Chest
Volume 120, Issue 4, October 2001, Pages 1190-1195
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Clinical Investigations
Esophagus
Chronic Aspiration Without Gastroesophageal Reflux as a Cause of Chronic Respiratory Symptoms in Neurologically Normal Infants

https://doi.org/10.1378/chest.120.4.1190Get rights and content

Objective

To describe 13 neurologically normal infants with chronic respiratory symptoms who had swallowing dysfunction with silent chronic aspiration without gastroesophageal reflux (GER) as the cause of their respiratory symptoms.

Background

Infants with neurologic disorders and infants with GER are known to have chronic respiratory symptoms. Isolated swallowing dysfunction and aspiration without GER in neurologically normal infants have not been widely reported.

Design

Retrospective chart review.

Setting

A tertiary pulmonary-care center at a children's hospital.

Patients

One hundred twelve otherwise healthy infants referred for respiratory symptoms who underwent esophageal pH studies and videofluoroscopic swallow studies (VSSs).

Methods

The records of infants referred between January 1997 and December 1999 to the Department of Pediatric Pulmonology who underwent 24-h esophageal pH monitoring and VSS as part of an evaluation for recurrent stridor and/or wheezing were reviewed. Significant GER was diagnosed if the percentage of time with esophageal pH < 4 was > 6%. Infants included in the study presented with recurrent respiratory symptoms, were born at term, were neurologically normal, had normal results of esophageal pH studies, but had abnormal results of VSSs (n = 13).

Results

All 13 infants presented with a variety of recurrent respiratory symptoms including wheezing and intermittent stridor. Ten of 13 infants had spitting and/or choking episodes with feeding. The mean (± SD) age at the onset of symptoms was 2.0 ± 1.6 months, and the mean age at VSS was 5.9 ± 3.4 months. All 13 infants had normal results of 24-h esophageal pH studies but had abnormal results for VSSs. All infants had evidence of swallowing dysfunction and direct silent aspiration of liquids with thin consistency. Six infants also were aspirating liquids with thick and/or semi-thick consistencies. None of the infants had evidence of structural anomalies on esophagograms. Nine infants were treated with thickened food, and in four infants oral feedings were stopped. Three of these infants required nasojejunal feeding, and one infant required gastrostomy tube feeding. VSSs were repeated every 3 months. In all infants, swallowing dysfunction resolved within 3 to 9 months. All infants tolerated the resumption of oral feeding. Videofluoroscopic documentation of the resolution of aspiration was followed by the resolution of respiratory symptoms in all infants.

Conclusion

There is a subgroup of otherwise healthy infants, presenting with wheeze and/or stridor, who have isolated swallowing dysfunction and silent aspiration as the cause of their respiratory symptoms.

Section snippets

Materials and Methods

The records of otherwise healthy infants who were referred between January 1997 and December 1999 to the Department of Pediatric Pulmonology at Children's Hospital in Columbus, OH, who underwent 24-h esophageal pH monitoring and videofluoroscopic swallow studies (VSSs) as part of an evaluation for recurrent stridor and/or wheezing were reviewed (n = 112) with the approval of the Children's Hospital Institutional Review Board. The Children's Hospital Pulmonary Division sees approximately 5,000

Results

Of 112 infants in this study, 26 infants (23%) had abnormal results for both the 24-h esophageal pH monitoring study and the VSS, 55 infants (49%) had normal results for both the 24-h esophageal pH monitoring study and the VSS, 18 infants (16%) had abnormal results for the 24-h esophageal pH monitoring study but normal results for the VSS, and 13 infants (11.6%) had normal results for the 24-h esophageal pH monitoring study but abnormal results for the VSS. We focused on the last group, and the

Discussion

In a retrospective review8 of patients undergoing a videofluoroscopic-modified barium swallow study at Children's Hospital of Buffalo, NY, it was noted that the vast majority of patients who aspirated were dependent on caregivers for feeding (90%) and had a diagnosis of cerebral palsy (71%). Importantly, it was noted also that many of these aspirators did so silently (ie, aspiration was not accompanied by cough or choking). Abnormalities in pharyngeal swallow function, such as reduced

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