Gastroesophageal reflux disease is not a significant cause of lung disease in children

Recurrent lower respiratory tract infections in children: a practical approach to diagnosis

Many children are affected by recurrent lower respiratory tract infections (LRTIs), but the majority of them do not suffer from serious lung or extrapulmonary disease. The challenge for clinicians is to distinguish the recurrent RTIs with self-limiting or minor problems from those with underlying disease. The aim of this review is to describe a practical approach to children with recurrent LRTIs that limits unnecessary, expensive and time-consuming investigations. The children can be divided into three groups on the basis of their personal and family history and clinical findings: 1) otherwise healthy children who do not need further investigations; 2) those with risk factors for respiratory infections for whom a wait-and-see approach can be recommended; and 3) those in whom further investigations are mandatory. However, regardless of the origin of the recurrent LRTIs, it is important to remember that prevention by means of vaccines against respiratory pathogens (i.e. type b Haemophilus influenzae, pertussis, pneumococcal and influenza vaccines) can play a key role.

Evaluation of infants and children with refractory lower respiratory tract symptoms

OBJECTIVE

To define the diagnostic possibilities for young children who present with recurrent wheeze.

DATA SOURCES

Review of medical literature and 30 years of practice experience.

STUDY SELECTION

Relevant medical literature.

RESULTS

When evaluating an infant or child presenting with recurrent respiratory symptoms, several diagnoses must be considered. The workup should include assessment of the risk factors for asthma and careful investigation into the specific symptoms. Recurrent or persistent wheezing and/or coughing often result in a diagnosis of asthma with therapeutic trials of asthma treatment. When the therapy is ineffective, other diagnoses should be considered, including gastroesophageal reflux, protracted bacterial bronchitis, tracheobronchomalacia, and cystic fibrosis. Appropriate testing should be performed in these pediatric patients.

CONCLUSION

In young children with recurrent lower airway symptoms who have a negative modified Asthma Predictive Index result, the described diagnostic possibilities should be considered.

Aspiration lung disease

The term aspiration lung disease describes several clinical syndromes, with massive aspiration and chronic lung aspiration being at two extremes of the clinical spectrum. Over the years, significant advances have been made in understanding the mechanisms underlying dysphagia, gastroesophageal function, and airway protective reflexes and new diagnostic techniques have been introduced. Despite this, characterizing the presence or absence of aspiration, and under what circumstances a child might be aspirating what, is extremely challenging. Many children are still not adequately diagnosed or treated for aspiration until permanent lung damage has occurred. A multidisciplinary approach is mandatory for a correct diagnosis in addition to timely and appropriate care.

Food for Thought on Pediatric Feeding and Swallowing

“Food for Thought” provides an opportunity for review of pertinent topics to add to updates in areas of concern for professionals involved with feeding and swallowing issues in infants and children. Given the frequency with which speech-language pathologists (SLPs) make decisions to alter feedings when young infants demonstrate silent aspiration on videofluoroscopic swallow studies (VFSS), the need for increased understanding about cough and its development/maturation is a high priority. In addition, understanding of the role(s) of laryngeal chemoreflexes (LCRs), relationships (or lack of relationships) between cough and esophagitis, gastroesophageal reflux (GER), and chronic salivary aspiration is critical. Decision making regarding management must take into account multiple systems and their interactions in order to provide safe feeding for all children to meet nutrition and hydration needs without being at risk for pulmonary problems. The responsibility is huge and should encourage all to search the literature so that clinical practice is as evidence-based as possible; this often requires adequate understanding of developmentally appropriate neurophysiology and function.

High viral frequency in children with gastroesophageal reflux-related chronic respiratory disorders

INTRODUCTION

In the pediatric population chronic respiratory disorders (CRDs) include many pathological entities in which gastroesophageal reflux (GER) may play a role in the induction or persistence of clinical symptoms. It is not well established whether infective agents may be present in lung aspiration. The aim of the work was to investigate whether different infective agents could be found in children with GER-related CRDs.

MATERIALS AND METHODS

Extensive microbiological investigations including culture for bacterial agents, serology, direct fluorescent antigen and polymerase chain reaction analyses for different respiratory viruses were performed in 32 children (18 males, 14 females, mean age 5.0 +/- 2.4 years). Fifteen children out of 32 considered as "aspirators" (lipid-laden macrophage index-LLMI->or=86 and pathological pH-assay) were compared to 17 "non-aspirators" (LLMI < 86 and normal pH-assay).

RESULTS

Aspirators were older (6.0 +/- 1.9 vs. 4.2 +/- 2.5 years, P = 0.006) and less frequently atopic (13% vs. 59%, P = 0.01) than non-aspirators. A high frequency of viral infections (20/32, 62.5%) was found, with frequent occurrence of multiple infections (10/20, 50%). Aspirators showed more frequent viral infections than non-aspirators (87% vs. 41%, P = 0.01). Rhinovirus and respiratory syncytial virus were the principal detected viruses in the aspirator group.

CONCLUSIONS

Viral infections could play a key role in the pathogenesis of GER-related CRDs.

Pulmonary aspiration shown by scintigraphy in gastroesophageal reflux-related respiratory disease

OBJECTIVES

Gastroesophageal reflux (GER) may underlie respiratory manifestations via vagally mediated airway hyperresponsiveness or microaspiration, and intraesophageal pH monitoring is generally used to identify GER in patients with such manifestations. We aimed to establish the frequency of retrograde pulmonary aspiration in patients with unexplained respiratory manifestations.

METHODS

Fifty-one patients with refractory respiratory symptoms (cough, n = 18; pneumonia, n = 14; apnea, n = 8; asthma, n = 7; and laryngitis, n = 4) were prospectively evaluated. They underwent 24-h intraesophageal pH monitoring and gastroesophageal 99Tc scintigraphy with lung scan 18 to 20 h after the test meal.

RESULTS

Thirteen of 51 patients (25.5%) had abnormal intraesophageal pH study results (mean reflux index, 11.3%; range, 6.5 to 50%); and in 25 of 51 patients (49%), overnight scintigraphy showed pulmonary aspiration. Nineteen of these 25 patients had entirely normal pH study results, whereas 6 of 13 patients with abnormal pH study results had aspiration. Pulmonary aspiration was demonstrated in all patients with apnea and 61.5% of patients with recurrent pneumonia. Nine of 25 patients (36%) with aspiration had histologic evidence of esophagitis, whereas histologic esophagitis was present in 5 of 13 patients (38.4%) with pathologic GER as shown by intraesophageal pH monitoring.

CONCLUSIONS

Pulmonary aspiration as demonstrated by overnight scintigraphy is common in children with unexplained and refractory respiratory manifestations, suggesting that GER could be the underlying cause of these manifestations. Since only a few children with chronic or recurrent respiratory symptoms have a pathologic gastroesophageal acid reflux, a normal intraesophageal pH study result does not rule out GER in these children.

Prevalence and impact of gastroesophageal reflux in adolescents with asthma: a population-based study

We determined the prevalence of gastroesophageal reflux disease (GERD) symptoms and the associations between GERD symptoms and asthma morbidity in a population of adolescents with asthma. Two thousand, three hundred and ninety-seven students attending six middle schools in Seattle completed the International Study of Asthma and Allergy in Children (ISAAC) written and video survey that included additional questions pertaining to GERD symptoms and asthma morbidity. Based on their responses, children were categorized as having undiagnosed current asthma, physician-diagnosed current asthma, or no asthma symptoms. The prevalence of GERD symptoms occurring at least weekly or daily was determined for each group. The asthma morbidity outcomes were emergency department visits, physician visits, missed school days, and use of inhaled medications for respiratory symptoms within the past year. Associations between GERD symptoms and asthma morbidity outcomes were determined using logistic regression. The prevalence of GERD symptoms was significantly higher among students with current asthma (19.3%; 95% confidence interval (CI), 14.9-24.2) than students with no asthma symptoms (2.5%; 95% CI, 1.8-3.4). In children with current asthma (n = 296), symptoms of GERD that occurred at least weekly were strongly associated with emergency department visits (odds ratio (OR), 5.0; 95% CI, 2.6-9.6), physician visits (OR, 2.5; 95% CI, 1.3-4.6), missed school (OR, 2.0; 95% CI, 1.1-3.7), and inhaled medication use (OR, 2.5; 95% CI, 1.3-4.7). The associations between GERD symptoms and emergency department visits, physician visits, and inhaled medication use were stronger among children with asthma who reported daily GERD symptoms (n = 14) than among children reporting weekly GERD symptoms (n = 57). The prevalence of GERD symptoms was greater in adolescents with current asthma than in those without asthma. In addition, the presence of at least weekly GERD symptoms was strongly associated with greater asthma morbidity and the use of asthma medications.

Cough and reflux esophagitis in children: their co-existence and airway cellularity

BACKGROUND

There are no prospective studies that have examined for chronic cough in children without lung disease but with gastroesophageal reflux (GER). In otherwise healthy children undergoing flexible upper gastrointestinal endoscopy (esophago-gastroscopy), the aims of the study were to (1) define the frequency of cough in relation to symptoms of GER, (2) examine if children with cough and reflux esophagitis (RE) have different airway cellularity and microbiology in bronchoalveolar lavage (BAL) when compared to those without.

METHODS

Data specific for chronic cough (> 4-weeks), symptoms of GER and cough severity were collected. Children aged < 16-years (n = 150) were defined as 'coughers' (C+) if a history of cough in association with their GER symptoms was elicited before BAL were obtained during elective esophago-gastroscopy. Presence of esophagitis on esophageal biopsies was considered reflux esophagitis positive (E+).

RESULTS

C+ (n = 69) were just as likely as C- (n = 81) to have esophagitis, odds ratio 0.87 (95%CI 0.46, 1.7). Median neutrophil percentage in BAL was significantly different between groups; highest in C+E- (7, IQR 28) and lowest in C-E+ (5, IQR 6). BAL positive bacterial culture occurred in 20.7% and were more likely present in current coughers (OR 3.37, 95%CI 1.39, 8.08). Airway neutrophilia (median 20%, IQR 34) was significantly higher in those with BAL positive bacterial cultures than those without (5%, 4; p = 0.0001).

CONCLUSION

In children without lung disease, the common co-existence of cough with symptoms of GER is independent of the occurrence of esophagitis. Airway neutrophilia when present in these children is more likely to be related to airway bacterial infection and not to esophagitis.

Frequency of gastroesophageal reflux disease in nonatopic children with asthma-like airway disease

Gastroesophageal reflux disease (GERD) is commonly associated with asthma; however, frequency in nonatopic children with asthmatic symptoms is unknown. The aim of this study was to determine the frequency of gastroesophageal reflux (GER) in nonatopic children with asthma-like airway disease that recur despite conventional asthma treatment and to evaluate the clinical response to lansoprazole treatment. Twenty-five nonatopic children aged between 1 and 16 years who have asthma-like airway disease and 25 healthy children were included in the study. All cases underwent 24 h pH monitoring with dual sensor catheters. Additionally, acid suppressor treatment was administered to patients diagnosed as having GERD and clinical response was evaluated. Major symptoms encountered in the patient group included wheezing and cough (88%, and 32%, respectively). Reflux episodes were more common in distal esophagus during the prone position (reflux index (RI) of 11.5+/-10.3 vs. 16.2+/-9.4 during supine vs. prone). All distal esophageal parameters were significantly higher in the patient group except number of reflux episodes lasting longer than 5 min (RI of 13.3+/-13.1 vs. 3.9+/-2.9 in the patient vs. control groups, respectively). There was a significant improvement in symptoms and requirement for medication with treatment (number of systems decreased from 2.3+/-0.6 to 0.4+/-0.6, P=0.00). In conclusion, GERD is significantly more common in nonatopic children with asthma-like airway disease compared to the controls and clinical improvement is significant after acid suppressor treatment. Thus, we suggest that children followed-up with the diagnosis of nonatopic asthma with recurrent exacerbations despite adequate asthma treatment have a high frequency of GER and that lansoprazole treatment may be considered early in management.