The Mean Duration of Gastroesophageal Reflux During Sleep as an Indicator of Respiratory Symptoms From GastroesophagealReflux in Children ByLloyd
M. Halpern, Stephen G. Jolley, William P. Tunell, Dale G. Johnson, and Carmen E. Sterling Las Vegas,
Nevada; Oklahoma City, Oklahoma; and Salt Lake City, Utah
@The coexistence of gastroesophageal reflux (GER) and respiratory symptoms has been reported in children, but identifying a reliable indicator of reflux-induced respiratory symptoms has been difficult. The mean duration of reflux episodes during sleep (ZMD), extracted from a I& to 24-hour esophageal pH recording, has been presented previously as a reliable correlate of respiratory symptoms caused by GER in infants. To reexamine the accuracy of the ZMD we report 519 consecutive children with respiratory symptoms (aged 1 week to 15 years) who were referred for documentation of GER by 18-to 24-hour esophageal pH monitoring. Follow-up information was obtained on 388 patients 1 to 115 months later (mean, 23 months). From the follow-up information, 259 children could be reliably classified; 128 as having refluxrelated and 131 as having reflux-unrelated respiratory symptoms. None of the 131 children with reflux-unrelated respiratory symptoms had a prolonged ZMD (>3.8 minutes). In comparison, 119 of the 128 children (93%) with reflux-related respiratory symptoms had a prolonged ZMD (P < .OOl). The nine children who had a normal ZMD and improvement in their respiratory symptoms with the successful control of GER had advanced esophagitis (n = 4), central apnea (n = 3). or associated disorders in which respiratory symptoms improved with the avoidance of oral feedings (n = 2). In conclusion, the ZMD was confirmed to correlate directly with both the presence and absence of respiratory symptoms caused by GER in children. Copyright o 1991 by W. B. Saunders Company INDEX WORDS:
Gastroesophageal
reflux, children.
T
HE COEXISTENCE of gastroesophageal reflux (GER) and a wide range of respiratory symptoms has been well reported in children.‘.l4 These studies have examined the association of GER with asthma,lm3recurrent pneumonia,4z5 apnea,6-9 near-miss sudden infant death syndrome (SIDS),‘09” bronchopulmonary dysplasia (BPD), and chronic pulmonary disease.123’3These reports concluded that there is a causal relationship between GER and some respiratory disorders.‘4 However, many children with GER may also have respiratory symptoms related to an From the Departments of Surgery and Pediatrics, Humana Children’s Hospital-Las Vegas, Las Vegas, W; Children’s Hospital of Oklahoma and the University of Oklahoma College of Medicine, Oklahoma City, OK; and Primary Children S Medical Center and the University of Utah College of Medicine, Salt Lake City, UT. Date accepted: April 6, 1990. Address reprint requests to Stephen G. Jolley, MD, 3201 Maryland Pkwy, Suite 414, Las Vegas, NV89109. Copyright Q 1991 by WB. Saunders Company 0022-3468/91/2606-0011$03.00/0
686
associated disorder rather than to GER. None of these studies provided a reliable method for documenting both the presence and absence of refluxinduced respiratory symptoms in all children prior to initiating treatment for GER. The mean duration of reflux episodes during sleep (ZMD) measured after the first 2 hours postcibal, and extracted from an 18- to 24-hour esophageal pH recording, has been proposed previously by us as a reliable correlate of respiratory symptoms caused by GER in children 6 months of age or less.15 This variable was the only reliable correlate of refluxrelated respiratory symptoms in the 40 variables examined from the esophageal pH recording. A ZMD prolonged beyond the normal range was found in virtually all infants whose respiratory symptoms responded to successful medical or surgical control of GER. In the present study, we isolate the ZMD as an indicator of risk for respiratory symptoms from GER and reexamine it’s validity in a larger group of both infants and children with respiratory symptoms. MATERIALS AND METHODS
Population A retrospective review was conducted on 837 consecutive children studied by the authors over a lo-year period (August 1977 to December 1987). The patients were referred for an evaluation of GER by 18- to 24-hour esophageal pH monitoring. The studies occurred at three separate institutions (Primary Children’s Medical Center, Children’s Hospital of Oklahoma, and Humana Children’s Hospital-Las Vegas). Of the 837 children reviewed, 519 were selected for this report because they represented all of the patients who presented with respiratory symptoms alone or in conjunction with other symptoms suggestive of GER. The ages ranged between 1 week and 15 years (mean, 11 months). There were 291 boys and 228 girls. Apnea or choking episodes occured in 317 (61%) children, recurrent pneumonia or chronic cough in 207 (40%) children, hyaline membrane disease (HMD) with subsequent BPD in 103 (20%) children, recurrent wheezing in 67 (13%) children, and chronic lung disease of unknown etiology in 15 (3%) patients. One hundred forty-eight children had more than one respiratory symptom. Two hundred thirty-four children (45%) had respiratory symptoms as the only symptom leading to referral for an evaluation of GER. Two hundred forty-one (47%) children had respiratory symptoms without a history of repeated emesis.
Esophageal pH Monitoring Extended (18 to 24 hours) esophageal pH monitoring with an analysis of the esophageal pH recording was performed in all Journal of Pediatric Surgery,
Vol 26,
No 6 (June), 1991: pp 686-690
GASTROESOPHAGEAL
REFLUX AND RESPIRATORY SYMPTOMS
children as described previously.‘6 The presence or absence of GER was determined by a composite pH score (normalvalue I 64) derived from data in the recording intervals after the first 2 hours following feedings. The discrimination of normal children from children with GER has been established with this composite pH score.16 The ZMD was extracted from the greater than 2 hours postcibal recording intervals in the esophageal pH recording by totalling the time of esophageal pH 12
6/31 (19%)
L P
M. Halpern, Stephen G. Jolley, William P. Tunell, Dale G. Johnson, and Carmen E. Sterling Las Vegas,
Nevada; Oklahoma City, Oklahoma; and Salt Lake City, Utah
@The coexistence of gastroesophageal reflux (GER) and respiratory symptoms has been reported in children, but identifying a reliable indicator of reflux-induced respiratory symptoms has been difficult. The mean duration of reflux episodes during sleep (ZMD), extracted from a I& to 24-hour esophageal pH recording, has been presented previously as a reliable correlate of respiratory symptoms caused by GER in infants. To reexamine the accuracy of the ZMD we report 519 consecutive children with respiratory symptoms (aged 1 week to 15 years) who were referred for documentation of GER by 18-to 24-hour esophageal pH monitoring. Follow-up information was obtained on 388 patients 1 to 115 months later (mean, 23 months). From the follow-up information, 259 children could be reliably classified; 128 as having refluxrelated and 131 as having reflux-unrelated respiratory symptoms. None of the 131 children with reflux-unrelated respiratory symptoms had a prolonged ZMD (>3.8 minutes). In comparison, 119 of the 128 children (93%) with reflux-related respiratory symptoms had a prolonged ZMD (P < .OOl). The nine children who had a normal ZMD and improvement in their respiratory symptoms with the successful control of GER had advanced esophagitis (n = 4), central apnea (n = 3). or associated disorders in which respiratory symptoms improved with the avoidance of oral feedings (n = 2). In conclusion, the ZMD was confirmed to correlate directly with both the presence and absence of respiratory symptoms caused by GER in children. Copyright o 1991 by W. B. Saunders Company INDEX WORDS:
Gastroesophageal
reflux, children.
T
HE COEXISTENCE of gastroesophageal reflux (GER) and a wide range of respiratory symptoms has been well reported in children.‘.l4 These studies have examined the association of GER with asthma,lm3recurrent pneumonia,4z5 apnea,6-9 near-miss sudden infant death syndrome (SIDS),‘09” bronchopulmonary dysplasia (BPD), and chronic pulmonary disease.123’3These reports concluded that there is a causal relationship between GER and some respiratory disorders.‘4 However, many children with GER may also have respiratory symptoms related to an From the Departments of Surgery and Pediatrics, Humana Children’s Hospital-Las Vegas, Las Vegas, W; Children’s Hospital of Oklahoma and the University of Oklahoma College of Medicine, Oklahoma City, OK; and Primary Children S Medical Center and the University of Utah College of Medicine, Salt Lake City, UT. Date accepted: April 6, 1990. Address reprint requests to Stephen G. Jolley, MD, 3201 Maryland Pkwy, Suite 414, Las Vegas, NV89109. Copyright Q 1991 by WB. Saunders Company 0022-3468/91/2606-0011$03.00/0
686
associated disorder rather than to GER. None of these studies provided a reliable method for documenting both the presence and absence of refluxinduced respiratory symptoms in all children prior to initiating treatment for GER. The mean duration of reflux episodes during sleep (ZMD) measured after the first 2 hours postcibal, and extracted from an 18- to 24-hour esophageal pH recording, has been proposed previously by us as a reliable correlate of respiratory symptoms caused by GER in children 6 months of age or less.15 This variable was the only reliable correlate of refluxrelated respiratory symptoms in the 40 variables examined from the esophageal pH recording. A ZMD prolonged beyond the normal range was found in virtually all infants whose respiratory symptoms responded to successful medical or surgical control of GER. In the present study, we isolate the ZMD as an indicator of risk for respiratory symptoms from GER and reexamine it’s validity in a larger group of both infants and children with respiratory symptoms. MATERIALS AND METHODS
Population A retrospective review was conducted on 837 consecutive children studied by the authors over a lo-year period (August 1977 to December 1987). The patients were referred for an evaluation of GER by 18- to 24-hour esophageal pH monitoring. The studies occurred at three separate institutions (Primary Children’s Medical Center, Children’s Hospital of Oklahoma, and Humana Children’s Hospital-Las Vegas). Of the 837 children reviewed, 519 were selected for this report because they represented all of the patients who presented with respiratory symptoms alone or in conjunction with other symptoms suggestive of GER. The ages ranged between 1 week and 15 years (mean, 11 months). There were 291 boys and 228 girls. Apnea or choking episodes occured in 317 (61%) children, recurrent pneumonia or chronic cough in 207 (40%) children, hyaline membrane disease (HMD) with subsequent BPD in 103 (20%) children, recurrent wheezing in 67 (13%) children, and chronic lung disease of unknown etiology in 15 (3%) patients. One hundred forty-eight children had more than one respiratory symptom. Two hundred thirty-four children (45%) had respiratory symptoms as the only symptom leading to referral for an evaluation of GER. Two hundred forty-one (47%) children had respiratory symptoms without a history of repeated emesis.
Esophageal pH Monitoring Extended (18 to 24 hours) esophageal pH monitoring with an analysis of the esophageal pH recording was performed in all Journal of Pediatric Surgery,
Vol 26,
No 6 (June), 1991: pp 686-690
GASTROESOPHAGEAL
REFLUX AND RESPIRATORY SYMPTOMS
children as described previously.‘6 The presence or absence of GER was determined by a composite pH score (normalvalue I 64) derived from data in the recording intervals after the first 2 hours following feedings. The discrimination of normal children from children with GER has been established with this composite pH score.16 The ZMD was extracted from the greater than 2 hours postcibal recording intervals in the esophageal pH recording by totalling the time of esophageal pH 12
6/31 (19%)
L P
