Elsevier

The Journal of Pediatrics

Volume 177, October 2016, Pages 53-58
The Journal of Pediatrics

Original Articles
Salivary Pepsin Lacks Sensitivity as a Diagnostic Tool to Evaluate Extraesophageal Reflux Disease

https://doi.org/10.1016/j.jpeds.2016.06.033Get rights and content

Objectives

To determine the sensitivity of salivary pepsin compared with multichannel intraluminal impedance with pH testing (pH-MII), endoscopy, and gastroesophageal reflux disease (GERD) questionnaires.

Study design

We prospectively recruited 50 children from Boston Children's Hospital who were undergoing pH-MII to evaluate for GERD. The patients completed 24-hour pH-MII testing, completed symptom and quality of life questionnaires, and provided a saliva specimen that was analyzed using the PepTest lateral flow test. A subset of patients also underwent bronchoscopy and esophagogastroduodenoscopy. Receiver operating characteristic curve analyses were performed to determine the sensitivity of salivary pepsin compared with each reference standard.

Results

Twenty-one of the 50 patients (42%) were salivary pepsin-positive, with a median salivary pepsin concentration of 10 ng/mL (IQR, 10-55 ng/mL). There was no significant difference in the distributions of acid, nonacid, total reflux episodes, full column reflux, or any other reflux variable in patients who were pepsin-positive compared with those who were pepsin-negative (P > .50). There was no significant correlation between the number of reflux episodes and pepsin concentration (P > .10). There was no positive relationship between salivary pepsin positivity, any extraesophageal symptoms or quality of life scores, or inflammation on bronchoscopy or esophagogastroduodenoscopy (P > .30).

Conclusion

Salivary pepsin measurement has a low sensitivity for predicting pathological gastroesophageal reflux in children.

Section snippets

Methods

This was a prospective cross-sectional study of children aged 1-19 years undergoing pH-MII testing and esophagogastroduodenoscopy for the evaluation of GERD. Patients who had undergone fundoplication or previous esophageal or gastric surgery were excluded. Approval was granted by our hospital's Institutional Review Board, and informed consent was obtained from each patient or adult guardian.

Recruited patients were asked to provide a random saliva sample for pepsin testing. Alternatively, for

Results

Fifty patients, including 34 boys (68%), with a mean age of 8.7 ± 5.3 years, were recruited. Eleven patients (22%) had abnormal impedance studies, and 19 patients (38%) had abnormal pH monitoring. Twenty-four patients (48%) remained on acid-suppression therapy while undergoing pH-MII testing; there was no significant difference across reflux variables between patients receiving and those not receiving these medications (P > .05). Twenty-one patients (42%) had pepsin detected in the saliva

Discussion

The paradigm that gastroesophageal reflux (GER) is one of the most common causes of chronic cough has greatly influenced clinical practice for over 2 decades.20, 21, 22 It has spurred an enormous increase in acid-suppression therapy among children, even when clinical trials have failed to find a consistent relationship between measured reflux and clinical response.23, 24, 25, 26

Cough and GER are separate commonplace occurrences in children, and thus establishing causality is extremely

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    Supported by Boston Translational Research Program, the North American Society for Pediatric Gastroenterology Hepatology and Nutrition/Astra Award for Diseases of the Upper Tract, and the National Institutes of Health (R01 DK097112-01A1). The authors declare no conflicts of interest.

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