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Philip M. Sherman
Chairperson, Global Definition of GERD Consensus Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA

Consensus Panel
Eric Hassall Ulysses Fagundes-Neto Benjamin j D. Gold Seiichi Kato Sibylle Koletzko S Susan R. R Orenstein O t i Colin Rudolph Nimish Vakil Yvan Vandenplas
University of British Columbia, Vancouver, British Columbia, CANADA Universidade Federal de São Paulo, BRAZIL Emory y University y School of Medicine, Atlanta, GA, USA Tohoku University School of Medicine, Sendai, JAPAN Ludwig Maximillians University, Munich, GERMANY University of Pittsburgh School of Medicine, Medicine Pittsburgh Pittsburgh, PA PA, USA Medical College of Wisconsin, Milwaukee, WI, USA University of Wisconsin School of Medicine and Public Health, Mil k WI, Milwaukee, WI USA Free University of Brussels, Brussels, BELGIUM

Consensus Panel

Salix (SO). Novartis (NV). Altana Alt (EH) (EH). AGI (NV). Meridian (NV). YV). Movetis (SKol. Bristol Myers Squibb (SO). Novartis (NV). Reliant (SO). Shire (NV). Boston Scientific (NV). TAP (BG). Shire (NV). SKol. Takeda (NV). B Braintree i t Labs (SO). Novartis (NV). Malesci (NV). Nestle (YV). SO. McNeil (SO). TAP (BG. Mead Johnson (PS). a significant financial interest as follows Advisory Board Consultant Abbott (EH. SHS (SKol. Santarus (BG) Abbott Abb tt (EH) (EH). YV) Research Support Speakers Bureau Stockholder Other . SKol). Fresenius (SKol). Proctor & Gamble (NV). SKol. Santarus (BG). Wyeth (YV) AstraZeneca (BG. SHS (SKol. NV). YV). W th (BG. CR Yes. YV). NV) Antibe Therapeutics (PS). Institute Rosell (PS). Johnson (SO). AstraZeneca (SKol). INSINConsulting (PS). AstraZeneca (EH. SK. (BG SO) Altana (NV). YV). Orexo (NV) Nestle Nutrition (PS – educational program. NV) Wyeth NV). Numico (YV). Mead.Disclosure No significant financial interest to report UF-N. A AstraZeneca t Z (BG. EH. NV) Axcan A (BG) (BG). NV. PS. TAP (BG. Orexo (NV). Bi Biocodex d (YV) (YV). Medtronics (NV). (BG NV).

The Montreal Definition of GERD in adults was recently developed using a rigorous process and aimed to simplify disease management by providing a universally accepted understanding d t di of f the th disease. di There is a need for clarity about GERD in infants. Am J Gastroenterol 2006. adolescents • Vakil N et al. children.Background • • Research and clinical practice in gastroesophageal reflux disease (GERD) have traditionally been hampered by inconsistent definitions of the disease. and adolescents.101:1900–20 .

Am J Gastroenterol 2006.Montreal Definition of GERD Vakil N et al.101:1900–20 .

www.is. 2002.Delphi Technique • A modified Delphi technique was used to develop a set of statements regarding the definition of GERD in pediatric patients.njit.edu/pubs/delphibook/ . Lindstone et al.

104:1278-95 . Sherman et al.Consensus Group Selection • • The group was led by a non-voting Chair The chair selected eight expert consensus group members based on their • • • relevant p peer-reviewed p publications research activities in the field. Am J Gastroenterol 2009. and participation in national or regional activities related to GERD in pediatric patients.

a family physician. pulmonologist. Sherman et al. b A general pediatrician. joined the pediatric consensus group as a non-voting ti member. but did not vote.Consensus Group Selection • • An adult gastroenterologist who chaired the Montreal Definition working group. four neonatologists a pediatric pulmonologist neonatologists. Am J Gastroenterol 2009. a pediatric otolaryngologist and a pediatric general surgeon also commented on statements.104:1278-95 .

Grades of Evidence • The strength of evidence for each statement was evaluated using the GRADE system. BMJ 2004.Systematic Literature Searches & Grades of Evidence S Systematic i Literature Li Searches S h • Relevant English-language studies in humans published b t between 1 January J 1980 and d 31 J July l 2007 were id identified tifi d via i systematic searches of Medline.328:1490–4 . Grade Working Group. EMBASE and CINAHL.

104:1278-95 . e mail Between each round of voting. Chair based on feedback from the group and outside experts.Voting • • • Four rounds of anonymous voting: two during two face-toface workshops and two via e-mail. A or A–) by ≥ 75% of the voting group members was defined a priori as consensus. consensus Sherman et al. statements were revised by the Chair. ( ). Agree with major reservations (A–) Disagree g with major j reservations ( (D–). ). Agree with minor reservations (A). Disagree g with minor reservations (D). Am J Gastroenterol 2009. The consensus group voted using a 6 6-point point scale: • • Agree strongly (A+). Disagree strongly (D+) • Agreement with a statement (A+.

Am J Gastroenterol 2009. which took place at the first workshop. Before the second vote.104:1278-95 . 117 Sherman et al. plus 12 additional pediatric-specific statements proposed by the Chair.Voting • For the first (electronic) vote 62 statements were presented: • • • • 43 statements t t t f from th the M Montreal t l Definition D fi iti 7 Montreal Definition statements revised by the Chair. many of the statements were separated for each of three age groups • • • • newborns and infants [0–12 months] toddlers and children [1–10 years] adolescents [11–17 years]) At this point in the process the number of statements increased to 117.

Am J Gastroenterol 2009. a ). 7 revised Montreal Definition statements. 28 new statements Sherman et al. 12 new statements Number of statements Proportion of statements with consensus Vote 1 (e-mail). 29 revised Montreal Definition statements. Nov o 2007 00 Vote 4 (2nd workshop).Voting 43 Montreal Definition statements. Dec 2007 62 117 86 59 76% 67% 66% 98% 2 Montreal Definition statements. Sept 2007 Vote ote 3 (e (e-mail). July 2007 Vote 2 (1st workshop).104:1278-95 .

Am J Gastroenterol 2009.Voting Level of Agreement A+ A ADD D+ Agree strongly Agree moderately Just agree Just disagree Di Disagree moderately d t l Disagree Strongly Agreement (% of Statements) 40 40 16 2 1 1 Sherman et al.104:1278-95 .

The Global Definition .

Am J Gastroenterol 2009. or older without cognitive ability to reliably report symptoms Symptomatic syndromes Older child or adolescent with cognitive ability to reliably report symptoms Syndromes with esophageal injury Extraesophageal Definite associations i ti Possible associations i ti • Sandifer’s syndrome • Dental erosion Bronchopulmonary • Asthma • Pulmonary fibrosis • Bronchopulmonary y dysplasia Laryngotracheal and pharyngeal • Chronic cough • Chronic laryngitis • Hoarseness • Pharyngitis Rhinological and otological • Sinusitis • Serous otitis media Infants • Pathological apnea • Bradycardia • Apparent lifethreatening events Excessive regurgitation Feeding refusal/anorexia Unexplained crying Ch ki / Choking/gagging/ i / coughing • Sleep disturbance • Abdominal pain • • • • • Typical reflux syndrome • • • • Reflux esophagitis Reflux stricture Barrett’s esophagus Ad Adenocarcinoma i *Where other causes have been ruled out (e. food allergy.g.GERD in p pediatric p patients is p present when reflux of g gastric contents is the cause of troublesome symptoms and/or complications Esophageal Symptoms purported to be due to GERD GERD* Infant or younger child (0–8 years). especially in infants) Sherman et al.104:1278-95 .

87. ¬Agreement 100% ¬A+. 12.104:1278-95 . Am J Gastroenterol 2009. A.5%. this definition is complicated by unreliable symptom reporting by: • • children younger than 8 years and pediatric patients of any age who have cognitive impairment Sherman et al.Statement #1 GERD in pediatric patients is present when the reflux of gastric content is the cause of troublesome symptoms and / or complications.5% ¬ GRADE: not applicable • However.

Statement #2 Symptoms of GERD vary by age age. ¬Agreement 100% ¬A+. 12.5% ¬ GRADE: high Sherman et al. A-. 87.104:1278-95 . Am J Gastroenterol 2009.5%.

12. A-. A. 75%. ¬Agreement 100% ¬A+.5% ¬ Grade: not applicable Sherman et al.104:1278-95 . Am J Gastroenterol 2009.5%.Statement #3 Symptoms due to gastroesophageal reflux (GER) are troublesome when they have an adverse effect on the wellwell-being of the pediatric patient. 12.

Statement #4 Otherwise healthy newborns (age 1– 1–30 days) and infants (age > 30 days – < 1 year) with reflux fl symptoms t th t are not that t troublesome t bl and d are without complications should not be diagnosed with GERD. A-. 12. 12.5% A+. Am J Gastroenterol 2009. D-.5% ¬ Grade: not applicable Sherman et al.5%. ¬ Agreement 87.5%. 62. 12.104:1278-95 .5%. A.

5%. 12. A.5% ¬ GRADE: not applicable Sherman et al. ¬Agreement 75% ¬A+. 37. Am J Gastroenterol 2009. 37.5%. 12.104:1278-95 .5%. D. D-.Statement #5 Reflux symptoms that are not troublesome in toddlers and children (age 1– 1–10) should not be diagnosed as GERD.

12.5% ¬ GRADE: not applicable Sherman et al. 37. Am J Gastroenterol 2009.5%. A.104:1278-95 .Statement #6 Reflux symptoms that are not troublesome in adolescents (age 11 11– –17) should not be diagnosed as GERD. 50%. ¬Agreement 87. D-.5% ¬A+.

5%. 87.104:1278-95 . A.Statement #7 Regurgitation in pediatrics is defined as the passage of refluxed contents into the pharynx. 12. Am J Gastroenterol 2009. pharynx mouth or from the mouth.5% ¬ GRADE: not applicable Sherman et al. ¬Agreement 100% ¬A+.

Statement #8
Bilious vomiting g should not be diagnosed g as GERD. ¬Agreement 100%
¬A+, 75%; A, 12.5%; A-, 12.5% ¬ GRADE: high

Sherman et al. Am J Gastroenterol 2009;104:1278-95

Statement #9
Regurgitation is a characteristic symptom of reflux in infants, , but is neither necessary y nor sufficient for a diagnosis of GERD, because it is not sensitive or specific. ¬Agreement 100%
¬A+, 62.5%; A, 37.5% ¬ GRADE: high

Sherman et al. Am J Gastroenterol 2009;104:1278-95

Statement #10
Symptoms of GERD, particularly in infants, may be indistinguishable from those of food allergy. ¬Agreement 100%
¬A+, 62.5%; A, 25%; A-, 12.5% ¬ GRADE: high

Sherman et al. Am J Gastroenterol 2009;104:1278-95

Statement #11
In clinical practice, adolescents are generally able to describe specific p GERD symptoms y p and to determine if those symptoms are troublesome. ¬Agreement 100%
¬A+, 62.5%; A, 37.5% ¬ GRADE: low

Sherman et al. Am J Gastroenterol 2009;104:1278-95

75%.Statement #12 Pediatric populationpopulation-based studies of reflux symptoms are insufficient and are a priority for further research. ¬Agreement 100% ¬A+. 25% ¬ GRADE: not applicable Sherman et al. A. Am J Gastroenterol 2009.104:1278-95 .

25% ¬ GRADE: high Sherman et al.Statement #13 The pediatric patient with central nervous system impairment has an increased risk of GERD. ¬ Agreement 100% ¬A+.104:1278-95 . A-. A. 62. Am J Gastroenterol 2009.5%.5%. 12.

5%. Am J Gastroenterol 2009.Statement #14 Esophageal atresia is associated with an increased risk of GERD.5% ¬ GRADE: high Sherman et al. ¬ Agreement A t 100% ¬A+. 75%. 12. 12.104:1278-95 . A-. A.

5%. 12. A-. ¬ Agreement A t 100% ¬A+. 12.Statement #15 Cystic fibrosis is associated with an increased risk of GERD.5% ¬ GRADE: high Sherman et al. 75%. Am J Gastroenterol 2009.104:1278-95 . A.

Symptomatic Syndromes & y p Purported p to be due to GERD Symptoms .

GERD in p pediatric p patients is p present when reflux of g gastric contents is the cause of troublesome symptoms and/or complications Esophageal Symptoms purported to be due to GERD GERD* Infant or younger child (0–8 years). Am J Gastroenterol 2009. food allergy. especially in infants) Sherman et al.g. or older without cognitive ability to reliably report symptoms Symptomatic syndromes Older child or adolescent with cognitive ability to reliably report symptoms Syndromes with esophageal injury Extraesophageal Definite associations i ti Possible associations i ti • Sandifer’s syndrome • Dental erosion Bronchopulmonary • Asthma • Pulmonary fibrosis • Bronchopulmonary y dysplasia Laryngotracheal and pharyngeal • Chronic cough • Chronic laryngitis • Hoarseness • Pharyngitis Rhinological and otological • Sinusitis • Serous otitis media Infants • Pathological apnea • Bradycardia • Apparent lifethreatening events Excessive regurgitation Feeding refusal/anorexia Unexplained crying Ch ki / Choking/gagging/ i / coughing • Sleep disturbance • Abdominal pain • • • • • Typical reflux syndrome • • • • Reflux esophagitis Reflux stricture Barrett’s esophagus Ad Adenocarcinoma i *Where other causes have been ruled out (e.104:1278-95 .

A-.Statement #16 Heartburn in older children is defined as a burning sensation in the retrosternal area.104:1278-95 .5% ¬ GRADE: not applicable Sherman et al. 12. ¬Agreement 100% ¬A+. 37. A. 50%.5%. Am J Gastroenterol 2009.

5%. Am J Gastroenterol 2009.Statement #17 Heartburn in adolescents is defined as a burning sensation in the retrosternal area.104:1278-95 . ¬Agreement 100% ¬A+.5% ¬ GRADE: not applicable Sherman et al. 87. A. 12.

Typical Reflux Syndrome .

food allergy) Sherman et al. or older without cognitive ability to reliably report symptoms Symptomatic syndromes Older child or adolescent with cognitive ability to reliably report symptoms Syndromes with esophageal injury Possible associations Bronchopulmonary • Asthma • Pulmonary fibrosis • Bronchopulmonary dysplasia • • • • Reflux esophagitis Reflux stricture Barrett’s oesophagus Adenocarcinoma Laryngotracheal • Chronic cough • Chronic laryngitis • Hoarseness Pharyngeal and oral • Pharyngitis • Dental erosion Rhinological and otological • Sinusitis • Serious otitis media Infants • Pathological apnea • Bradycardia • Apparent life lifethreatening events Sandifer’s syndrome • • • • Excessive regurgitation g refusal/anorexia Feeding Unexplained crying Choking/gagging/ coughing • Sleep disturbance • Abdominal pain • Typical reflux syndrome *Where other causes have been ruled out (e.104:1278-95 .Definition of GERD in Pediatric Patients GERD in pediatric patients is present when the reflux of gastric content is the cause of troublesome symptoms and/or complications Esophageal Extraesophageal Symptoms purported to be due to GERD Infant* or younger child (0–8 years). Am J Gastroenterol 2009.g.

5%.5%.Statement #18 The Typical yp Reflux Syndrome y is characterized by heartburn with or without regurgitation. ¬Agreement 100% ¬A+. A-. A. 25% ¬ GRADE: not applicable Sherman et al. 37.104:1278-95 . 37. Am J Gastroenterol 2009.

with cognitive development sufficient ffi i t to t reliably li bl report t symptoms. A. 37. t are characteristic symptoms of the Typical Reflux y Syndrome. 62. ¬Agreement 100% ¬A+.Statement #19 Heartburn and regurgitation in adolescents and older children. Am J Gastroenterol 2009.5%.104:1278-95 .5% ¬ GRADE: not applicable Sherman et al.

104:1278-95 .5%. ¬Agreement 75% ¬A+. 12. 12.5%. 37. D-.5% ¬ GRADE: not applicable Sherman et al.Statement #20 Typical Reflux Syndrome cannot be diagnosed in infants and children who lack the cognitive ability to reliably report symptoms. A.5%. Am J Gastroenterol 2009. 37. D+.

12. Am J Gastroenterol 2009.5% ¬ GRADE: low Sherman et al.Statement #21 Gastroesophageal reflux in older children and adolescents is the most common cause of heartburn ¬Agreement 87.104:1278-95 . D-.5% ¬A+.5%. 37. 50%. A.

104:1278-95 . A.Statement #22 Heartburn in older children and adolescents can have a number of non non-reflux related causes. 50%. 12. A-.5%.5% ¬ GRADE: high Sherman et al. The prevalence of these is unknown. Am J Gastroenterol 2009. ¬Agreement 100% ¬A+. 37.

¬Agreement 87.5%. D-.5% ¬A+. A-.Statement #23 In neurologically intact adolescents.5%. A. 12.104:1278-95 . 12. without additional diagnostic testing. the Typical yp Reflux Syndrome y can be diagnosed g on the basis of the characteristic symptoms.5%.5% ¬ GRADE: low Sherman et al. 12. 62. Am J Gastroenterol 2009.

A.Statement #24 Non-erosive reflux disease in the pediatric Nonpatient is defined by the presence of troublesome symptoms caused by the reflux of gastric contents and the absence of mucosal py breaks at endoscopy. 12. ¬Agreement 100% ¬A+.5% ¬ GRADE: not applicable Sherman et al.5%. 12. 75%. Am J Gastroenterol 2009. A-.104:1278-95 .

¬Agreement 100% ¬A+. 75%. Am J Gastroenterol 2009. A-.Statement #25 Epigastric pg pain p in older children and adolescents can be a major symptom of GERD.104:1278-95 . 25% ¬ GRADE: moderate Sherman et al.

25%. 37. D+.Statement #26 GERD in newborns and infants may y be associated with sleep disturbances. ¬ Agreement 87 87. 25%.5% 5% ¬A+.5%. 12.104:1278-95 .5% ¬ GRADE: low Sherman et al. A-. A. Am J Gastroenterol 2009.

Am J Gastroenterol 2009. 12.104:1278-95 . 50% ¬ GRADE: very low Sherman et al. 37.5%. A.5%. A-.Statement #27 GERD in toddlers and children may y be associated with sleep disturbances. ¬ Agreement 100% ¬A+.

Am J Gastroenterol 2009.5% ¬ GRADE: very low Sherman et al.Statement #28 GERD in adolescents may y be associated with sleep disturbances. ¬ Agreement 100% ¬A+.104:1278-95 .5%. 62. A-. 37.

75%. ¬ Agreement 87. 12. 12.5%. A-.104:1278-95 . D-. Am J Gastroenterol 2009.5% ¬A+.5% ¬ GRADE: very low Sherman et al.Statement #29 Physical exercise in toddlers and children may induce troublesome symptoms of GERD in individuals who have no or minimal symptoms at other times (exercise (exercise-induced reflux).

Statement #30 Physical exercise in older children and adolescents may induce troublesome symptoms of GERD in individuals who have either no or minimal symptoms at other times (exercise (exercise-induced reflux) . A A-. A. 25%. ¬ Agreement 100% A+ 25%.104:1278-95 . 50% ¬ GRADE: very low Sherman et al. A ¬A+. Am J Gastroenterol 2009.

62.104:1278-95 . GERD rumination should be distinguished from regurgitation. A-. Am J Gastroenterol 2009.5% ¬ GRADE: not applicable Sherman et al. 12. 25%. A.5%. ¬ Agreement A t 100% ¬A+.Statement #31 When assessing GERD.

Syndromes with Esophageal Injury .

Am J Gastroenterol 2009.104:1278-95 . food allergy. or older without cognitive ability to reliably report symptoms Symptomatic syndromes Older child or adolescent with cognitive ability to reliably report symptoms Syndromes with esophageal injury Extraesophageal Definite associations i ti Possible associations i ti • Sandifer’s syndrome • Dental erosion Bronchopulmonary • Asthma • Pulmonary fibrosis • Bronchopulmonary y dysplasia Laryngotracheal and pharyngeal • Chronic cough • Chronic laryngitis • Hoarseness • Pharyngitis Rhinological and otological • Sinusitis • Serous otitis media Infants • Pathological apnea • Bradycardia • Apparent lifethreatening events Excessive regurgitation Feeding refusal/anorexia Unexplained crying Ch ki / Choking/gagging/ i / coughing • Sleep disturbance • Abdominal pain • • • • • Typical reflux syndrome • • • • Reflux esophagitis Reflux stricture Barrett’s esophagus Ad Adenocarcinoma i *Where other causes have been ruled out (e.g.GERD in p pediatric p patients is p present when reflux of g gastric contents is the cause of troublesome symptoms and/or complications Esophageal Symptoms purported to be due to GERD GERD* Infant or younger child (0–8 years). especially in infants) Sherman et al.

104:1278-95 . ¬ Agreement 100% ¬A+. A.5%. adenocarcinoma. hemorrhage.Statement #32 In pediatric patients. 25%. 62. Barrett’s esophagus and rarely.5% ¬ GRADE: high Sherman et al. A-. hemorrhage stricture. 12. Am J Gastroenterol 2009. esophageal complications of GERD are reflux esophagitis esophagitis.

12.104:1278-95 .5%. ¬ Agreement 87.5% ¬A+. 37.5% ¬ GRADE: not applicable Sherman et al. 25%. A-.Statement #33 Insufficient data exist to recommend histology as a tool to diagnose or exclude GERD in children. 25%. D+. Am J Gastroenterol 2009. A.

12. Am J Gastroenterol 2009. 37. ¬ Agreement 100% ¬A+.5%. 50%.Statement #34 A primary role for esophageal histology is to rule out other conditions in the differential diagnosis. A.104:1278-95 .5% ¬ GRADE: high Sherman et al. A-.

5%. D. 50%. 12. D+. 12.104:1278-95 . ¬ Agreement 62. 25% ¬ GRADE: not applicable Sherman et al.5% ¬A+. Am J Gastroenterol 2009.Statement #35 Reflux esophagitis in pediatrics is defined endoscopically by visible breaks of the distal esophageal mucosa. A-.5%.

Am J Gastroenterol 2009. 50%. A.Statement #36 When refluxreflux-related erosions are present at endoscopy the grade should be described endoscopy.104:1278-95 . according to one of the recognized classifications of erosive esophagitis. 50% ¬ GRADE: not applicable Sherman et al. ¬ Agreement 100% ¬A+.

12.104:1278-95 . A. ¬ Agreement 100% ¬A+. 75%. Am J Gastroenterol 2009. A-.5%.Statement #37 In otherwise healthy children.5% ¬ GRADE: low Sherman et al. reflux esophagitis may not be chronic or recurrent following treatment. 12.

A-. 12.5%.5% ¬A+. 62.Statement #38 Reflux esophagitis in children with chronic neurologic impairment.5%. 12. A.5% ¬ GRADE: moderate Sherman et al.5%. hiatal hernia or chronic respiratory diseases is usually chronic and recurrent. ¬ Agreement 87.104:1278-95 . D. 12. impairment repaired esophageal atresia. Am J Gastroenterol 2009.

A-.Statement #39 Although GER symptom frequency and intensity in pediatrics correlate with the severity of mucosal injury. neither will accurately predict the severity of mucosal injury in the individual patient.104:1278-95 . A ¬A+. ¬ Agreement 100% A+ 12 5%. Am J Gastroenterol 2009. 12.5%.5%. 25% ¬ GRADE: low Sherman et al. 62 62. A. A 5%.

25% ¬ GRADE: not applicable Sherman et al. Am J Gastroenterol 2009. ¬ Agreement 100% ¬A+. A. 75%.104:1278-95 .Statement #40 A reflux stricture is defined as a persistent luminal narrowing of the esophagus caused by GERD in pediatric patients.

104:1278-95 .5% ¬ GRADE: high Sherman et al. 37. A. Am J Gastroenterol 2009. 12. ¬ Agreement 100% ¬A+. A-.Statement #41 The characteristic symptom of a stricture in pediatrics is persistent troublesome dysphagia.5%. 50%.

12.5%.Statement #42 Dysphagia in older children and adolescents is a perceived impairment of the passage of food from the mouth into the stomach. A. A-.5% ¬ GRADE: not applicable Sherman et al. ¬ Agreement 100% ¬A+. Am J Gastroenterol 2009. 50%. 37.104:1278-95 .

A. 25%.5%.104:1278-95 . Am J Gastroenterol 2009. 62. ¬ Agreement 100% ¬A+. 12.5% ¬ GRADE: not applicable Sherman et al. A-.Statement #43 Troublesome dysphagia is present when older children and adolescents need to alter eating patterns or report food impaction.

62.104:1278-95 . 25%. A-. ¬ Agreement 100% ¬A+.5%.Statement #44 In the pediatric age group. Am J Gastroenterol 2009.5% ¬ GRADE: low Sherman et al. hernia and in those with certain underlying disorders that predispose to severe GERD. Barrett's esophagus mainly occurs in individuals with hiatal hernia. 12. A.

A. A ¬A+. ¬ Agreement 100% A+ 25%.Statement #45 The term ‘Endoscopically Suspected Esophageal Metaplasia’ (ESEM) describes endoscopic findings consistent with Barrett’s esophagus that await histological confirmation.104:1278-95 . 75% ¬ GRADE: not applicable Sherman et al. Am J Gastroenterol 2009.

5%. A. D-.5%. 62.5% ¬ GRADE: moderate Sherman et al.5%.5% ¬A+.104:1278-95 .Statement #46 Documentation of esophogastric landmarks together with multiple biopsies are necessary to characterize endoscopically suspected esophageal metaplasia. 12. ¬ Agreement 87. 12. A. Am J Gastroenterol 2009. 12.

A 12 5% ¬A+.104:1278-95 . A 5%. 12. 37 37. Am J Gastroenterol 2009.Statement #47 When biopsies from endoscopically suspected esophageal metaplasia show columnar epithelium it should be called Barrett’s esophagus and the presence or absence of intestinal metaplasia specified. A-.5%.5% ¬ GRADE: not applicable Sherman et al. A. ¬ Agreement 100% A+ 50%.

Possible Associations .

especially in infants) Sherman et al.GERD in p pediatric p patients is p present when reflux of g gastric contents is the cause of troublesome symptoms and/or complications Esophageal Symptoms purported to be due to GERD GERD* Infant or younger child (0–8 years). or older without cognitive ability to reliably report symptoms Symptomatic syndromes Older child or adolescent with cognitive ability to reliably report symptoms Syndromes with esophageal injury Extraesophageal Definite associations i ti Possible associations i ti • Sandifer’s syndrome • Dental erosion Bronchopulmonary • Asthma • Pulmonary fibrosis • Bronchopulmonary y dysplasia Laryngotracheal and pharyngeal • Chronic cough • Chronic laryngitis • Hoarseness • Pharyngitis Rhinological and otological • Sinusitis • Serous otitis media Infants • Pathological apnea • Bradycardia • Apparent lifethreatening events Excessive regurgitation Feeding refusal/anorexia Unexplained crying Ch ki / Choking/gagging/ i / coughing • Sleep disturbance • Abdominal pain • • • • • Typical reflux syndrome • • • • Reflux esophagitis Reflux stricture Barrett’s esophagus Ad Adenocarcinoma i *Where other causes have been ruled out (e. food allergy. Am J Gastroenterol 2009.104:1278-95 .g.

62. ¬ Agreement A t 100% ¬A+.5% ¬ GRADE: high Sherman et al.5%. A-. Am J Gastroenterol 2009.104:1278-95 . 37.Statement # 48 Sandifer’s Sandifer s syndrome (torticollis) is a specific manifestation of GERD in pediatric patients.

104:1278-95 .Statement #49 There is insufficient evidence that GERD causes or exacerbates sinusitis sinusitis. ¬ Agreement 100% ¬A. 100% ¬ GRADE: low Sherman et al. pharyngitis and serous otitis media in the pediatric population. Am J Gastroenterol 2009. pulmonary fibrosis.

A. laryngitis hoarseness and asthma may be associated with GERD.5% ¬ GRADE: very low Sherman et al. 25%. ¬ Agreement A t 87. 12. chronic laryngitis. D-.5% 87 5% ¬A+. 37.104:1278-95 . A-. Am J Gastroenterol 2009. 25%.5%.Statement #50 Chronic cough cough.

unexplained asthma is less likely to be related to GERD. A-. Am J Gastroenterol 2009.5% ¬ GRADE: low Sherman et al.104:1278-95 .Statement #51 In the absence of heartburn or regurgitation. 12. 75%. A. ¬ Agreement 100% ¬A+.5%. 12.

A. 25%. Am J Gastroenterol 2009. ¬ Agreement 87. 37. 25%. hoarseness and asthma are multifactorial disease processes and acid reflux can be an aggravating cofactor. 12.5 ¬ GRADE: very low Sherman et al. D-. chronic laryngitis.104:1278-95 . A-.5%.Statement #52 Chronic cough.5% ¬A+.

A-. A. Am J Gastroenterol 2009. 50% ¬ GRADE: very low Sherman et al.Statement #53 GERD may cause dental erosions in children.104:1278-95 .5%.5%. ¬ Agreement 100% ¬A+. 37. 12.

25% ¬ GRADE: low Sherman et al.Statement #54 There is an association between GERD and bronchopulmonary dysplasia in neonates and infants. but the causecause-and and-effect relationship is uncertain. A-. 25%. Am J Gastroenterol 2009. A. ¬ Agreement 100% ¬A+.104:1278-95 . 50%.

50%. A. A-. ¬ Agreement 100% ¬A+.5% ¬ GRADE: high Sherman et al. 37. 12. a relationship between gastroesophageal reflux and pathologic apnea and/or bradycardia has not been established.Statement #55 In premature infants.5%.104:1278-95 . Am J Gastroenterol 2009.

A-.5%.Statement #56 Although reflux causes physiologic apnea. it causes pathologic apneic episodes in only a very small number of newborns and infants. 37. A. Am J Gastroenterol 2009.104:1278-95 .5%. ¬ Agreement 100% ¬A+. 25% ¬ GRADE: moderate Sherman et al. 37.

A. Am J Gastroenterol 2009.Statement #57 When reflux causes pathological apnea.104:1278-95 . ¬ Agreement 100% ¬A+. 25%. A-. 25%. the infant is more likely to be awake and the apnea is more likely to be obstructive in nature. 50% ¬ GRADE: moderate Sherman et al.

25%. ¬ Agreement 100% ¬A+. A. 25% ¬ GRADE: high Sherman et al. Am J Gastroenterol 2009. 50%.104:1278-95 .Statement #58 A diagnosis of an acute lifelife-threatening event (ALTE) warrants consideration of causes other than gastroesophageal reflux. A-.

Statement #59 At present. A.5%.104:1278-95 . ¬ Agreement 100% ¬A+. 37. no single diagnostic test can prove or exclude extraesophageal presentations of GERD in pediatrics. Am J Gastroenterol 2009.5% ¬ GRADE: not applicable Sherman et al. 62.

t t l i t and d other th i interested t t d parties. Am J Gastroenterol 2009. Sherman et al. details symptoms associated with the disease. children and adolescents has been developed. The definition clarifies the role of histology in the diagnosis of GERD. and id ifi f identifies future research h priorities.Summary • • • • A global definition of GERD in infants. ti The consensus statements should prove useful for the development of clinical practice guidelines and in the establishment of high quality clinical trials to answer unresolved issues in the field. i ii Critical feedback is now being sought from pediatric gastroenterologists.104:1278-95 .