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A GLOBAL, EVIDENCE-BASED CONSENSUS ON THE DEFINITION OF GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN THE PEDIATRIC POPULATION
P ShermanThe Hospital for Sick Children, Toronto, Ontario
Aims: The Montreal definition of GERD established a global consensus to define reflux disease in adults. The aim of this work was to clarify terms related to reflux symptoms and signs in children by developing an international consensus on the definition of GERD in pediatric patients.
Methods: A set of statements to define GERD was developed using the Delphi process. The group comprised 8 voting pediatric gastroenterologists with expertise in the field and 8 non-voting participants (chair - P. Sherman, primary care physician, pediatrician, pediatric surgeons, pediatric otolaryngologists and pulmonologist, neonatologists, internal medicine-trained gastroenterologist). Statements were based on systematic searches of the literature employing Medline, EMBASE and CINAHL. Voting was conducted using a 6-point scale, with consensus defined as agreement by 75% of the group. The strength of each statement was assessed by using the GRADE system.
Results: There were four rounds of voting. At the first workshop, many of the statements were separated for each of 3 age groups (newborns/infants, toddlers/children, and adolescents). In the final vote, consensus was reached on 98% of 59 statements. In this vote, 95% of the statements were accepted by 7 of 8 voters. Salient consensus items were: 1) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms by children under 8 years, 2) Utility of histology for the diagnosis of pediatric GERD is limited; its primary role is to exclude other conditions, especially eosinophilic esophagitis and esophageal infections, 3) Extra-esophageal conditions (chronic cough, laryngitis, hoarseness, dental erosions, and reactive airway diseases) may be associated with pediatric GERD, but causality remains to be established, 4) Barrett's esophagus has been re-defined. Population-based studies of reflux-based symptoms in children should be a future research priority.
Conclusions: A definition of GERD in pediatric patients has been developed. The consensus statements should prove useful for the development of future clinical practice guidelines and in the establishment of high quality clinical trials to address unresolved issues.
*Voting members of the Consensus Group: Ulysses Fagundes-Neto, Benjamin D. Gold, Eric Hassall, Seiichi Kato, Sibylle Koletzko, Susan R. Orenstein, Colin Rudolph, Yvan Vandenplas
Support/funding provided by INSINC Consulting Inc. through an unrestricted grant from AstraZeneca RandD Mölndal. The sponsor had no input into process, meetings or output.