AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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Background

Aspiration syndromes include all conditions in which foreign substances are inhaled into the lungs. Most commonly, aspiration syndromes involve oral or gastric contents associated with gastroesophageal reflux (GER), swallowing dysfunction, neurological disorders, and structural abnormalities.

GER is very common in infants and children and has been associated with a spectrum of pediatric problems; however, the percentage of reflux that causes respiratory complications is unknown. In 1912, Sir William Osler described the relationship between asthma and GER by stating that "attacks may be due to direct irritation of the bronchial mucosa or... indirectly, too, by reflex influences from stomach." Recent literature describes GER and aspiration syndromes as common occurrences with increasing diagnostic rates. Eosinophilic GI disorders (eg, eosinophilic esophagitis, gastroenteritis) may also manifest similarly to GER but are refractory to traditional reflux therapies.

Swallowing dysfunction is a known etiology of aspiration in children. Divided into 4 distinct phases, swallowing is a complex action that involves 5 cranial nerves and 26 muscles. Any anatomic, neurologic, or physiologic defect in the swallowing mechanism may lead to aspiration.

Cricopharyngeal dysfunction, cricopharyngeal incoordination of infancy, and transient pharyngeal muscle dysfunction are well described in the pediatric literature. Cricopharyngeal dysfunction involves cricopharyngeal muscle spasm or achalasia of the superior esophageal sphincter. Cricopharyngeal incoordination of infancy is noted in infants who have a normal suck reflex but have incoordination during swallowing; this is possibly secondary to delayed development or may be associated with cerebral palsy.

Neurological disorders, including congenital and progressive diseases, may manifest as aspiration syndromes in infants and children. Isolated superior laryngeal nerve damage, vocal cord paralysis, cerebral palsy, muscular dystrophy, and Riley-Day syndrome (ie, familial dysautonomia) are a few of the neurological disorders associated with increased risk of aspiration.

Anatomic disorders, such as cleft palate, esophageal atresia, tracheoesophageal fistula, duodenal obstruction, or malrotation, may have associated aspiration risk. Motility disorders, such as achalasia, are associated with increased risk of aspiration.

Frequency

United States

Medical practitioners are diagnosing GER and its respiratory complications more frequently now than in the past. Theories of the increased frequency of GER diagnosis include an increased prevalence of pathologic GER, improvement in diagnostic tests for GER, misdiagnosis, and overdiagnosis. The increase in diagnostic rate probably is multifactorial, but factors such as formula feeding, increased volume of feeds, and prolonged use of infant seating devices in infants too young to sit have been suggested as epidemiologic causes for this increase.^{1, 2}

In a study of the diagnostic rate of GER in Army hospitals over a 25-year period (1971-1995), the total diagnoses of GER increased 20-fold, with 84% of cases in infants younger than 6 months.³ The diagnostic rate for GER diagnosis rose from 0.74 in 1000 persons in 1971 to 8.16 in 1000 persons in 1995. Orenstein states that 40% of healthy infants regurgitate more than once a day, and as many as 20% of children reflux to the extent that parents feel it is a problem.^{4, 5, 6} Nelson et al (1998) described that most infants outgrow this physiologic reflux but that as many as 5% of infants have persistent reflux symptoms.⁷

Approximately 7% of infants have reflux severe enough to be brought to a physician's attention. As many as 40-50% of infants with GER present with respiratory symptoms. Approximately 25-80% of children with asthma have GER,⁸ but as many as one third of patients with pulmonary symptoms of GER have no esophageal symptoms.

Incidence of eosinophilic GI disorders has increased during the past decade. Eosinophilic esophagitis has been diagnosed in approximately 2 of 10,000 children in the Cincinnati region.⁹ Another group of investigators noted that 1% of patients with esophagitis have eosinophilic esophagitis.

The incidence of swallowing dysfunction associated with aspiration syndromes is not known because clinical signs of aspiration may be quite subtle. As many as 70% of patients with pharyngeal dysphagia with aspiration have silent aspiration (ie, no overt clinical signs during aspiration).

The incidence of aspiration syndromes associated with anatomic or neurologic disorders is unknown. The incidence of an isolated cleft palate is approximately 0.5 per 1000 live births, whereas the incidence of cleft lip and palate differs by ethnicity. Patients with a cleft palate are at risk for aspiration secondary to an abnormal communication with the nasal and oral cavities. Nasopharyngeal reflux commonly is observed in patients with cleft palate with or without associated cleft lip. Unilateral or bilateral vocal cord paralysis accounts for approximately 10% of all congenital laryngeal lesions. Esophageal atresia occurs in 1 per 3000-4000 live births, with 85% associated with tracheoesophageal fistulas.

International

International data on frequency of aspiration syndromes are not available.

Mortality/Morbidity

Patients with an aspiration syndrome are at risk for severe respiratory sequelae and, possibly, death. Patients with a massive aspiration event have a mortality rate of 25%.¹⁰ One study by Kohda et al examined 72 infants with documented aspiration by fluoroscopy for etiology of the aspiration and prognosis.¹¹ None of the patients without underlying neurologic disorders had evidence of aspiration after one year. In patients with neurological disorders, two thirds of patients had prolonged aspiration on follow-up. In patients who initially presented with a near-miss sudden infant death syndrome, or acute life-threatening episode (ALTE), 3 of 13 patients had prolonged aspiration.

No standard case definition of GER disease is recognized; thus, morbidity statistics are difficult to interpret. In 1959, Carre studied the natural history of severe GER and found that less than 5% of clinically affected patients died as a consequence of reflux.¹²

Race

In whites, cleft lip and palate occurs in approximately 1 in 1000 births; in Asians, it occurs in approximately 2 in 1000 births. In blacks, the incidence of cleft lip and palate is approximately 0.41 in 1000 births.

Sex

One study revealed an increased incidence of GER in males over females, but no strong prevalence in one sex has been observed. Cleft lip and palate are seen more commonly in males than in females, with approximately 60-80% incidence in males. Isolated cleft palates occur more frequently in females.

Age

Physiologic GER (ie, benign regurgitation) occurs most commonly in the first few months of life but generally resolves by age 1-2 years. Approximately 84% of patients diagnosed with GER in Army hospitals in a 25-year period were younger than 6 months.³ Patients with anatomic, physiologic, or neurologic disorders associated with aspiration are often diagnosed early. Esophageal atresia with or without tracheoesophageal fistula may be diagnosed in the delivery room or shortly after birth. The prevalence of respiratory complications of GER in infants and children by age is not known.

CLINICAL

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History

The 4 syndromes that may be associated with aspiration and pulmonary symptoms are recurrent wheezing, apnea, chronic cough, and recurrent pneumonia. Recurrent wheezing and asthma symptoms can be related to aspiration of gastric contents. Evaluate patients for aspiration who have asthma symptoms unresponsive to standard therapy; unexplainable or nocturnal symptoms; or whose symptoms are not associated with allergens, upper respiratory infection (URI) symptoms, or exercise.

Recurrent pneumonia is often observed in infants who are neurologically challenged and in children who chronically aspirate who may be neurologically healthy. These children often have impaired airway protection mechanisms and are noted to both directly and indirectly aspirate. Apneic episodes, both obstructive and central in nature, may be associated with aspiration in young infants and children. Obstructive apnea secondary to laryngospasm is observed in infants who are awake or asleep.

Microaspiration from indirect reflux causes laryngeal inflammation and bronchorrhea, manifested as hoarseness and cough. Chronic cough, defined as a cough that lasts 3 or more weeks, may be the only manifestation of recurrent aspiration. Failure to thrive (FTT) is also associated with gastroesophageal reflux (GER) and can be caused by a wide variety of factors, including cystic fibrosis.

• Patients often have a latent period after the aspiration event and the onset of symptoms. Symptoms usually occur within the first hour of aspiration, but almost all patients have symptoms within 2 hours of aspiration. Elicit a history of recurrent pulmonary symptoms from the parents and patient, including the following:
• • Wheezing, bronchospasm
  • Apnea, cyanotic episodes
  • Stridor, hoarseness, sore throat
  • Unexplained nocturnal fevers
  • Night sweats
  • Purulent sputum
  • Chronic cough (at least 4 wk in duration)
  • Nocturnal wheezing or cough
• Other associated findings or conditions include the following:
• • FTT secondary to calorie wasting
  • ALTE
  • Hiccups
  • Cystic fibrosis
  • Bronchopulmonary dysplasia
  • Pulmonary abscess
  • Pulmonary fibrosis
  • Bronchiectasis
  • Chronic bronchitis
  • Obliterative bronchiolitis
  • Other chronic lung diseases

Physical

Physical findings may include the following:

• Fever
• Tachypnea
• Heterophonous wheezing versus homophonous wheezing: Heterophonous wheezing is noted with small airway obstruction, whereas homophonous wheezing is noted with central airway involvement
• Crackles
• Noisy breathing
• Cough (characteristics, timeframe, triggers)
• Congestion
• Clubbing associated with chronic lung disease
• Increased work of breathing; grunting, flaring, retractions
• Cyanosis
• Hypoxemia
• Weak suck
• Shock
• Stridor
• Hoarse voice or cry
• Irritability
• Dental erosions
• Globus hystericus

Causes

• The act of swallowing is divided into the following 4 discrete phases: oral preparatory, oral, pharyngeal, and esophageal.
• • The oral preparatory phase begins when foods and liquids are placed into the mouth, mixed with saliva, and formed into a bolus.
  • The oral phase consists of moving the bolus into the pharynx, triggering the reflex swallow, which is the major component of the pharyngeal phase.
  • During the pharyngeal phase, the larynx elevates and closes at the level of the epiglottis, aryepiglottic folds, and true and false vocal cords. Normally, the laryngeal reflex during the pharyngeal phase of swallowing acts as a protective mechanism against direct or indirect aspiration.
  • The esophageal phase is initiated when the bolus passes through the relaxed cricopharyngeal muscle and enters the esophagus.
• Aspiration may occur when foreign substances enter the hypopharynx, either before relaxation of the cricopharyngeal muscle or before closing of the laryngeal sphincters. In patients with neurological disorders that affect swallowing, the absence of a swallowing reflex within 30 seconds of the completion of the oral preparatory phase results in direct aspiration. Direct aspiration is the aspiration of a food bolus while swallowing, whereas indirect aspiration is the reflux of food from the stomach into the esophagus and pulmonary system.
• Patients with structural abnormalities, such as H-type tracheoesophageal fistula, duodenal atresia, and achalasia, may have problems with direct aspiration, indirect aspiration, or both. Patients with H-type tracheoesophageal fistulas often aspirate pharyngeal secretions. If the fistula is distal, indirect aspiration of gastric contents is a risk. Patients with malrotation may have GER with associated aspiration risk.
• GER is often caused by transient lower esophageal sphincter (LES) relaxation. Other mechanisms include a low resting LES pressure and increased intragastric pressure. Increased intra-abdominal pressure due to coughing raises the gastroesophageal pressure gradient and increases the risk of reflux. However, GER may be the etiology of chronic cough. This cause-and-effect relationship may be difficult to elucidate.
• Several mechanisms, including the cough reflex, pulmonary macrophages, and the mucociliary escalator, are protective if aspiration occurs. If any of these actions are absent, impaired, or overwhelmed, chronic or acute aspiration symptoms may occur. The extent of injury is related to the amount and characteristics of the aspirate, the frequency of occurrences, and the effectiveness of protective lung-clearance mechanisms.
• Model and Boysen reviewed the pathophysiology of pulmonary aspiration of stomach contents.¹³ Laboratory studies revealed that aspiration of significant amounts of gastric contents, regardless of the nature of the aspirate, causes acute respiratory insufficiency and chemical pneumonitis. Acidic refluxate with pH less than 2.5 appears to be the most caustic to the pulmonary system. Histologically, one may see damage to alveolar lining cells and capillaries, as well as bacterial invasion, mucosal desquamation, and mononuclear cell inflammation.
• Respiratory symptoms due to aspiration of gastric contents may occur via several mechanisms. A vagally mediated reflex bronchospasm occurs in response to gastric acid irritation of the distal esophageal mucosa. Thus, reversible bronchospasm often occurs without documented indirect aspiration. Other potential mechanisms include heightened bronchial reactivity and microaspiration. However, as many as 70% of patients with pharyngeal dysphagia with aspiration have no obvious clinical signs of coughing, gagging, or choking. Chronic lung hyperinflation with flattening of the diaphragm decreases the protective reflux barrier of the diaphragm. An increased transdiaphragmatic pressure gradient predisposes to the movement of gastric contents into the esophagus.
• Medications used to treat asthma may contribute to symptoms. Beta-agonists and methylxanthines decrease the LES tone. Aminophylline is known to increase gastric acid secretion. Angiotensin-converting enzyme (ACE) inhibitors and inhaled corticosteroids have been reported to cause chronic cough.
• Apnea, obstructive and central, has also been associated with aspiration of gastric contents. Laryngospasm manifests as obstructive apnea secondary to reflux. Classically, obstructive apnea occurs within one hour after a feed when a patient suddenly stops, becomes apneic, stares, and develops a rigid opisthotonic posture. Continued ineffective respiratory effort is observed, but coughing or gagging is not necessarily present. If this progresses, pallor, cyanosis, and possible hypotonia ensue. The complete obstruction of the larynx impedes air movement, causing an obstructive picture. If incomplete laryngeal obstruction occurs, stridor may be noted during the examination. Central apnea has also been noted as a result of reflux. The superior laryngeal nerve has been implicated in this mechanism. Central apnea can be differentiated from obstructive apnea by the lack of respiratory effort observed.
• Chronic inflammation of the larynx and subglottic space from recurrent aspiration may cause stridor and hoarse voice.

DIFFERENTIALS

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WORKUP

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Lab Studies

• Laboratory studies in a thorough evaluation should include the following:
• • CBC count with manual differential
  • ABG or pulse oximetry
  • Sweat chloride
  • Pulmonary function test 
  • Serum immunoglobulin G (IgG) and subclasses, immunoglobulin M (IgM), immunoglobulin A (IgA), and immunoglobulin E (IgE) levels (possibly) 
• Skin prick testing and/or IgE radioallergosorbent assay testing (RAST) should be performed if eosinophilic esophagitis or eosinophilic gastroenteritis is considered to determine reactions to common foods.

Imaging Studies

• Chest radiography may reveal hyperinflation; marked diffuse interstitial or perihilar infiltrates, unilateral or bilateral; pleural effusion; lobar or segmental consolidation; or bronchiectasis.
• Upper GI and/or modified barium swallow is used to evaluate for anatomic or physiologic abnormalities of the upper GI tract, to quantify the degree of aspiration during swallowing, and to assess texture-specific foods and swallowing. Anatomic abnormalities, including a hiatal hernia, malrotation, pyloric stenosis, and antral or duodenal webs, may be diagnosed and may predispose an individual to gastroesophageal reflux (GER). These tests are neither sensitive nor specific in the diagnosis of GER.
• Gastroesophageal scintigraphy, also referred to as a milk scan, is a radionuclide study that provides a more functional or physiologic assessment for GER. This test also lacks sensitivity and specificity in the diagnosis of pathologic GER.

Procedures

• Pulse oximetry
• Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) with staining for lipid-laden macrophages: Some have found evaluation for pepsin in BAL fluid to be helpful.
• Twenty-four–hour intraesophageal pH monitoring: This is a very sensitive test for evaluating for GER.
• Esophagogastroduodenoscopy (EGD) with biopsies to assess eosinophilic infiltration: GER disease may be represented with distal esophageal erythema, erosions, ulcers, and mucosal friability. Characteristics of eosinophilic esophagitis include linear furrowing, mucosal granularity, scattered exudates, and concentric esophageal rings.
• Texture-specific swallowing evaluation
• Intraesophageal impedance monitoring: This can measure both acid and nonacid reflux and evaluates the change in intraluminal electrical resistance that occurs with advancement of a bolus. It is currently used only in research studies. Normal values for impedance have not been established for pediatric age groups.
• Flexible laryngoscopy: This study may reveal erythema and edema of the medial wall of the arytenoids, interarytenoid bar, and posterior pharyngeal cobblestoning.
• Immunocytochemical staining of alveolar macrophages for milk proteins (experimental)

Histologic Findings

• Bronchoscopy may reveal airway mucosal desquamation, mononuclear cell inflammation with granuloma formation, bacterial invasion, and cell damage.
• Lipid laden macrophages may be identified with oil red O stain on bronchoalveolar lavage samples.
• Eosinophilic esophagitis can be distinguished from GER if the inflammatory infiltrate has more than 15-20 eosinophils per high-power field.

TREATMENT

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Medical Care

• Conservative therapy is the initial treatment of choice to prevent aspiration syndromes and often results in significant improvement in respiratory symptoms. Position infants in the prone or upright position. Avoid placing infants younger than 6 months in a seated position for approximately 90 minutes after a feed. Do not feed the infant within 90 minutes before bedtime. Elevation of the head of the bed approximately 30° may help, although young infants may slide down the bed during the night. Dietary modifications include thickening feeds for infants; breastfeeding; decreasing volume of feeds (10-20 mL/kg per feeding); and feeding small, frequent meals. Patients with swallowing dysfunction may benefit from certain food consistencies, positioning, and adaptive feeding equipment or utensils.
• The management of an acute aspiration event consists of conservative management, observation, and possible antibiotic therapy. Initially, the patient's upper airway should be cleared and endotracheal intubation should be considered if the patient is unable to protect his airway. Close monitoring in an inpatient setting is recommended for at least 48 hours. Initially, empiric antibiotic therapy is not recommended, even if fever, clinical, laboratory, or radiographic findings are present. Selection of resistant organisms with the use of empiric, broad-spectrum antibiotic therapy is always a concern, especially in an uncomplicated chemical pneumonitis picture. If the patient fails to improve after 48 hours, the addition of broad-spectrum antibiotics is recommended.
• A second or third generation cephalosporin is appropriate to cover potential gram-positive flora from the oropharynx and gram-negative organisms from the GI tract. Anaerobic coverage is not routinely required initially. Limited and controversial data on the role of corticosteroids in the management of acute aspiration events are available. Numerous animal studies and clinical trials fail to demonstrate a significant beneficial effect of corticosteroids after acute aspiration events. Based on these data, routine administration of systemic corticosteroids is not recommended.

Surgical Care

• Surgical management with Nissen fundoplication and/or gastrojejunostomy is generally not first-line therapy for gastroesophageal reflux (GER) lung disease but may be appropriate for some individuals with neurological impairment.¹⁴ Surgical treatment of curable anatomic disorders, such as malrotation, is paramount.
• Patients who are neurologically impaired, have GER, and require a feeding tube are usually initially treated with fundoplication and gastrostomy. However, a percutaneous endoscopic gastrojejunostomy may be an intermediate step before surgical intervention.
• Several surgical procedures have been tried as an adjunct to fundoplication and gastrostomy to prevent direct aspiration. Total laryngectomy, glottic closure, tracheostomy, and injection of Teflon into the vocal cords have all been tried in patients with persistent direct aspiration.
• Laryngotracheal separation, with or without end-to-side laryngoesophagectomy, has been tried more recently in children with neurological impairment who have intractable aspiration pneumonia as an adjunct to fundoplication and gastrostomy.¹⁵ In this procedure, the larynx and trachea are permanently divided; therefore, aspiration can never occur, but phonation is sacrificed.

Consultations

• A primary care provider can successfully provide routine medical care for children with aspiration syndromes.
• Consultation with a speech-language pathologist or occupational therapist is recommended to assess swallowing dysfunction. Oral structure and function, clinical signs of safe swallowing, and positioning should be assessed.
• Refer patients to a pediatric pulmonologist and/or pediatric gastroenterologist if the patient does not respond to conservative or simple medical therapy or if the ordered studies are equivocal.
• A pediatric neurologist should thoroughly evaluate patients with possible neuromuscular disorders.

Diet

• Several dietary modifications can be initiated to decrease the risk of aspiration. Decreasing volume and increasing frequency of feeds, breastfeeding, thickening feeds, and not feeding within 90 minutes of nap or bedtime may decrease GER and aspiration.
• Special feeding equipment or utensils and positioning may also help patients with swallowing dysfunction or anatomical defect.
• In certain cases, transpyloric feedings may be necessary to decrease the risk of aspiration.
• In addition, avoidance of certain foods (eg, caffeine, fatty meals, carbonated beverages, peppermint, citrus) may decrease GER in older children and adults.
• If the volume of aspiration is greater than 10% of the bolus feed, enteral feeds may not be appropriate.

Activity

• Simple modifications in activity help decrease incidence of physiologic and pathologic GER.
• Elevation of the head of the bed approximately 30° and avoidance of seated devices for approximately 90 minutes after feeding may decrease GER and aspiration.
• Avoidance of prolonged use of seated devices in very young infants may be beneficial.

MEDICATION

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Consider medical therapy if conservative therapies have failed. One may consider an upper GI before the administration of medications to rule out an anatomic abnormality.

Drug Category: Prokinetic agents

These agents are used to augment cholinergic activity and to improve motility in the GI tract.

Drug Category: Histamine (H2) receptor antagonists

These agents do not reduce the frequency of reflux but decrease the amount of acid in the refluxate by inhibiting acid production. All are equipotent when used in equivalent doses and work best in nonerosive esophagitis. Because of the superiority of proton pump inhibitors (PPIs), H2 blockers may be reserved for use in patients unable to tolerate PPIs.

Drug Category: Proton pump inhibitors

These agents act by blocking the enzyme system responsible for active transport of protons into the GI lumen (ie, hydrogen/potassium adenosine triphosphatase [H⁺/K⁺ ATPase]) of the gastric parietal cell, also known as the proton pump.

Administer with the first meal of the day; children with nasogastric or gastrostomy tubes may have granules mixed with an acidic juice, and then the tubes are flushed to prevent blockage.

FOLLOW-UP

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Further Inpatient Care

• Admit infants and children with aspiration syndromes if a documented oxygen requirement is noted, if the patient has altered mental status, or if adequate medical care is unable to be met in the outpatient arena.

Further Outpatient Care

• Patients should be seen by their primary care manager for routine well-child visits and regularly for follow-up care.

In/Out Patient Meds

• See Medication.

Transfer

• Admit to the intensive care unit if the patient requires intubation, shows signs of impending respiratory failure, or shows instability on the ward with requirement of closer monitoring.

Deterrence/Prevention

• Conservative measures are the best deterrence against gastroesophageal reflux (GER). Attention to feeding volumes, positioning, and encouragement of breastfeeding may be helpful to decrease GER signs and symptoms in infants.

Complications

• Chronic lung disease may develop from repeated aspiration of refluxate.
• Pulmonary fibrosis may occur over time secondary to repeated aspiration of small volumes of gastric secretions, promoting a progressive fibrotic pulmonary response.
• Chronic bronchitis and bronchiectasis are also recognized complications.

Prognosis

• In general, the prognosis for an infant or child with an aspiration syndrome is good; but this depends partly on the underlying disorder.
• GER spontaneously resolves in most children by age 1-2 years.

Patient Education

• Educate patient and family regarding basic and conservative measures to prevent GER and ensuing complications.
• For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Bronchoscopy.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Evaluate patients who have clinical symptoms of obstructive pulmonary disease not responsive to therapy for gastroesophageal reflux (GER) and pulmonary disease.
• One must remember that GER may exacerbate respiratory symptoms in a patient with correctly diagnosed pulmonary disease.
• Providers may be dissuaded by negative diagnostic studies or negative history of regurgitation in the child.
• Barium swallow and scintigram may both be negative, even in the face of significant reflux. These studies are most helpful when positive but have very poor negative predictive value.
• Evaluate episodes of ALTEs because they could possibly be caused by GER.
• Chronic aspiration syndromes may mask disorders such as cystic fibrosis, bronchopulmonary dysplasia, immune deficiency, interstitial lung disease, and asthma.

Special Concerns

• Children with neurological disorders may need surgical treatment, in addition to conservative and medical management.

MULTIMEDIA

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Media file 1:  Chest radiograph of a child with a tracheostomy and recurrent aspiration reveals patchy infiltrates and increased interstitial markings.
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Media type:  Radiograph

Media file 2:  Lateral chest radiograph of the same child as in Media file 1 reveals increased interstitial markings and patchy and perihilar infiltrates.
	View Full Size Image
Media type:  Radiograph

REFERENCES

Section 11 of 11

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Article Last Updated: Apr 21, 2008