The link between airway reflux and non-acid reflux in children: a review

Saniasiaya, Jeyasakthy; Kulasegarah, Jeyanthi

doi:10.1016/j.bjorl.2022.05.002

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Brazilian Journal of Otorhinolaryngology

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Brasil

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Sumário

Review Article • Braz. j. otorhinolaryngol. 89 (2) • Mar-Apr 2023 • https://doi.org/10.1016/j.bjorl.2022.05.002 copy

The link between airway reflux and non-acid reflux in children: a review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

Airway reflux, a member of extra-esophageal reflux, has been linked to countless respiratory pathologies amongst children. The advent of novel instrumentation has enabled the discovery of non-acid reflux which was postulated as the main culprit of airway reflux. The objective of this review is to outline the association between non-acid reflux and airway reflux in children.

Methods:

A comprehensive review of recent literature on non-acid reflux and airway reflux in children was conducted. Studies ranged from January 2010 till November 2021 were searched over a period of a month: December 2021.

Results:

A total of eleven studies were identified. All studies included in this review revealed a strong link between non-acid reflux and airway reflux in children. 6 of the included studies are prospective studies, 3 retrospective studies, 1 cross-section study, and type of study was not mentioned in 1 study. The most common reported respiratory manifestation of non-acid reflux in children was chronic cough (7 studies). Predominant non-acid reflux was noted in 4 studies. The total number of children in each study ranges from 21 to 150 patients. MII-pH study was carried out in all studies included as a diagnostic tool for reflux investigation.

Conclusion:

Non-acid reflux is the culprit behind airway reflux as well as other myriads of extra-esophageal manifestations in children. Multicentre international studies with a standardized protocol could improve scientific knowledge in managing non-acid reflux in airway reflux amongst children.

KEYWORDS
Gastroesophageal reflux; Laryngopharyngeal reflux; Airway reflux; Non-acid reflux; Children

HIGHLIGHTS

Airway reflux, a form of extra-esophageal reflux, has been linked to countless respiratory pathologies amongst children.

Review of the literature revealed that non-acid reflux is the culprit behind airway reflux and other myriads of extra-esophageal manifestations in children.

Non-acid reflux explains the exasperation faced by numerous otorhinolaryngologists following the futile outcome of devout usage of acid suppression in children to treat airway reflux.

A recent surge in the implementation of multichannel intraluminal impedance monitoring amongst children has enabled the discovery of non-acid reflux.

Multicentre international studies with a standardized protocol could improve scientific knowledge in managing non-acid reflux in airway reflux amongst children.

Name, Year	Type of study	Total	Mean age (years)	Gender	Respiratory manifestations	GI symptoms	MII-pH results	Additional investigations	Prior anti-reflux
Borelli et al.²2 Borrelli O, Battaglia M, Galos F. Non-acid gastro-oesophageal reflux in children with suspected pulmonary aspiration. Dig Liver Dis. 2010;42:115–21. 2010	Cross-sectional	21	4.1 (1.2–8.1)	9M/12F	Suspected pulmonary aspirations: 9 BA; 6 lung consolidation; 6 Recurrent croup	N/A	Total: 1505 reflux 736 (48.9%) NAR; 769 (51.1%) AcR; 1113 (74%) proximal	Fibreoptic bronchoscopy BAL LLM	NIL
Blondeau et al.³3 Blondeau K, Mertens V, Dupont L. The relationship between gastroesophageal reflux and cough in children with chronic unexplained cough using combined impedance-pH-manometry recordings. Pediatr Pulmonol. 2011;46:286–94. 2011	N/A	26	4 (1–10.5)	12M/14F	Chronic cough >8 weeks	Heartburn/ Abdominal pain/ Vomiting	Total: 967 reflux; 55.2% AcR; 41.5% WaC; 3.3% Walk; 26% Prox GER	Gastroesophageal manometry	NIL
Borelli et al.⁴4 Borrelli O, Marabotto C, Mancini V. Role of gastroesophageal reflux in children with unexplained chronic cough. J Pediatr Gastroenterol Nutr. 2011;53:287–92. 2011	Prospective	45	7.8 (1–16)	25M/19F	Chronic cough >4 weeks	N/A	CRR (Median); 86 reflux; 46 AcR; 12 Wac; 10 Walk; 43 Prox reflux	N/A	NIL
Ghezzi et al.⁵5 Ghezzi M, Guida E, Ullmann N. Weakly acidic gastroesophageal refluxes are frequently triggers in young children with chronic cough. Pediatr Pulmonol. 2013;48:295–302. 2013	Retrospective	106	4.84 (2.76–8.16)	63M/43F	Chronic cough >8 weeks	Heartburn regurgitation, abdominal pain, vomiting	Total: 6623 reflux; 73.1% AcR; 26.9% Wac; 0 Walk	N/A	NIL
Rosen et al.⁶6 Rosen R, Amirault J, Johnston N, Haver K, Khatwa U, Rubinstein E, et al. The utility of endoscopy and multichannel intraluminal impedance testing in children with cough and wheezing. Pediatr Pulmunol. 2014;49:1090–6. 2014	Prospective cross-sectional	112	76 months (13–200 months)	58M/54F	Cough 79% Croup 18%	N/A	Total: 48 reflux (med); 26 AcR; 22NAR; Prox 0.8%	Bronchoscopy & BAL Upper GI ensdocopy	NIL
Blasco-Alonso et al.⁷7 Blasco-Alonso J, Yun-Castilla C, Girón Fernández-Crehuet F. Esophageal multichannel intraluminal impedance and pH testing in the study of apparent life-threatening episode incidents in infants. Rev Esp Enferm Dig. 2014;106:159–64. 2014	Prospective	39	3.52	25M/14F	ALTE	N/A	2692refluxes (83.6%); Reflux: 75; AcR 17(21.6); WaR 67.33; Other: 3.34; NAR 58	Laryngoscopy N/A	NIL
Dziekiewicz et al.⁸8 Dziekiewicz MA, Karolewska-Bochenek K, Dembinski L, Gawronska A, Krenke K, Lange J, et al. Gastroesophageal reflux disease in children with interstitial lung disease. Adv Exp Med Biol. 2016;912:57–64. 2016	Prospective	18	1.7 (0.2–11.6)	15M/3F	Interstitial lung disease	12 neuroendocrine cell hyperplasia of infancy	1000 refluxes; 585 (58.5%) AcR; 407 (40.7%) WAR; 8 (0.8%) Walk; 637 (63.7%) Prox Ger	N/A	NIL
Pavic et al.⁹9 Pavic I, Cepin-Bogovic J, HojsakI. The relationship between gastroesophageal reflux and unexplained chronic cough in children. Clin Pediatr. 2016;55:639–44. 2016	Retrospective	150	7.5 (0.3–18)	90M/60F	Chronic cough >8 weeks	Gastrointestinal symptoms in 32 (26.7%)	Reflux 42; AcR 14; Wac 23; Walk 0	Lung function test Radiological Immunological Allergy test	NIL
Zenzeri et al.¹⁰10 Zenzeri L, Quitadamo P, Tambucci R, Ummarino D, Poziello A, Miele E, et al. Role of non-acid gastro-esophageal reflux in children with respiratory symptoms. Pediatr Pulmonol. 2017;52:669–74. 2017	Prospective	40	58.3 (2–163 month)	20M/20F	Chronic cough: 82.5% Recurrent apnoe 7.5% Recurrent pneumonia 7.5%		Reflux 65.1 (Mean); AcR 40.8; WaC 2.2; Walk 22.1; Prox 57.9%		NIL
Pavic et al.¹¹11 Pavic I, Babic I, Cepin-Bogovic J, Hojsak I. The importance of combined 24-hour multichannel intraluminal impedance-pH monitoring in the evaluation of children with suspected laryngopharyngeal reflux. Clin Otolaryngol. 2017;42:544–9. 2017	Prospective	104	8.9 (0.4–17.9)	57M/47F	LPR	N/A	Reflux 42; AcR 15.5; WAc 21; Alk 0; Prox 15	Endoscopy Eosinophil in nasal swab	NIL
Socso et al.¹²12 Sacco O, Silvestri M, Ghezzi M, Capizzi A, Rossi GA. Airway inflammation and injury in children with prevalent weakly acidic gastroesophageal refluxes. Resp Med. 2018;143:42–7. 2018	Retrospective	24	6.54	17M/7F	Recurrent LRTI Chronic cough Recurrent croup BA	Vomiting/ regurgitation	Median; AcR 37.5; Wac 16.5	Fibreoptic bronchoscopy BAL LLM	NIL

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[1] * Corresponding author. E-mail: jeyasakthy@um.edu.my (J. Saniasiaya).