Pediatric Aspiration Syndromes

Pediatric aspiration syndromes include all conditions in which foreign content are inhaled into the lungs. Most commonly, aspiration syndromes involve oral or gastric contents associated with gastroesophageal reflux (GER), dysphagia (swallowing dysfunction), neurological disorders, and structural abnormalities. The volume of refluxate may be significant, usually causing acute symptoms associated with the penetration of gastric contents into airways, or there may be episodic incidents of small amounts of oral or gastric reflux or saliva that enter the airways causing intermittent or persistent symptoms. Syndromes associated with chronic lung aspiration include:

• Recurrent wheezing
• Chronic cough (3 or more weeks)
• Apnea
• Recurrent pneumonia

Pediatric aspiration syndromes are often caused by:

• Dysphagia: Swallowing dysfunction in which the muscles of the pharynx or esophagus do not function properly
• Gastroesophageal reflux disease (GERD): Digestive condition in which stomach contents or stomach acids flow back into the esophagus
• Anatomic disorders: Risk of aspiration can be associated with structural abnormalities such as cleft palate, esophageal atresia, laryngeal cleft, duodenal obstruction, and tracheoesophageal fistula

Common pediatric aspiration syndromes are:

• Aspiration pneumonia: Inflammation of the bronchial tubes and lungs caused by the inhalation of foreign material, such as food, vomit, or liquid, which can result in bacterial infection
• Diffuse aspiration bronchiolitis: Occurs when recurrent aspiration results in chronic inflammation of the bronchioles

A small amount of aspirated material may not be harmful at all, especially to a child with no health problems. Children with dysphagia or other respiratory conditions are at greater risk of pediatric aspiration syndromes.

Signs and Symptoms of Pediatric Aspiration

Symptoms of pediatric aspiration can vary greatly depending on the amount of aspirated material, how often your child aspirates, and the age and overall health of your child. Onset of aspiration symptoms typically occurs within 1-2 hours of the aspiration event. Symptoms of pediatric aspiration may include:

• Choking, coughing, or gagging while eating
• Weak sucking
• Fast or stopped breathing while feeding
• Hoarse voice or cry
• Noisy breathing or wheezing
• Slight fever after eating
• Chest discomfort or complaints of food coming back up or feeling stuck
• Recurring lung or airway infections
• Apnea, bradycardia, or cyanosis
• Excessive salivation

Children affected by a pediatric aspiration syndrome may present with symptoms shortly after eating, over time, or show no symptoms at all (silent aspiration). Other medical conditions which can lead to, or are associated with, pediatric aspiration syndrome include:

• Failure to thrive
• Cystic fibrosis
• Pulmonary abscess or fibrosis
• Bronchopulmonary dysplasia
• Bronchiectasis
• Obliterative bronchiolitis

Diagnosis of Pediatric Aspiration

Diagnosing pediatric aspiration will involve a thorough physical examination with a complete history of any past or current medical conditions, as well as symptoms your child may be having. Your doctor may recommend further testing, including:

• Chest x-ray
• CT scan
• Modified barium swallow (MBS): Patient swallows a barium-containing liquid allowing muscle problems, physiological abnormalities, and degree of aspiration to be seen
• Pulmonary function test
• Pulse oximetry or ABG test
• Fiber optic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallow study (VFSS): Often used together to assess the phases of swallowing
• Esophagogastroduodenoscopy (EGD) with biopsies: Endoscopic procedure of the upper gastrointestinal tract
• Esophageal pH monitoring: To assess acid reflux
• Fiberoptic bronchoscopy
• Gastroesophageal scintigraphy: Radionuclide study to assess gastroesophageal reflux

Your doctor will use results from these tests to determine if there is an underlying medical cause for your child’s aspiration.

Treatment of Pediatric Aspiration

Treatment for pediatric aspiration will largely depend on the cause and the severity of your child’s condition. Conservative therapy to prevent aspiration is generally the first course of treatment. Changing position during and after meals can reduce your child’s risk of aspirating. Posturing methods to treat aspiration include:

• Place infants in an upright/prone position during feedings
• Avoid placing babies under 6 months in a lying position for approximately 1 ½ hours after feeding
• Avoid feedings before bedtime (within 90 minutes)
• Elevate the head of your child’s bed by 30˚

Other treatments for pediatric aspiration are:

• Dietary modifications: Thickening infant formula, breastfeeding, feeding smaller, more frequent meals, and changing textures of food in the diet. Avoiding certain foods may be recommended if your child has GERD.
• Swallowing exercises: Consulting an occupational therapist or speech-language pathologist may be recommended.
• Medication: Medical therapy, botox injection, or antibiotic therapy
• Feeding tube: A nasogastric tube (through the nose to the stomach) or a gastrostomy tube (surgically placed into the stomach) may be temporarily used to ensure proper nutrition as other treatments are considered.
• Surgery: To reduce reflux or correct an abnormality.

Medications to Treat Pediatric Aspiration

Treating pediatric aspiration usually involves treating the underlying condition causing the aspiration events. Your doctor may prescribe:

• Prokinetic agents: Commonly prescribed for gastrointestinal disorders, prokinetics are used to improve gastrointestinal motility. Common prokinetics are urecholine (Bethanechol®) and metoclopramide (Clopra®, Maxolon®, Reglan®).
• Histamine receptor antagonists (H2 blockers): Inhibit acid production resulting in a reduction of acid in the refluxate. H2 blockers that may be prescribed for aspiration syndrome are ranitidine (Zantac®) and cimetidine (Tagamet®).
• Proton pump inhibitors (PPIs): Potent inhibitors of gastric acid production which include omeprazole (Prilosec®), lansoprazole (Prevacid®), and esomeprazole (Nexium®).

If your child is experiencing pediatric aspiration symptoms or has a condition at high risk for pediatric aspiration, please submit an online appointment request or contact the office of Dr. Peter N. Schochet at 972-981-3251.