•“Silent” aspiration (ie, without choking or coughing) occurs especially in neurologically impaired patients.

•GER may be a coincident finding in patients with other chronic conditions, such as cystic fibrosis, primary ciliary dyskinesia, and asthma.

Diagnostic Considerations

•Considerable clinical judgment is required to diagnose microaspiration (frequent aspiration of small volumes).

•A careful history should include the timing of symptoms and the relationship to feedings, positional changes, spitting, vomiting, or arching of the back. In older children, gastric discomfort or increased nocturnal symptoms of coughing or wheezing may be reported.

•The value of observing a feeding cannot be overemphasized.

—A child who presents with repeated gagging, coughing, wheezing, or crackles after feeding or after visible regurgitation may need very little further evaluation.

—Other findings may include difficulty with sucking, nasopharyngeal reflux, decreased or markedly increased gag reflex, drooling, or pooling of oral secretions.

—Postprandial crackles or wheezes may be heard.

Laboratory Studies

•The initial imaging study for a child suspected of having recurrent aspiration is plain chest radiography. However, there are no findings specific to aspiration, and the results may range from normal to classically described consolidations in dependent lobes or segments, similar to pneumonia.

•Computed tomography (CT) is usually not necessary, but CT may show infiltrates with decreased attenuation, which are suggestive of lipoid pneumonia, particularly in dependent areas.

—A small amount (approximately 0.1 mL) of radionuclide is given orally, and scanning is performed to look for tracheal or pulmonary aspiration.

—This test is probably more sensitive than a gastroesophageal scintiscan and has approximately the same sensitivity as VSS, but it has far less radiation exposure than VSS.

—When used in conjunction with plain chest radiographs, it can help to determine, with a substantial degree of accuracy, which children are at risk for lung disease due to the aspiration of saliva.

•Fiber-optic endoscopic evaluation of swallowing (FEES) is shown to be of similar sensitivity to VSS, without the radiation.

—FEES and VSS can be used to assess only 1 brief period of time, which can lead to both false-positive and false-negative results.

—An advantage to both VSS and FEES is that they can be used to assist with providing treatment recommendations, such as thickening of feedings or special positioning.

•In patients with a tracheostomy or endotracheal tube, a small amount of dye or food coloring can be placed on the tongue or mixed into food, followed by suctioning to look for stained tracheal secretions. Reports of sensitivity and specificity are varied. Using large volumes of dye is not advised, since this technique is highly insensitive for detecting aspiration and also has the potential for causing severe toxicity and even death.

Diagnosing GER

•GER may produce respiratory symptoms, with or without aspiration.

—Glucose

—Vegetable or meat fibers

—Lipid-laden macrophages

—Pepsin analysis can only be used to detect aspiration that occurs from GER, not from dysphagia, although detection of pepsin in bronchoalveolar lavage fluid may aid in the decision whether or not to recommend an antireflux surgical procedure.

—The finding of lipid-laden macrophages is nonspecific to aspiration, but when these cells are semiquantitated, this has been shown to have a high correlation with other test results for aspiration. By using proper histologic technique, the absence of lipid-laden macrophages highly suggests that lipid aspiration is not occurring.

—Other limited studies have been used to look at various substances added to foods, such as carbon or polystyrene microspheres.

• It is critically important to consider diagnoses other than aspiration as the cause of respiratory disease.

—Children with cystic fibrosis, asthma, interstitial pneumonitis, and primary ciliary dyskinesia, among other conditions, may present with an abnormal history or study findings that indicate aspiration, thus markedly delaying diagnosis of their primary problem.

Management

•Treatment should be directed at the underlying condition that contributes to aspiration, if known.

•Other treatment will depend on the severity of respiratory problems and whether the aspiration is caused by a swallowing dysfunction or GER.

• Conservative measures to improve aspiration during swallowing include thickening of food, pacing feedings, performing swallow stimulation, and changing the feeding position.

•Thickening food, eating in the upright position, avoiding bottle propping and smoke exposure, and losing weight (if the child is obese) can all be helpful in reducing GER.

•Medical treatment with histamine-2 blockers or proton pump inhibitors can reduce acid reflux but has not been shown to reduce nonacid reflux.

•Prokinetic agents available in the United States include metoclopramide and erythromycin. The effectiveness of either drug is not well substantiated, and side effects are common with metoclopramide.

•A trial of nasogastric feedings can be used while waiting for temporary swallowing dysfunction to improve.

•With significant GER, postpyloric feedings may be considered.

•Fundoplication is usually successful in eliminating GER and should be performed in conjunction with gastrostomy tube placement in children with clinically significant GER. Judgment must be used to decide if this should be performed at the time of gastrostomy in children without clinically significant GER, since many patients develop GER after gastrostomy tube placement.

•Recurrent pneumonia may continue even after both fundoplication

and gastrostomy, owing to the continued aspiration of oral secretions, especially in neurologically impaired children.

—Anticholinergic agents, such as glycopyrrolate and scopolamine, may reduce excess salivation, but tolerance can develop, and adverse side effects may occur, such as blurred vision, behavioral change, and difficulty urinating.

—These agents also affect airway mucus hydration, and thickened mucus may be problematic, particularly in children with a tracheostomy.

•Salivary gland injection of botulinum toxin has been shown to reduce salivation, but the effects are usually short term.

•Surgical intervention with salivary gland removal, ductal ligation, or laryngotracheal separation may be considered in children who are not responsive to more conservative therapy.

•Tracheotomy, although often associated with an increase in aspiration, can be considered in a patient with chronic aspiration and poor ability to clear the airway as a means to improve pulmonary hygiene and to provide ventilatory assistance and oxygen delivery.

•The care of children with chronic aspiration is difficult. There are many variables with diagnosis and treatment that are best individualized for the patient by means of close collaboration between the primary physician, pulmonologist, family, and, surgical subspecialists.

When to Refer

•Refer a child who has recurrent pneumonia or persistent chest radiographic abnormality, dysphagia, coughing or choking with feedings, or recurrent wheezing that is not responsive to routine asthma therapy.

•Refer a child when aspiration is suspected in the presence of severe underlying disease, such as congenital heart disease or pulmonary hypertension.

•Admit a child for clinically significant dyspnea, hypoxemia, progressive pulmonary signs or symptoms, equivocal history, and acute life-threatening events. Any of these may indicate acute or cumulative effects of chronic aspiration.

Resource for Families