A new study from the University of Chicago establishes that Gastroesophageal Reflux Disease (GERD) may contribute to pediatric swallowing dysfunction. The study further suggests that GERD treatment may improve the swallowing function in distress.

Infant swallowing is a highly coordinated process. In order for an infant to swallow, intact sensorimotor reflexes must be integrated at the brainstem level. Any changes in this sequence can lead to difficulty in feeding and swallowing which may ultimately lead to aspiration. If an infant experiences swallowing problems and they are untreated, then the child is at risk for malnutrition, dehydration, and respiratory problems.

There are a variety of causes for infant swallowing problems including GERD. GERD is extremely common, affecting some 5-8 percent of the pediatric population. GERD is defined as a backflow of acid from the stomach into the swallowing tube or esophagus. Common symptoms of GERD include vomiting, regurgitation, pain and excessive crying or constant fussiness. Symptoms can range from mild to life-threatening.

The relationship between GERD, microaspiration, and respiratory diseases is an accepted and frequently described scenario in medical literature. Despite this, the scientific study of such changes, by which a neurologically-intact larynx, which should protect the lower airway, can allow microaspiration to occur, is rarely discussed.

A new study attempts to address that relationship in the study, “Improved Infant Swallowing after GERD Treatment: A Function of Improved Laryngeal Sensation?” The authors are Dana L. Suskind MD, Penny Huddleston M.A., CCC-SLP, Fuad M. Baroody MD, and Donald C. Liu MD PhD all from the University of Chicago; Dana M. Thompson MD from the Division of Pediatric Otolaryngology, Mayo Clinic and Mayo Eugenio Litta Children’s Hospital; and Martha Gulati MD with the Department of Preventive Medicine and Cardiology, Northwestern University. Their findings will be presented at the 21st annual meeting of the American Society of Pediatric Otolaryngology, being held May 20-22, 2006, at the Hyatt Regency Hotel in Chicago, IL.

Methodology: The authors hypothesized that laryngopharyngeal reflux (LPR) has a negative impact on laryngopharyngeal sensation with resulting microaspiration/penetration in infants and children, and that reflux treatment will have a positive impact on swallowing function in these patients. A review of 28 patient records (21 males, seven females) neurologically-intact infants and children (e.g. no evidence of cerebral palsy, seizures, etc.), ranging in age from one to thirty-two months, from two different tertiary-care children’s hospitals with evidence of gross as well as micro-aspiration, swallowing dysfunction, and LPR, was made. Each child underwent either medical or surgical intervention for control of their GERD. The patients had their swallow function and laryngeal sensitivity evaluated before and after treatment of gastroesophageal reflux.

LPR was treated either with a course of anti-reflux medication or anti-reflux surgery as guided by the treating physician. A repeat Videofluoroscopic Swallow Study (VSS) or Flexible Endoscopic Evaluation of Swallowing and Sensation Testing (FEESST) was performed at the end of treatment. During the VSS, the infants were positioned in a typical feeding position consistent with their age and development. They were given a variety of food consistencies (thin liquid, thick liquid, puree, soft solid, hard solid) injected with barium. The study assessed all three phases of the swallow from the oral preparatory phase, oral initiation phase, and the pharyngeal phase. FEESST is an alternative test to the X-ray test of swallowing that uses a specifically designed endoscope in order to assess both the sensory and motor components of swallowing.

Results: Some 28 patients presented with clinical evidence of dysphagia. There were seven females and 21 males with ages ranging from four to 42 weeks at the time of initial evaluation (not adjusted for prematurity), with a median age of 23.6 weeks. A history of prematurity was the predominant medical issue in 8/11 from institution #1 and 7/17 from institution #2 with 54 percent of the patients overall being born before 37 weeks gestation. All patients had clinical evidence of gastroesophageal reflux disease which was supported with adjunctive tests; five had an abnormal both barium swallow and pH probe, thirteen had an abnormal barium swallow and two had an abnormal pH probe. All study participants demonstrated varying degrees of swallow dysfunction on VSS and FEESST.

Repeat swallow evaluation was performed from three to 78.1 weeks post intervention with a median of 18 weeks. Whereas the pre treatment assessment yielded 23/28 (82 percent) patients with aspiration, the post-treatment assessment only showed 4/28 (14 percent) patients still aspirating, a significant reduction. Correlating with their improved swallowing, all patients who underwent FEESST testing demonstrated a significant reduction in the sensory threshold required to elicit the LPR reflex indicating improved sensation level. In addition, those who underwent VSS demonstrated significant improvement in both pharyngeal impairment scores and swallow scores with a significant reduction, displaying a qualitative equivalent of a change from mild-moderate pharyngeal impairment to basically normal pharyngeal function and from moderate swallowing impairment to mild swallowing impairment. The researchers found that 26 of 28 patients being able to resume age-appropriate, unrestricted diets; these 26 included two of the four who were unable to tolerate any type of oral intake prior to treatment.

Conclusion: The study authors acknowledge that swallowing function improves with maturation, but they speculate that it could also be related to better control of GERD. Their study suggests that LPR may lead to impaired laryngeal sensation with resultant dysphagia and microaspiration. It further suggests that treatment of acid reflux with anti-reflux medication or surgery can reverse the deleterious changes and thus improve swallowing in these children.

American Society of Pediatric Otolaryngology (ASPO)