Etiology

The recurrent aspiration of small quantities of gastric, nasal, or oral contents can lead to several clinical presentations, including recurrent bronchitis or bronchiolitis; recurrent pneumonia; atelectasis; wheezing; cough; apnea; and/or laryngospasm. Pathologic outcomes include granulomatis inflammation, interstitial inflammation, fibrosis, lipoid pneumonia, and bronchiolitis obliterans. Most cases, although associated with significant morbidity, do not come to pathologic inspection, but clinically manifest as airway inflammation. Underlying disorders that are frequently associated with recurrent aspiration are listed in Table 390-1. Oropharyngeal incoordination is reportedly the most common underlying problem associated with recurrent pneumonias in hospitalized children. In one series of 238 children hospitalized with recurrent pneumonia, 48% were found to have dysphagia as the underlying problem. Lipoid pneumonia may occur after the use of home/folk remedies involving oral or nasal administration of animal or vegetable oils to treat various childhood illnesses. Lipoid pneumonia has been reported as a complication of these practices in the Middle East, Asia, India, Brazil, and Mexico. The initial underlying disease, language barriers, and a belief that these are not “medications” may delay the diagnosis.

Gastroesophageal reflux disease (GERD) is also a common underlying finding that may predispose to recurrent respiratory disease, but it is less frequently associated with recurrent pneumonia than dysphagia. GERD is discussed in Chapter 315.1. Aspiration has also been observed in infants with respiratory symptoms but no other apparent abnormalities. Recurrent microaspiration has been reported in otherwise apparently normal newborns, especially premature infants. Aspiration is also a risk in patients suffering from acute respiratory illness from other causes, especially respiratory syncytial virus infection. These patients, when studied with modified barium swallow and videofluoroscopy, have been seen to have silent aspiration. This finding emphasizes the need for a high degree of clinical suspicion for ongoing aspiration in a child with an acute respiratory illness, being fed enterally, who deteriorates unexpectedly.

Diagnosis

Some underlying predisposing factors (see Table 390-1) are frequently clinically apparent but may require specific further evaluation. Initial assessment begins with a detailed history and physical examination. The caregiver should be asked about spitting, vomiting, arching, or epigastric discomfort in an older child, the timing of symptoms in relation to feedings, positional changes, and nocturnal symptoms such as coughing and wheezing. It is important to remember that coughing or gagging may be minimal or absent in a child with a depressed cough or gag reflex. Observation of a feeding is an essential part of the exam when a diagnosis of recurrent aspiration is being considered. Particular attention should be given to nasopharyngeal reflux, difficulty with sucking or swallowing, and associated coughing and choking. The oral cavity should be inspected for gross abnormalities and stimulated to assess the gag reflex. Drooling or excessive accumulation of secretions in the mouth suggests dysphagia. Lung auscultation may reveal transient crackles or wheezes after feeding, particularly in the dependent lung segments.