Exenatide corrects postprandial hyperglycaemia in young people with cystic fibrosis and impaired glucose tolerance: A randomized crossover trial.

Impaired glucose tolerance (IGT) in cystic fibrosis (CF) manifests as postprandial hyperglycaemia. Pancreatic enzyme supplementation reduces the latter; restoring incretin secretion and slowing gastric emptying. We aimed to determine the acute effect of exenatide on postprandial glycaemia in young people with CF and IGT. Six participants with CF and IGT were studied on 2 days, in a double-blind randomized crossover trial. After overnight fasting, they received exenatide 2.5 mcg or placebo (0.9% saline) subcutaneously 15 minutes before a pancake meal labelled with 13 C octanoate and pancreatic enzyme replacement. The primary outcomes, area under the curve over 240 minutes (AUC 240 ) for blood glucose (P < 0.0001) and peak blood glucose (7.65 mM ± 0.34 [mean ± SE] vs 9.53 mM ± 0.63, P < 0.0001), were markedly lower after exenatide than placebo. AUC240 for insulin, C-peptide, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) was also lower after exenatide. Gastric emptying was markedly slower after exenatide, as assessed by time for 10% gastric emptying and peak 13 CO2 excretion. We report for the first time that exenatide corrects postprandial hyperglycaemia in young people with CF and IGT. GLP-1 agonists are a candidate treatment in CF-related diabetes.

Cognition, temperament, and cerebral blood flow velocity in toddlers and preschool children with sleep-disordered breathing or behavioral insomnia of childhood.

BACKGROUND: Cognitive decrements, problematic behaviors, and increased cerebral blood flow velocities (CBFVs) have been reported in children aged 3-7 years with sleep-disordered breathing (SDB). Whether similar impairments exist in younger children or those with behavioral insomnia of childhood (BIC) remains unclear. This study aimed to compare cognition and temperament in children aged 1-5 years with SDB or BIC to healthy control children, and to investigate whether cognitive or behavioral deficits associated with sleep problems are related to changes in CBFV. METHOD: Toddlers and preschool-aged children (12-67 months) who had been referred for the clinical evaluation of SDB (n = 20) or BIC (n = 13) and a comparative sample of non-snoring healthy sleepers (controls; n = 77) were recruited from the community. Children underwent cognitive assessment (Mullen's Scale of Early Learning) and measurement of resting bilateral CBFV in the middle cerebral artery (MCA) using Transcranial Doppler. Parents completed temperament scales (Early Childhood or Childhood Behavior Questionnaire), a sleep problem questionnaire (Pediatric Sleep Problem Survey Instrument) and performed home-based pediatric sleep monitoring (Actigraphy and Sleep Diary). RESULTS: SDB children demonstrated impaired receptive skills, more hyperactive and energetic temperaments, and higher bilateral CBFV than controls and children with BIC. Logistic regression analyses indicated that impaired cognition, temperamental difficulties, and increased CBFV are independently associated with SDB. CONCLUSIONS: During early childhood, problematic temperaments, cognitive deficits, and altered cerebrovascular functioning are associated with SDB but not BIC. CBFV does not appear to mediate these daytime deficits and instead may be an independent outcome of SDB. The findings support the need for an early intervention in pediatric SDB.

Sleep, executive functioning and behaviour in children and adolescents with type 1 diabetes.

OBJECTIVE: The aim of the study was to examine sleep, neurocognitive and behavioural functioning in children and adolescents with type 1 diabetes (T1D) compared to controls and to test whether sleep quality mediates the relationship between diabetes and neurocognitive and behavioural deficits. METHODS: Participants include 49 children and adolescents with T1D (recruited from a hospital clinic) and 36 healthy controls (age range = 6-16 years). Parents completed a survey consisting of the Sleep Disturbances Scale for Children, the Behavior Rating Inventory of Executive Functions, and the Behavior Assessment System for Children-2. Diabetic and demographic parameters were collated from medical records. The survey was posted to participants. RESULTS: Children with T1D compared to controls reported a higher frequency of sleep problems, and mild deficits in executive and behavioural functioning. Mediational analyses revealed that sleep quality fully mediated metacognitive functioning, externalised problematic behaviour, and internalised problematic behaviour, but not behavioural regulation. CONCLUSIONS: Rather than the direct impact of T1D on daytime functioning, it is the consequent impact of T1D on sleep and the resulting sleep disruption which can explain much of the neurocognitive and behavioural deficits reported in children with T1D. Maintaining good nocturnal glycaemic control may play a much larger role than previously thought in regulating daytime functioning in children with T1D.

Pancreatic enzyme supplementation improves the incretin hormone response and attenuates postprandial glycemia in adolescents with cystic fibrosis: a randomized crossover trial.

CONTEXT: Cystic fibrosis-related diabetes is characterized by postprandial, rather than fasting, hyperglycemia. Gastric emptying and the release of the incretin hormones [glucagon-like peptide-1 (GLP-1) and glucose dependent insulinotropic polypeptide (GIP)] are central to postprandial glycemic control. Lipolysis is required for fat to slow gastric emptying and stimulate incretin release. OBJECTIVE: We aimed to determine the effect of pancreatic enzyme replacement therapy (PERT) on postprandial glycemia in adolescents with cystic fibrosis (CF). DESIGN: This was a double-blinded randomized crossover trial. Subjects consumed a high-fat pancake, with either PERT (50 000 IU lipase) or placebo. Gastric emptying was measured by a breath test and blood sampled frequently for plasma blood glucose, insulin, glucagon, GLP-1, and GIP. Data were also compared with seven healthy subjects. PARTICIPANTS: Fourteen adolescents (13.1 ± 2.7 y) with pancreatic-insufficient CF and seven healthy age-matched controls participated in the study. MAIN OUTCOME MEASURE: Postprandial hyperglycemia was measured as peak glucose and area under the curve for blood glucose at 240 minutes. RESULTS: CF subjects had postprandial hyperglycemia compared with controls (area under the curve, P < .0001). PERT reduced postprandial hyperglycemia (P = .0002), slowed gastric emptying (P = .003), and normalized GLP-1 and GIP secretion (P < .001 for each) when compared with placebo, without affecting insulin. CONCLUSION: In young people with pancreatic insufficient CF, PERT markedly attenuates postprandial hyperglycemia by slowing gastric emptying and augmenting incretin hormone secretion.

Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis.

INTRODUCTION: Pediatric sleep-disordered breathing is a continuum, with primary snoring at one end, and complete upper airway obstruction, hypoxemia, and obstructive hypoventilation at the other. The latter gives rise to obstructive sleep apnea. An important predisposing factor in the development and progression of pediatric sleep-disordered breathing might be craniofacial disharmony. The purpose of this systematic review and meta-analysis was to elucidate the association between craniofacial disharmony and pediatric sleep-disordered breathing. METHODS: Citations to potentially relevant published trials were located by searching PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials. The MetaRegister of controlled trials database was also searched to identify potentially relevant unpublished trials. Additionally, hand-searching, Google Scholar searches, and contact with experts in the area were undertaken to identify potentially relevant published and unpublished studies. Inclusion criteria were (1) randomized controlled trials, case-control trials, or cohort studies with controls; (2) studies in nonsyndromic children 0 to 18 years of age with a diagnosis of sleep-disordered breathing or obstructive sleep apnea by either a sleep disorders unit, screening questionnaire, or polysomnography; and (3) principal outcome measures of craniofacial or upper airway dimensions or proportions with various modalities of imaging for the craniofacial and neck regions. The quality of the studies selected was evaluated by assessing their methodologies. Treatment effects were combined by meta-analysis with the random-effects method. RESULTS: Children with obstructive sleep apnea and primary snoring show increased weighted mean differences in the ANB angle of 1.64° (P <0.0001) and 1.54° (P <0.00001), respectively, compared with the controls. An increased ANB angle was primarily due to a decreased SNB angle in children with primary snoring by 1.4° (P = 0.02). Children with obstructive sleep apnea had a distance from the posterior nasal spine to the nearest adenoid tissue measured along the PNS-basion line reduced by 4.17 mm (weighted mean difference) (P <0.00001) and a distance from the posterior nasal spine to the nearest adenoid tissue measured along the line perpendicular to the sella-basion line reduced by 3.12 mm (weighted mean difference) (P <0.0001) compared with the controls. CONCLUSIONS: There is statistical support for an association between craniofacial disharmony and pediatric sleep-disordered breathing. However, an increased ANB angle of less than 2° in children with obstructive sleep apnea and primary snoring, compared with the controls, could be regarded as having marginal clinical significance. Therefore, evidence for a direct causal relationship between craniofacial structure and pediatric sleep-disordered breathing is unsupported by this meta-analysis. There is strong support for reduced upper airway width in children with obstructive sleep apnea. Larger well-controlled trials are required to address the relationship of craniofacial and upper airway morphology to pediatric sleep-disordered breathing in all 3 dimensions.

Cystic fibrosis in Australia, 2009: results from a data registry.

OBJECTIVES: To describe the demographics, clinical features and outcomes among people with cystic fibrosis (CF) in Australia and to estimate incidence of the disease. DESIGN AND SETTING: Cross-sectional analysis using data from the Australian Cystic Fibrosis Data Registry for 2009. MAIN OUTCOME MEASURES: Numbers of diagnoses, pulmonary and anthropometric measurements, microbiological culture results, rates of hospitalisation and transplantation, and numbers of medical complications and deaths. RESULTS: In 2009, data were submitted on 2986 people (48% female). Median age was 17.6 years and 49% of people were aged 18 years or over. Seventy-eight people were newly diagnosed. Fourteen people died and 14 people underwent lung transplantation in the year. Lung function and nutrition were relatively normal among children but deteriorated (more rapidly) among adolescents. With increasing age, progressive respiratory disease was apparent, and the frequency of CF-related complications and use of health care resources increased. In all age groups, there was a wide range in severity of lung disease and nutritional status. CONCLUSIONS: CF remains a progressive respiratory disease and is associated with multisystem complications. The acceleration in disease severity in adolescence and early adulthood suggests that better treatment at these stages is required to further improve survival.

Inconsistent sleep schedules and daytime behavioral difficulties in school-aged children.

OBJECTIVES: Current recommendations for healthy sleep in school-aged children are predominantly focused on optimal sleep duration (9-11h). However, given the importance of routine for circadian health, the stability of sleep/wake schedules may also be important, especially for daytime behavioral functioning. We examined the relationship between short sleep duration, sleep schedule instability and behavioral difficulties in a community sample of Australian children. METHODS: Children, aged 5-10 years (N=1622), without chronic health or psychological conditions, were recruited from primary schools in Adelaide, South Australia. A parent-report questionnaire was used to assess sleep/wake behavior. Behavioral functioning was assessed using the Strengths and Difficulties Questionnaire. RESULTS: Most children met sleep duration recommendations with approximately 5% reporting <9h and 3% >12h. Weekly variability of bed and rise times >1h were reported in up to 50% of children. Multinomial regression analysis revealed sleep duration <10h, bedtime latency >60 min, and bed and rise time variability >60 min significantly increased the risk of scoring in the 95th percentile for behavioral sub-scales. CONCLUSIONS: Inconsistent sleep schedules were common and, similar to short sleep duration, were associated with behavioral difficulties. Considering the lack of study in this area, further research is needed for the development of new recommendations, education and sleep health messages.

Differences in parental attitudes towards sleep and associations with sleep-wake patterns in Caucasian and Southeast Asian school-aged children in Australia.

Caucasian (N = 47) and Southeast (SE) Asian (N = 36) families completed a questionnaire on their attitudes toward sleep, as well as a 7-day sleep diary for their children aged 5 to 11 years. Cultural differences were found in the perceived importance of sleep, particularly compared to homework and belief of how much sleep a child needs. Differences were also found in sleep-wake behaviors and amount of time spent on homework, with SE Asian children reporting a shift in sleep timing and increased homework load compared to Caucasian counterparts. Parental attitudes toward sleep, perception of sleep need, and homework load were not associated with the regulation of actual sleep behaviors in children, regardless of cultural heritage.

Eczema, sleep, and behavior in children.

INTRODUCTION: There is a general consensus that sleep disruption in children causes daytime behavioral deficits. It is unclear if sleep disruption in children with eczema has similar effects particularly after controlling for known comorbid disorders such as asthma and rhinitis. METHODS: Parents of children (6-16 y) with eczema (n = 77) and healthy controls (n = 30) completed a validated omnibus questionnaire which included the Sleep Disturbance Scale for Children, Conners Parent Rating Scale-Revised (S), Child Health Questionnaire, Children's Dermatology Life Quality Index, and additional items assessing eczema, asthma, rhinitis, and demographics. RESULTS: Compared to controls, children with eczema had a greater number of sleep problems with a greater percentage in the clinical range, lower quality of life, and higher levels of ADHD and oppositional behavior. They also had elevated rhinitis and asthma severity scores. Importantly, structural equation modelling revealed that the effect of eczema on the behavioral variables of Hyperactivity, ADHD Index, and Oppositional Behaviors were mediated through sleep with no direct effect of eczema on these behaviors. The comorbid atopic disorders of rhinitis and asthma also had independent effects on behavior mediated through their effects on sleep. CONCLUSIONS: The present findings suggest that the daytime behaviors seen in children with eczema are mediated independently by the effects of eczema, asthma, and rhinitis on sleep quality. These findings highlight the importance of sleep in eczematous children and its role in regulating daytime behavior.

Chronic respiratory failure and neuromuscular disease.

The outlook for children with respiratory complications of neuromuscular disease has improved significantly in the past 15 years. This has been the result of many advances in clinical care, including improved monitoring of lung function and hypoventilation during sleep; coordinated respiratory care by experienced physicians with access to specialized respiratory services, especially physiotherapy; and, most importantly, the widespread introduction of noninvasive ventilation.

Differences in the association between obesity and obstructive sleep apnea among children and adolescents.

STUDY OBJECTIVES: Overweight and obesity are thought to increase the risk of obstructive sleep apnea syndrome (OSAS) among children. However, previous results have been inconsistent and appear to be confounded by both ethnicity and the different ages of children studied. To determine whether the association between excess weight and OSAS varies with age across childhood, we assessed polysomnographic data from a series of Caucasian children and adolescents referred for clinical evaluation of snoring. METHODS: Sleep and OSAS severity were assessed using polysomnography in 234 children aged 2.0 to 18.0 years. All children were referred for overnight evaluation of suspected OSAS. Severity of OSAS as a function of body mass and age were then evaluated. RESULTS: Risk of OSAS among adolescents (age > or =12 years) was increased 3.5 fold with each standard-deviation increase in body mass index z-score. Risk of OSAS was not significantly increased with increasing body mass among younger children. CONCLUSIONS: Similar to adults, adolescent children show an increased risk for having OSAS in association with overweight and obesity. For Caucasian children, overweight and obesity should be considered a significant risk for OSAS among adolescents or from age 12 years, especially when in combination with other established risk factors, including snoring and adenotonsillar hypertrophy.

Safety of bronchoalveolar lavage in young children with cystic fibrosis.

OBJECTIVE: Our aim was to determine the safety of BAL in young children <6 years with CF. METHODS: As part of a multi-center study of BAL-directed therapy, children with CF < 6 years had one or more BALs between September 1999 and December 2005. Adverse events were recorded intraoperatively and for 24 hr thereafter. Clinical characteristics before BAL, findings at bronchoscopy and BAL results were assessed as risk factors for adverse events. RESULTS: 333 BALs were conducted in 107 (56 males) children, median age 23.5 (range 1.6-67.5) months, including 170 (51%) for pulmonary exacerbation. 29 BALs (8.7%) were followed by fever >or=38.5 degrees C and 10 (3%) had clinically significant episodes (five intraoperative hemoglobin desaturations to <90% requiring intervention, one tachyarrhythmia, two needing post-operative supplemental oxygen, one hospitalization for stridor). Two contaminated bronchoscopes were detected. 180 minor adverse events were recorded in 174 (52%) BAL procedures (137 altered cough, 41 fever <38.5 degrees C). Low percentage BAL return (P = 0.002) and focal bronchitis (P = 0.02) were associated with clinically significant deterioration. Multivariable analysis identified Streptococcus pneumoniae (OR 22.3; 95% confidence interval (CI); 6.9,72), Pseudomonas aeruginosa (OR 2.4; 95% CI 1.0, 5.8), respiratory signs (OR 5.0; 95% CI 1.7, 14.6) and focal bronchitis (OR 5.9; 95% CI 1.2, 29.8) as independent risk factors for post-bronchoscopy fever >or=38.5 degrees C. CONCLUSIONS: Adverse events are common with BAL in young CF children, but are usually transient and well tolerated. Parents should be counseled that signs of a pre-existing lower respiratory infection are associated with increased risk of post-BAL fever.

Mental, emotional, and social problems among school children with asthma.

OBJECTIVES: To use representative population chronic disease and risk factor data to investigate the relationship between asthma and social factors in school-age children. METHODS: Representative cross-sectional data for children 5 to 15 years of age were collected from 2002 to June 2007 (n = 4,611) in the South Australian Monitoring and Surveillance System (SAMSS) using Computer-Assisted Telephone Interviews (CATI). Univariate and multivariate analyses were conducted to investigate the variables that were associated with asthma among children. RESULTS: The overall prevalence of self-reported asthma among children 5 to 15 years of age was 18.6% (95% CI = 17.5-19.8). Children with asthma were more likely to have been treated for a mental health problem, have been unhappy at school, have been absent from school in the last month, have fair or poor overall health and well-being, have ongoing pain or chronic illness, and less likely to have a group of friends to play with. Asthma was also more prevalent among males and less likely to occur in children from households where the gross annual income was greater than $AU80,000. CONCLUSIONS: Children with asthma were more likely to be treated for a mental health problem and demonstrate more negative social outcomes as well as poorer overall health and well-being. Asthma management plans need to be sensitive to these psychosocial factors for adequate care of these vulnerable young patients.

Treatment burden and health-related quality of life of children with diabetes, cystic fibrosis and asthma.

AIM: To identify the time required by children with cystic fibrosis (CF), diabetes or asthma to complete daily treatment tasks and the hassle they experienced when completing these tasks. To compare parent and child reports of daily treatment time and hassle. To investigate the relationship between treatment time and hassle, and (i) children's health-related quality of life (HRQL); and (ii) disease severity. METHODS: 160 children aged 10-16 years with CF, type 1 diabetes, or asthma were followed over a 2-year period. Information about children's treatment time and hassle, and their HRQL was obtained from parents and children at baseline, 1-year and 2-year follow-up assessments. RESULTS: On average, children with CF reported spending 74.6 +/- 57.0 min completing treatment tasks, children with diabetes spent 56.9 +/- 27.8 min and children with asthma spent 6.4 +/- 9.3 min. Parents reported that children spent less time that was reported by their children. Over the two years, parent and child reports describing treatment time for children with CF did not vary significantly (P = 0.3). Treatment time for children with diabetes increased (P = 0.02) whereas that for children with asthma reduced (P = 0.001). The level of hassle experienced by children when completing individual treatment tasks was low for all three conditions. There was no significant relationship between treatment time and children's HRQL. CONCLUSION: Children with CF or diabetes spent a substantial amount of time each day completing the treatment tasks. Although this was not related to HRQL, it could impact the ability to comply with complex and all home-based-therapies for some children.

New measure of parental asthma management for school-age children.

A new parent-completed questionnaire to measure parental asthma management was developed. The new questionnaire takes a parental perspective, with content of items and scoring focusing on all behaviors considered important by parents and not just those considered appropriate by clinicians. Parents of 101 school-age children with a previous hospital admission with asthma completed the questionnaire during home visits. The questionnaire was based on five asthma scenarios. Parents were asked to indicate on a 6-point Likert scale how likely they would be to carry out a series of behaviors if the situations occurred. Two methods of scoring were used: scenario-based scoring, and factor-based scoring. Scenario-based subscale scores suggested that parent's level of activity was consistent across different situations. Factor analysis showed that the questionnaire had three dominant factors. The medical assessment subscale describes parent's level of activity in terms of seeking medical care, the external advice subscale describes parent's level of activity in terms of seeking assistance from knowledgeable others, and the home management subscale describes parents' approaches to monitoring and treating children at home. Alpha coefficients for scenario-based and factor-based subscales indicated good internal reliability (0.65-0.84 and 0.81-0.91, respectively). Test-retest reliability, 4 weeks apart, was also adequate (correlation coefficients of 0.75-0.87). This exploratory study describes the development of a new questionnaire, the Asthma Management Questionnaire (AMQ). The questionnaire has a unique parent focus, consistent with contemporary notions of patient-centered chronic-disease management.

Effect of a consultation teaching behaviour modification on sleep performance in infants: a randomised controlled trial.

OBJECTIVE: To evaluate the effect of a behaviour modification program, taught to parents in a single visit to a trained nurse, in improving sleep performance in newborn infants, Australia. DESIGN: Randomised controlled trial. SETTING AND PARTICIPANTS: 268 families with normal newborn infants in the community, recruited between October 1996 and March 1997 from birth notices published in a South Australian daily newspaper. INTERVENTION: A 45-minute consultation with a nurse 2-3 weeks after the birth, including a tutorial discussion on normal sleep patterns in newborn infants, supported by retained written material and, for infants with weight gain < 30 g daily, referral to their usual postnatal care provider. MAIN OUTCOME MEASURES: Hours of daytime sleep (0600-1800), night sleep (1800-0600) and total sleep per 24 h; and number of daily records with total sleep >/= 15 h per 24 h, assessed by 7-day sleep diary at ages 6 and 12 weeks. RESULTS: 268 families returned at least one sleep diary (137/171 intervention, 131/175 control), recording 3273 days. Two intervention infants were referred for low weight gain. Total sleep time was 15 h or more per 24 h on 62% of recorded days in the intervention group, compared with 36% in the control group (P < 0.001). At 6 weeks of age, intervention infants slept a mean 1.3 h per day more than control infants (95% CI, 0.95-1.65), comprising a mean 0.5 h more night sleep (95% CI, 0.32-0.69) and 0.8 h more daytime sleep (95% CI, 0.56-1.07). At 12 weeks, intervention infants slept a mean 1.2 h per day more (95% CI, 0.94-2.14), comprising 0.64 h more night sleep (95% CI, 0.19-0.89) and 0.58 h more daytime sleep (95% CI, 0.39-1.03). There was no significant difference in crying time between the groups. CONCLUSIONS: A single consultation supported by written material in the first 3 weeks of a child's life improves sleep performance at 6 weeks of age. This improvement is maintained at 3 months.

Natural history and familial relationships of infant spilling to 9 years of age.

OBJECTIVES: To determine the natural history of infant spilling (regurgitation/vomiting) during the first 2 years of life and to determine the relationship between infant spilling and gastroesophageal reflux (GER) symptoms at 9 years of age. METHODS: A prospective birth cohort was followed with daily symptom diaries during the first 2 years of life and reviewed at 9 years of age (range: 8-11 years). The prevalence of infant spilling during the first 2 years of life, the prevalence of GER symptoms between 8 and 11 years of age (mean age: 9.7 years), relative risk of infant spilling predisposing to GER symptoms at 9 years of age, and prevalence of maternal GER symptoms and relationship with infant spilling and GER at 9 years of age were measured. RESULTS: A total of 693 children who represented 83% of an original sample of 836 children and were followed for 2 years from birth with daily symptom diaries were contacted at 9 (8-11) years of age. Spilling of most feeds each day was common in infancy and reached a peak prevalence of 41% between 3 and 4 months of age and thereafter declined to < 5% between 13 and 14 months of age. Infants with spilling on 90 days or more during the first 2 years of life (classified as frequent spilling) were more likely to have GER symptoms at 9 years of age. Children with frequent infant spilling, compared with those with no spilling, had a relative risk of 2.3 (95% confidence interval [CI]: 1.3-4.0) of 1 or more GER symptoms at 9 years of age, 4.6 (95% CI: 1.5-13.8) for heartburn, 2.7 (95% CI: 1.4-5.5) for vomiting, and 4.7 (95% CI: 1.6-14.0) for acid regurgitation. Gender, breastfeeding, and environmental tobacco smoke exposure were not significant factors related to infant spilling. Prepregnancy smoking and smoking in the same room as the child at the 9-month and 18-month follow-ups had a significant effect on GER symptoms at 9 years of age. Infant spilling and GER at 9 years of age were significantly related to maternal GER symptoms but not to paternal GER symptoms. CONCLUSIONS: Spilling in infancy is very common, but the majority of children settle by 13 to 14 months of age. However, those with frequent spilling (>90 days) are more likely to have GER symptoms at 9 years of age. In addition, a maternal history of GER was significantly related both to infant spilling and to GER at 9 years, suggesting that a genetic component may be involved. Physicians should consider studying children with a history of frequent infant spilling to determine whether this group is at increased risk for GER disease.