Analysis of multichannel intraluminal impedance and phmonitoring values in children with cerebral palsy laspghan working group comparative multicenter study

Abstract

Multichannel Intraluminal Impedance and pH Monitoring (pHMII) is considered the "gold standard" for gastroesophageal reflux (GER) evaluation, but pediatric reference values are still controversial. In children with cerebral palsy (CP), gastroesophageal reflux disease (GERD) is a common complication, but diagnosis is challenging. Interpreting symptoms is challenging, and there is limited research on pHMII reference values in this group.Aim: To compare the features of pHMII tracings in children with CP and children with suspected GERD without CP, whose results were normal according to Mousa reference values.Materials and Methods: Multicenter, retrospective and analytical study. We evaluated tracings of children from 1 to 15 years old evaluated from May 2017 to January 2024 carried out by members of the LASPGHAN motility group work in centers of Latin America and Spain.Population n: 245; Group 1: n: 110(CP children), Group 2: n:135(children without CP)Children under 1 year of age, patients with esophageal atresia, or previous Nissen surgery, corrected or uncorrected diaphragmatic hernia, medical treatment with antacids or prokinetics during the study, and less than 18 hours studies were excluded.All patients underwent 24-hour pHMII under the same protocol.Prior to the study, proton pump inhibitors were suspended for at least 7 days, and prokinetics and H2 antagonists were suspended 48 hours before.Catheters of age-appropriate caliber were used, calibrated in buffers solutions pH 4 and pH 7 before placement. The catheter was inserted posteriorly and the tip was positioned in the second vertebral body above the diaphragm, using the Stroebbel formula to calculate the approximate length. Position was confirmed with x-ray. After connecting the catheter to the external impedance equipment, parents were given information about its use and they were given an event recording sheet to mark symptoms that they could not mark on the equipment. All tracings were automatically evaluated in BioVIEW software, and then analyzed manually.Exploratory analyses were performed using hierarchical clustering with Euclidean distance. Quantitative variables were described by their mean and standard deviation, and statistical significance was assessed using ANOVA and t-tests. Qualitative variables were described using contingency tables and assessed with the chi-square test. All analyses were conducted and visualized using the R statistical package. A p-value < 0.05 was considered significant.Results: 245 patients were included, of which 110 belonged to the CP group and the rest to the control group. The total number of reflux episodes by pHMII was lower in the CP group (p= 0.001488). Significant differences were observed in the 24-hour baseline and at night being in both cases lower in group 1 (p = 1,816e-07 and p = 7,497e-07) respectively.In children with CP, higher values were found in acid clearance time (p-value = 0.02247).Conclusion: Acid clearance is higher in children with CP with fewer reflux episodes than in the normal population. This could explain why esophageal damage can be found with fewer reflux episodes. We found baseline significant lower values in CP children, which could be due to associated motor disorders. Prospective studies including scope findings are necessary to establish reference values of pHMII in children with cerebral palsy. The use of a validated method like pHMII could be an important tool to avoid more invasive studies and have better monitoring of treatment.