Title: To GERD or not to GERD, this is the question
Abstract: To the Editor: The report by Orenstein et al on the use of lansoprazole in infants with signs of gastroesophageal reflux disease (GERD), according to Infant-GastroEsophageal Reflux Questionnaire Infant GastroEsophageal Reflux Questionnaire (I-GERQ) score, not only indicates proton pump inhibitors (PPI) inefficacy in these cases, but also elicits the question whether this score is valid.1Orenstein S.R. Hassall E. Furmaga-Jablonska W. Atkinson S. Raanan M. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease.J Pediatr. 2009; 154: 514-520Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar If we agree that this score is valid, we should simply conclude that we must try another anti-reflux treatment (ie, surgical treatment or a still undiscovered PPI) and focus the diagnosis, looking for both acid and non-acid reflux through impedance studies in all patients with suspected GERD before treatment.2Loots C.M. Benninga M.A. Davidson G.P. Omari T.I. Addition of pH-impedance monitoring to standard pH monitoring increases the yeld of symptom association analysis in infants and children with gastroesophageal reflux.J Pediatr. 2009; 154: 248-252Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar However, it has been shown that <10% of the symptoms listed in I-GERQ score (crying, regurgitation, feeding refusal, back arching, wheezing, coughing, hoarseness) are truly related to episodes of GER when detected with combined pH monitoring and impedance measurement.3Condino A.A. Sondheimer J. Pan Z. Gralla J. Perry D. O'Connor J.A. Evaluation of infantile acid and nonacid gastroesophageal reflux using combined pH monitoring and impedance measurement.J Pediatr Gastroenterol Nutr. 2006; 42: 16-21Crossref PubMed Scopus (96) Google Scholar It has been suggested that these symptoms, part of the physiological behaviors of infants more than GERD, are often misinterpreted as pathological events because of a “misalignment” between culture of the mother and of the pediatrician and the biological events.4Douglas P.S. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture.Med Hypotheses. 2005; 64: 887-898Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Pediatricians who deal with “unquiet babies” are more prone to start with anti-reflux therapy and elimination diets without any evidence of GERD or allergy, respectively, rather than to educate parents on how to cope with infant crying as a part of anticipatory guidance. In our experience, this unjustified and ineffective approach may confuse the family, leading at the end to food refusal in the baby, with an impact on growth.5Ventura A. Marchetti F. Cannioto Z. Barbi E. Martelossi S. Feeding difficulties in infants: how much a iatrogenic condition?.Arch Dis Child. 2008; ([eLetter]) (Available at:) (Accessed July 7, 2009)http://adc.bmj.com/cgi/eletters/adc.2006.108829v1Google Scholar The work by Orenstein et al is an essential step: apart from taking cognizance of PPI inefficacy in “unquiet babies,” it urges us to reconsider the validity of I-GERQ score in the diagnosis of GERD. ReplyThe Journal of PediatricsVol. 155Issue 4PreviewTo the Editor: Full-Text PDF