Published online August 1, 2005
PEDIATRICS
Vol. 116
No. 2
August 2005, pp.
513
(doi:10.1542/peds.2005-0859)
Misconceptions Concerning Gastroesophageal Reflux in Children
George S. Bisset, III, MD
Donald R. Frush, MD
Division of Pediatric Radiology
Department of Radiology
Duke University Medical Center
Durham, NC 27710
To the Editor.—
After reading the
article "Yield of Diagnostic Testing in Infants Who Have Had an
Apparent Life-Threatening Event" by Brand et
al,1
we were dismayed because of the perpetuation of a myth by well-meaning
but misinformed pediatricians. The authors state that a subset of tests
that led to the identification of all occult causes of an apparent
life-threatening event would include screening for gastroesophageal
reflux (GER). To this point we agree. However, their basis for this
statement comes from the evaluation of 68 children who had upper
gastrointestinal (UGI) series; 36 of the 37 children in whom findings
contributed to the final diagnosis of an apparent life-threatening
event had GER.
On a daily basis we are deluged with requests in
our radiology department to perform UGIs to "rule out
GER." In fact, the purpose of the UGI is usually to exclude
upper intestinal obstruction. The finding of GER is happenstance.
Cleveland et
al2
and Seibert et
al3
demonstrated that GER is present in a large percentage of pediatric
patients who are studied for any reason and in many children whose
symptoms would not suggest its presence. If we assume (based on prior
studies) that the sensitivity for the UGI is 85% and the
specificity is 25%, then the predictive value of the positive
result is 
54%, and the predictive value of the negative
result is
65%.2–4
As Leonidas astutely pointed out, "we may as well toss a
coin."4
If we examine the UGI series more closely, we can explain the poor
predictive values. The infant is placed in a recumbent position
(gastroesophageal junction is "under water"), is
frequently strapped to an immobilization device, and is sometimes
irritable (which may increase gastric pressure). The infant is then
administered a dense liquid barium, usually by mouth but sometimes
through a nasogastric tube (if they are uncooperative), and then turned
into a variety of unphysiologic positions to demonstrate anatomy. The
experience does not simulate the daily feeding experience. Moreover,
the technique for performing and interpreting the examination is
variable (eg, retained contrast in the esophagus from swallowing may be
mistaken for GER). One must also bear in mind that up to two thirds of
normal infants (<4 months old) regurgitate daily, and this
finding may be of little
significance.5
One might conclude from Fig 1B of the article that the UGI ranked highest
in contributing to establishing the diagnosis in patients with a
noncontributory history. We would look at this figure with great
skepticism. As advocates for children we must be cognizant of risks
with any radiographic study that makes use of ionizing radiation. The
UGI potentially represents a relatively high (when compared to chest
radiography) radiation exposure, particularly to vital organs like
breast, liver, and bone marrow. The most effective way to reduce
exposure in the population is to not do unnecessary
examinations.
Although the UGI is not ideal for identification of
GER, gastroesophageal scintigraphy using Tc99m sulfur colloid and the
24-hour pH probe are excellent tests. It is beyond the scope of this
letter to discuss advantages and disadvantages of both tests, but
suffice it to say that if one is considering a screening test for GER,
the UGI is not an appropriate
procedure.
REFERENCES
- Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event.
Pediatrics. 2005;115
:885
–893[Abstract/Free Full Text]
- Cleveland RH, Kushner DC, Schwartz AN. Gastroesophageal reflux in children: Results of a standardized fluoroscopic approach.
AJR Am J Roentgenol. 1983;141
:53
–56[Abstract/Free Full Text]
- Seibert JJ, Byrne WJ, Euler AR, Latture T, Leach M, Campbell M. Gastroesophageal reflux—the acid test: scintigraphy or the pH probe.
AJR Am J Roentgenol. 1983;140
:1087
–1090[Abstract/Free Full Text]
- Leonidas JC. Gastroesophageal reflux in infants: role of the upper gastrointestinal series.
AJR Am J Roentgenol. 1984;143
:1350
–1351[Free Full Text]
- Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux in infancy. A pediatric practice-based survey.
Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997;151
:569
–572
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
