Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition.

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Neonatal jaundice, animal-induced injuries and disease, and immunizations.

The past years' literature on topics of interest to the general practitioner in the areas of neonatal jaundice, animal-induced injury and disease, and immunizations is reviewed. Highlighted are current practice implications of recent publications. As always, the pursuit of excellence in clinical care involves balancing new information with experienced practice. Public health policy, child advocacy, and managed care demands additionally influence the current practice of pediatrics and modify our behavior as pediatricians. However, it is at the bedside that we must strive to provide the most beneficial and compassionate care.

Animal-induced injuries and disease, neonatal jaundice, immunizations, and viral infections.

Highlights from the past years' literature on the topics of animal-induced injuries and diseases, neonatal jaundice, immunizations, and viral infections are discussed from the perspective of the general pediatrician. An effort is made to place recent advances in care or understanding of clinical problems into the context of the pediatric office practice. The current reality of health care-be it managed care, care for the underserved, or the recent pressures on academic and hospital-based medicine-does not alter the importance of the delivery of quality care at the office level. Although it is now popular to define quality of health care in cute advertising copy, as if we are selling durable goods, excellence in pediatric office-based practice continues to require broad strokes of medical knowledge coupled with a unswerving commitment to and advocacy for the needs and well-being of infants, children, and young adults.

Immunizations, animal-induced injuries and disease, neonatal jaundice, and viral infections.

Four areas of concern for the pediatric practitioner are examined by the review of recent literature on the topics of immunization, animal-induced illness and injury, neonatal jaundice, and viral infections. An attempts to place these subjects into the perspective of the primary care office and into the current social and political climate as it applies to health care will also be made. By highlighting the literature of the past year on the above categories, I hope to provide topical information for pediatricians as they care for patients and their families.

Animal-induced injuries and disease, viral infections, neonatal jaundice, and immunizations.

This review highlights recent advances in four areas of interest to the pediatrician: animal-induced injuries and disease, viral infections, neonatal jaundice, and immunizations. Molecular biology techniques are dramatically impacting our understanding of the pathophysiology of disease states. The application of this "modern medicine" to the bedside is rapidly becoming commonplace. As clinicians we need to understand the opportunities this affords us as well as its potential limitations. The above four areas of concern will be explored with this in mind.

Sudden infant death syndrome, child maltreatment, oral rehydration therapy, infectious diseases, and vaccinations.

With this section, I review five areas of concern to the pediatrician in the office setting: sudden infant death syndrome, child maltreatment, oral rehydration therapy, infectious diseases, and vaccinations. In keeping with the structure of Current Opinion in Pediatrics, I focus on these topics through the vantage point of this past year's literature. I would be amiss, however, if my commentary neglected to integrate the impact of major factors, often regulatory, on pediatric practice and to acknowledge the precarious nature and thus the renewed challenge of children's health in the United States today.

Anticonvulsant-induced aplastic anemia: increased susceptibility to toxic drug metabolites in vitro.

A 53-yr-old man sequentially developed aplastic anemia from phenytoin and carbamazepine. Both compounds undergo metabolism to potentially toxic arene oxide intermediates. We tested the hypothesis that the patient's adverse reactions were due to a defect in detoxification of such metabolites by challenging his peripheral lymphocytes with drug metabolites generated by a murine hepatic microsomal system in vitro. The patient's cell viability was normal in the absence of drugs. However, his cells showed greater toxicity from both phenytoin and carbamazepine metabolites than did controls. Toxicity was dependent on microsomes and NADPH. Intermediate toxicity was noted in cells from the patient's mother. The results provide the first evidence for a role of arene oxide drug metabolites in aplastic anemia in humans and suggest that enhanced susceptibility to toxicity may be based on an inherited abnormality in metabolite detoxification.