GASTROENTEROLOGY/PULMONOLOGY: Aspiration and GER in recurrent pneumonia

With little data supporting any particular approach, preventing recurrent pneumonia (RP) secondary to dysfunctional swallowing presents complex challenges requiring individualized solutions, said Gerald M. Loughlin, MD, FAAP, in his presentation “Aspiration and Gastroesophageal Reflux: Most Common Cause of Recurrent Pneumonia in Children.”

Aspiration-inhalation of food, saliva, or gastric contents below the vocal cords-causes between 3%¹ and 48%² of RP cases. Populations at particular risk for gastroesophageal reflux (GER) and RP include premature infants and those with congenital abnormalities, upper airway trauma, central nervous system (CNS) dysfunction, vascular compression of the esophagus, and acute respiratory illness associated with tachypnea and increased effort of breathing. Gastroesophageal reflux also may strike apparently normal infants, Loughlin added.

Because clinical manifestations of GER may occur independent of feeding times, physicians must have a high index of suspicion for dysphagia, particularly in infants with atypical pneumonia or response to therapy. In such cases, said Loughlin, clinicians and parents must make tough choices, considering factors ranging from the parents' acceptance of the diagnosis to the child's age, CNS status, and underlying conditions.

If liquids of all consistencies pose a problem, a nasogastric (NG) tube can provide a temporary solution to relieve symptoms, and may help to confirm the diagnosis of aspiration while swallowing. While the child is on orders for nothing by mouth, Loughlin recommended determining the role of GER and the child's ability to tolerate tube feedings.

A child who will be on an NG tube for a long period may be a good candidate for a percutaneous endoscopic gastrostomy tube. Conversely, continued symptoms on NG feedings may suggest reflux contributing to the RP. Current medical therapies for reflux focus mainly on reducing the acid burden rather than the number of episodes, said Loughlin. If medical therapies fail, antireflux surgery may be appropriate, provided there's a documented causal relationship between GER and the child's respiratory disease.

Gerald M. Loughlin, MD, FAAP, is chair and pediatrician-in-chief, New York Presbyterian Hospital, New York.

REFERENCES

1. Ciftçi E, Günes M, Köksal Y, Ince E, Dogru U. Underlying causes of recurrent pneumonia in Turkish children in a university hospital. J Trop Pediatr. 2003;49(4):212-215.

2. Owayed AF, Campbell DM, Wang EE. Underlying causes of recurrent pneumonia in children. Arch Pediatr Adolesc Med. 2000;154(2):190-194.

Aspiration is a very important condition for general pediatricians to consider, given that they're on the front lines seeing infants with symptoms. Pediatricians especially need to be able to recognize concerns that parents may be expressing about their infant’s feeding or breathing that may be suspicious for aspiration. As a specialist in pediatric gastroenterology, even I can be surprised that an infant may be suffering from aspiration. Aspiration can be quite subtle, and it may not be the presenting complaint.

I do think it’s important to recognize that all aspiration does not necessarily involve gastric contents. Aspiration can occur with swallowing of food or saliva, as well as when gastric contents reflux up into the esophagus. On the other hand, the 2 issues certainly overlap. Additionally, babies who aspirate their food may be more at risk if they reflux. Sorting out the role of reflux in aspiration is very important, in part because the answer to aspiration may not solely involve treating reflux. It may actually be that the child shouldn't be eating by mouth, or is at risk when eating by mouth, so clinicians need to be prepared to mitigate each of these risks.

When I counsel families about aspiration and reflux, I emphasize that it's likely a multifactorial story.  There may be additional issues with esophageal motility or delayed clearance, or gastric emptying. There can also be underlying reasons for esophageal and gastric conditions. For instance, an infant may have a protein allergy that you need to fix by changing the diet, not just by suppressing acid.

The flipside is that reflux as a contributing factor to aspiration can actually worsen the situation. Most gastroenterologists believe that persistent gastroesophageal reflux disease in and of itself can perpetuate aspiration. Empirically, most of us would treat a baby with aspiration for reflux, whether or not that's part of the story, almost to make sure reflux does not pose a risk, as we continue to treat the patient. Of course, Loughlin also highlighted how difficult it can be to treat reflux effectively.

-Jenifer R. Lightdale, MD, MPH, is division chief, Pediatric Gastroenterology, Hepatology, and Nutrition, and chief quality officer, UMass Memorial Children's Medical Center, Worcester, Massachusetts.

Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.