%). The diagnostic test most frequently mentioned was 24-hour esophageal pH-monitoring (21.9%). The medications most frequently indicated were domperidone (30.3%), the combination of domperidone with ranitidine (12.1%) and paracetamol (6%). CONCLUSIONS: In the approach of the infant who cries excessively, diagnostic tests are frequently requested and unnecessary medical treatment is usually recommended...

Evaluar la actitud, la práctica y el conocimiento de pediatras sobre el manejo del lactante que llora excesivamente durante los primeros meses de vida. MÉTODOS: Estudio transversal descriptivo, del que participaron pediatras (n=132), entrevistados aleatoriamente en evento destinado a la especialidad en agosto de 2012. Se recogieron los datos en una ficha estandarizada y autoadministrada después de la lectura del caso hipotético de un lactante que lloraba excesivamente. RESULTADOS: Se observó mayor proporción de pediatras del sexo femenino, promedio de edad de 39 años y tiempo de formación profesional mediano de 14 años, siendo que el 52,2% eran portadores del título de especialista por la Sociedad Brasileña de Pediatría. La hipótesis diagnóstica más frecuentemente considerada fue enfermedad del reflujo gastroesofágico (62,9%), seguida por cólicos del lactante (23,5%) y alergia a la proteína de la leche vacuna (6,8%). El examen complementar más frecuentemente indicado fue la pH-metría esofagiana de 24 horas (21,9%). Los medicamentos indicados con mayor frecuencia fueron domperidona en 30,3%, combinación de domperidona con ranitidina (12,1%) y paracetamol (6%). CONCLUSIONES: En el abordaje del tratamiento del lactante que llora excesivamente, se solicitan frecuentemente exámenes complementarios y se prescriben medicamentos innecesarios...

Avaliar a atitude, a prática e o conhecimento de pediatras sobre o manejo do lactente que chora excessivamente nos primeiros meses de vida. MÉTODOS: Estudo transversal descritivo, do qual participaram pediatras (n=132), entrevistados aleatoriamente em evento destinado a especialidade em agosto de 2012. Coletaram-se os dados em uma ficha padronizada e autoadministrada após a leitura do caso hipotético de um lactente que chorava excessivamente. RESULTADOS: Observou-se maior proporção de pediatras do sexo feminino, média de idade de 39 anos e tempo de formação profissional médio de 14 anos, sendo que 52,2% eram portadores do título de especialista pela Sociedade Brasileira de Pediatra. A hipótese diagnóstica mais frequentemente considerada foi doença do refluxo gastroesofágico (62,9%), seguida por cólica do lactente (23,5%) e alergia à proteína do leite de vaca (6,8%). O exame complementar mais frequentemente indicado foi a pH-metria esofagiana de 24 horas (21,9%). As medicações indicadas com maior frequência foram domperidona em 30,3%, combinação de domperidona com ranitidina (12,1%) e paracetamol (6%). CONCLUSÕES: Na abordagem do lactente que chora excessivamente, solicitam-se frequentemente exames complementares e prescrevem-se medicamentos desnecessários...

Gastroesophageal reflux disease: exaggerations, evidence and clinical practice / Doença do refluxo gastroesofágico: exageros, evidências e a prática clínica

OBJECTIVE: there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. DATA SOURCE: a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. DATA SYNTHESIS: abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. CONCLUSIONS: there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected. .

OBJETIVO: há muitas dúvidas e poucas evidências para o diagnóstico e tratamento da doença do refluxo gastroesofágico (DRGE) na criança. A relação entre a DRGE e a alergia às proteínas do leite de vaca (APLV), o uso exagerado da ultrassonografia abdominal para diagnóstico da DRGE e o excesso de medicamentos, especialmente dos inibidores de bomba de prótons (IBP), são alguns aspectos que necessitam esclarecimentos. Esta revisão tem como objetivo estabelecer as evidências científicas atuais para o diagnóstico e tratamento da DRGE em pediatria. FONTES DOS DADOS: foram pesquisadas nas bases de dados eletrônicos do Medline, Pubmed, Lilacs, Cochrane Library e Scielo, nas diferentes faixas etárias da pediatria, até maio de 2013, as seguintes palavras-chave: refluxo gastroesofágico, doença do refluxo gastroesofágico, inibidores da bomba de prótons e procinéticos. SíNTESE DOS DADOS: a ultrassonografia de abdome não deve ser recomendada para pesquisa de refluxo gastroesofágico (RGE). O tratamento simultâneo da DRGE e da APLV induz, muitas vezes, ao uso desnecessário de medicação ou dieta de exclusão. Não existem evidências suficientes para prescrição de procinéticos em todos os portadores de RGE/DRGE. Poucas evidências fornecem suporte para a supressão ácida, no primeiro ano de vida, para tratamento de sintomas inespecíficos, sugestivos de DRGE. O tratamento conservador traz muitos benefícios e poucos gastos, sem efeitos colaterais. CONCLUSÕES: existem poucos estudos controlados e randomizados que avaliam a DRGE na criança e nenhum exame pode considerado padrão-ouro para o seu diagnóstico. Por esses motivos, ocorrem exageros no diagnóstico e no tratamento dessa doença, e que necessitam ...

Gastroesophageal reflux disease: exaggerations, evidence and clinical practice.

OBJECTIVE: there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. DATA SOURCE: a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. DATA SYNTHESIS: abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. CONCLUSIONS: there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected.

Dificuldades alimentares na infância: revisão da literatura com foco nas repercussões à saúde / Feeding difficulties in infancy: review of the literature focusing on the impact

O presente trabalho foi conduzido com a finalidade de revisar os conhecimentos científicos atuais sobre as dificuldades alimentares na infância, focalizando especialmente os estudos que avaliaram suas consequências à saúde.

Open challenge for the diagnosis of cow's milk protein allergy.

OBJECTIVE: To report the results of open challenge tests performed in children fed with cow's milk-free diet. DESCRIPTION: Cross-sectional study evaluating cow's milk open challenge performed under supervision in a hospital setting during 2.5 hours and ambulatory follow-up for 30 days when no immediate reaction occurred. One hundred and twenty-one patients were included, with ages between 4 and 95 months. Cow's milk open challenge tests were positive in 28 patients (23.1%). A clinical manifestation of cow's milk allergy different from the one presented at diagnosis occurred in 12 (24.9%) patients with positive challenge. Positive challenge was more frequent (p = 0.042) in patients fed with extensively hydrolyzed formulae or amino acid-based formulae (30.3%) when compared to those fed with other exclusion diets (14.5%). CONCLUSION: Open challenge allowed the interruption of exclusion diet in a significant proportion of the patients.

Teste de desencadeamento aberto no diagnóstico de alergia à proteína do leite de vaca / Open challenge for the diagnosis of cow's milk protein allergy

OBJETIVO: Relatar os resultados de testes de desencadeamento aplicados em crianças alimentadas com dieta de exclusão das proteínas do leite de vaca. DESCRIÇÃO: Estudo transversal que avaliou testes de desencadeamento oral aberto, com leite de vaca, realizados sob supervisão em ambiente hospitalar por 2,5 horas e ambulatoriamente por 30 dias quando não ocorreu reação imediata. Foram incluídos 121 pacientes, com idades entre 4 e 95 meses. O teste de desencadeamento com leite de vaca foi positivo em 28 (23,1 por cento) pacientes. Manifestação clínica de alergia ao leite de vaca diferente da apresentada por ocasião da suspeita diagnóstica ocorreu em 12 (42,9 por cento) pacientes com desencadeamento positivo. O desencadeamento positivo foi mais frequente (p = 0,042) nos pacientes alimentados com fórmulas extensamente hidrolisadas ou de aminoácidos (30,3 por cento) quando comparados com os alimentados com outras dietas de exclusão (14,5 por cento). CONCLUSÃO: O teste de desencadeamento permitiu que fosse suspensa a dieta de exclusão de grande parte dos pacientes.

OBJECTIVES: To report the results of open challenge tests performed in children fed with cow's milk-free diet. DESCRIPTIONS: Cross-sectional study evaluating cow's milk open challenge performed under supervision in a hospital setting during 2.5 hours and ambulatory follow-up for 30 days when no immediate reaction occurred. One hundred and twenty-one patients were included, with ages between 4 and 95 months. Cow's milk open challenge tests were positive in 28 patients (23.1 percent). A clinical manifestation of cow's milk allergy different from the one presented at diagnosis occurred in 12 (24.9 percent) patients with positive challenge. Positive challenge was more frequent (p = 0.042) in patients fed with extensively hydrolyzed formulae or amino acid-based formulae (30.3 percent) when compared to those fed with other exclusion diets (14.5 percent). CONCLUSION: Open challenge allowed the interruption of exclusion diet in a significant proportion of the patients.