Pediatric Extraesophageal Reflux Disease: A Diagnostic Dilemma

Nancy M. Bauman, MD, FAAP, FACS, is Professor of Otolaryngology-Head and Neck Surgery at Children’s National Medical Center and George Washington University in Washington, DC. She may be reached at nbauman@cnmc.org.

Pediatric extraesophageal reflux disease (EERD) refers to the manifestations of gastroesophageal reflux that arise outside of the gastrointestinal tract. Of the many manifestations of EERD, the most common observed in pediatric patients are chronic cough, sore throat, apnea, wheezing, stridor, recurrent pneumonia/bronchitis, and hoarseness. The term EERD is preferred to the terms supraesophageal or laryngopharyngeal reflux disease, as it encompasses pulmonary manifestations as well. In this editorial, I will discuss salient features of the pathophysiology, diagnosis, and treatment of this entity, with an emphasis on the pitfalls and controversies in our current understanding of EERD.

The diagnosis of EERD requires a high index of suspicion. The manifestations are diverse, and suggestive clues such as heartburn and water brash are often lacking in pediatric patients. Observations can be drawn from the trends seen in clinical practice to improve the diagnostic yield.

The pathophysiology of EERD is multifactorial. The mucosa of the upper and lower airways is particularly vulnerable to injury from contact with noxious gastroesophageal refluxate. Other mechanisms of EERD are often overlooked but are important to recognize, especially in pediatric patients. In 1994, we described potent vagal airway reflexes that can be induced by chemical stimulation of sensory nerve endings in the distal esophagus.1 The laryngospasm and central apnea elicited were far more pronounced in developing animals than in mature animals. This observation mirrors our clinical experience, as apnea from reflux disease is seen in infants, but typically not in older children. Finally, chemical neuromediators that are likely released from injured esophageal mucosa and their systemic effect on the aerodigestive tract remain to be identified. Discoveries in this area of medicine may unravel novel pharmacologic approaches to treating reflux disease by blocking the end-organ effect, as opposed to merely reducing gastric acid output.

Diagnosis

The diagnosis of EERD requires a high index of suspicion. The manifestations are diverse, and suggestive clues such as heartburn and water brash are often lacking in pediatric patients. Observations can be drawn from the trends seen in clinical practice to improve the diagnostic yield. Just as reflux-induced apnea demonstrates an age predilection for infants, other manifestations of EERD also show an age predilection. Chronic sore throat is an uncommon sign of EERD in toddlers and young children, but is one of the most common presenting symptoms in adolescents, particularly those with nocturnal reflux symptoms. Chronic cough, bronchitis, and recurrent pneumonia from reflux disease are most frequently observed in toddlers and young children.