1. Gastro-oesophageal reflux & aspiration
Definitions: Gastro-oesophageal reflux is the retrograde passage of the stomach contents into
oesophagus. The refluxate need not be acidic, and is often neutral or even alkaline. Some degree of
reflux is extremely common in neonates usually has few symptoms, this is termed Physiological
reflux.
Pathological reflux, on the other hand, is synonymous with gastro-oesophageal reflux disease &
implies that the child is coming to harm in some way. This may be in form of symptoms or as tissue
damage in the absence of symptoms ( silent reflux).
Secondary reflux occurs in a child predisposed by the presence of other abnormalities of the
oesophagus such as trachea-oesophageal fistula or neuromuscular disease.
Gastro-oesophageal reflux ascends above the level of the upper oesophageal sphincter & has been
implicated in a number of respiratory & otolaryngological disease.
Natural history
Physiological reflux is almost universal in neonates. These reflux episodes are usually post-prandial,
brief & asymptomatic. It is likely that a significant proportion of these children will go on to have
gastro-oesophageal reflux as adults.
Pathophysiology
1. The short length of the intra-abdominal portion of the oesophagus in neonates may
predispose them to reflux to some degree.
2. Reflux in children of all ages is primarily caused by transient lower oesophageal sphincter
relaxations. Transient relaxation can occur for many reasons, including gastric distension &
are prolonged (more than ten seconds) compared with the normal relaxation that occurs
during swallowing.
3. Children with neuromuscular disorders may have upper gastro-oesophageal dysmotility
with gastroparesis.
4. Reflux is more likely in the presence of a nasogastric tube. It is more likely in infants fed
formula milk rather than breast milk.
5. Intolerance to cow’s milk may play a role for some infant with reflux.
Symptoms & signs
The most common manifestation of reflux is regurgitation of feeds also known as posseting.
Most affected infants may show evidence of colicky pains, irritability, perharps with arching of the
back.
With severe reflux, infants may have severe vomiting, aversion to feeds & failure to thrive.

2. 1)Apnoea & life-threatening events
Apnoea are not uncommon in infants, particularly those born prematurely. Gastro-oesophageal
reflux causing largyngospasm may be a factor in some, but other causing need to be considered,
including tracheomalacia, seizures & central apnoea. Reflux events are common in neonates & are
not always associated temporally with apnoea. But if symptoms &signs & investigations suggest that
reflux may be a factor, anti-reflux treatment may be effective.
Apparent life-threatening events occur when a child becomes limp(weak), bradycardic , cyanosed &
clearly requires resuscitation. Infants with apparent life-threatening events are at risk of sudden
infant death syndrome. Approximately half of apparent life-threatening event are thought to be
related to reflux-related laryngospasm or aspiration.
2)Airway disorders
Gastro-oesophageal reflux may cause a variety of upper airway symptoms in children & has been
found to be associated with hoarseness, recurrent croup & laryngitis.
The highly negative intrathoracic pressures generated by a child with upper airway obstruction will
encourage reflux of gastric contents. Reflux in turn worsen airway obstruction by causing laryngeal
oedema & laryngospasm.
3)Rhinosinusitis
The reflux of gastric contents into the nasopharynx or even the nose has been postulated to cause
inflammation & oedema& thereby lead to chronic rhinosinusitis. Reflux might also cause nasal
disease through colonization of the nose with helicobacter pylori & autonomic dysfunction.
4)Otitis media
Extremely high levels of pepsin in middle ear effusions from children with otitis media. Gastric acid &
pepsin could cause inflammation of middle ear mucosa & dysfunction of the Eustachian tube, &
reflux is therefore a plausible cause of OME.
Diagnostic tests
1. 24 hour ambulatory pH probe monitoring.
2. Endoscopy can be highly suggestive of reflux, particularly the presence of hypopharyngeal
cobblestone mucosa, oedema of the arytenoids, obliteration of ventricle, vocal fold oedema
& oedema of the posterior commissure. Other suggestive features include lingual tonsil
hypertrophy, blunting of carina, increased bronchial secretions.
Oesophagitis is diagnostic but is present in only a minority of children with reflux. In fact, the
appearance of the oesophageal mucosa is often normal despite the presence of reflux, & biopsy is
required to establish the diagnosis with certainty.

3. Treatment
For many children with physiological reflux or very mild symptoms, if more significant reflux is
suspected, a therapeutic trial of feed thickeners & advice on positioning, possibly with concomitant
acid suppression, should be the first step.
Selected children with reflux resistant to medical treatment may be selected for surgery in the form
of a fundiplication. The procedure (now often performed laparoscopically) involves wrapping the
fundus of the stomach around the intraabdominal portion of the oesophagus to produce a valve-like
effect.it is extremely effective for selected children with extra-oesophageal symptoms.
Best clinical practice
1. Reflux is often physiological & can be managed expectantly if symptoms are mild.
2. A therapeutic trial of positioning, feed thickerners & acid suppression is an appropriate first
step when significant reflux is suspected.
3. The left lateral position is effective & in children above one year old, a degree of head
elevation should also be used.
4. Acid suppression with H2 receptor antagonists or PPIs appears to be safe & effective but
supportive published evidence is lacking.
5. Diagnostic tests have limitations & should be reserved for cases where medical treatments
have failed.
6. Fundoplication surgery should be considered where symptoms are significant & medical
treatment have failed.
Aspiration
Definition : aspiration is the passage of foreign material beyond vocal cords. This chapter will not
cover acute airway obstruction due to aspiration of a foreign body, but rather the aspiration
( chronic) of saliva, feeds & / or refluxed gastric contents.
Causes of aspiration
1. Impaired or incordinate swallowing
2. Impaired laryngeal sensation;
3. Impaired laryngeal elevation on swallowing(presence of a tracheostomy tube & by
endotracheal intubation both of which predispose to aspiration. Although aspiration can be
reduced by applying positive pressure(positive-end expiratory pressure or continuous
positive airway pressure).
4. Impaired true vocal fold adduction.
Most commonly aspiration presents in children with some combination of oesophageal dysmotility,
poorly coordinated oral & pharyngeal phases of swallowing & impaired laryngeal refluxes resulting

4. from neuromuscular disorders or cerebral palsy. Swallowing dysfunction may also be due to
inadequate of neurological control in premature infants.
The following are risk factors for aspiration;
- Cerebral palsy;
- Neuromuscular disorders;
- Impaired oesophageal motility;
- Prematurity;
- Gastro-oesophageal reflux;
- Tracheostomy
- Laryngeal cleft;
- Tracheooesophageal fistula;
- Vocal cord palsy.
Symptoms & signs
The typical clinical features in infant are apnoea, bradycardia& choking attcks with feeds. There may
be life-threatening events& aspiration is not uncommon as a cause of sudden infant death. Chronic
aspiration may present as recurrent pneumonia. Aspiration may also occur without overt signs(silent
aspiration), manifestation as progressive deterioration in respiratory function.
Diagnostic tests
The best available investigation at present are video-fluoroscopy & fibreoptic endoscopic evaluation
of swallow(FEES).
1. The videofluoroscopic modified barium swallow(often referred to simply as
videofluoroscopy) is usually carried out in conjunction with a speech & language therapist.
Various consistencies of radio-opaque material ranging from liquid to solid are swallowed &
followed on x-ray fluoroscopy.
The investigation provides excellent information about the coordination & completeness of the oral
& pharyngeal stages of the swallow as well as aspiration.
2. FEES has the advantage over videofluoroscopy of being performed at the bedside. The
swallow is observed using a fibreoptic endoscope positioned just behind soft palate via nose.
Coloured liquid is easiest to see. The investigation gives information about palatal elevation,
leakage into pharynx during the oral phase, pharyngeal residue & aspiration.
Fibreoptic endoscopic evaluation of swallowing with sensory testing(FEESST) is an extension
of the technique that also provides information on laryngeal sensation( not use in children).
3. Bronchoscopy to exclude a laryngeal cleft.

5. Management
Minor degree of aspiration may be managed by altering the consistency of feeds. A speech &
language therapist should supervise this& will also be able to give advice on head positioning during
feeds. The decision to stop oral feeding in infant in favour of tube feeding.
When aspiration of refluxed gastric contents is a major problem, control of the reflux by
fundoplication may be helpful.
If aspiration of saliva is a major issue despite tube feeding,a procedure to reduce saliva production
may be beneficial. This may take the form of excision of the submandibular glands with bilateral
parotid duct ligation or ligation of all four major salivary gland ducts.
Injection for medialization of a paralyzed vocal cords may reduce aspiration but carries a risk of
imparing the airway.
Tracheostomy will often make aspiration worse by preventing laryngeal elevation on swallowing.
Low-pressure cuff & a suction port tube above it if this is a problem.
Ultimately, when all else has been tried, it may be necessary to considered a procedure to separate
the air & food passages completely. The procedure involves transecting the cervical trachea & bring
out the lower end as a parmanant end-stoma. The upper end of the trachea can be closed off as a
blind pouch or anastomosed end-to side to the oesophagus. The procedure produces good results &
may allow the resumption of oral feeding. However this is at the expense of voice.

6. Management
Minor degree of aspiration may be managed by altering the consistency of feeds. A speech &
language therapist should supervise this& will also be able to give advice on head positioning during
feeds. The decision to stop oral feeding in infant in favour of tube feeding.
When aspiration of refluxed gastric contents is a major problem, control of the reflux by
fundoplication may be helpful.
If aspiration of saliva is a major issue despite tube feeding,a procedure to reduce saliva production
may be beneficial. This may take the form of excision of the submandibular glands with bilateral
parotid duct ligation or ligation of all four major salivary gland ducts.
Injection for medialization of a paralyzed vocal cords may reduce aspiration but carries a risk of
imparing the airway.
Tracheostomy will often make aspiration worse by preventing laryngeal elevation on swallowing.
Low-pressure cuff & a suction port tube above it if this is a problem.
Ultimately, when all else has been tried, it may be necessary to considered a procedure to separate
the air & food passages completely. The procedure involves transecting the cervical trachea & bring
out the lower end as a parmanant end-stoma. The upper end of the trachea can be closed off as a
blind pouch or anastomosed end-to side to the oesophagus. The procedure produces good results &
may allow the resumption of oral feeding. However this is at the expense of voice.