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© Borgis - New Medicine 4/2016, s. 114-118 | DOI: 10.5604/14270994.1228141
Krzysztof Ślączka1, Marcin Dziekiewicz2, Monika Jabłońska-Jesionowska1, *Lidia Zawadzka-Głos1
Gastroesophageal reflux disease in children with recurrent croup
1Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
2Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
Head of Department: Piotr Albrecht, MD, PhD
Summary
Introduction. Episodic croup occurs most often in children between 0.5 and 3 years of age. Recurrent croup presents most often in older children. It shows an association with gastroesophageal reflux disease, allergy and laryngeal abnormalities.
Aim. The aim of this study was to explore the relationship between recurrent croup and gastroesophageal reflux disease in children with the history of at least one episode of severe croup.
Material and methods. The study included 22 children with recurrent croup admitted to the Department of Pediatric Otolaryngology of the Medical University of Warsaw between the years 2013 and 2016. Information concerning leading symptoms and medical history was obtained from the medical documentation of the patients. All the patients underwent rigid laryngoscopy and were diagnosed using 24-hours, single probe esophageal pH monitoring.
Results. 22 children aged between 1.5 year to 7.5 years were examined and their medical records were analyzed. An acid reflux was diagnosed in fourteen patients (63.6%) and the mean Reflux Index was 11.6. On endoscopic examination of the larynx, 15 patients (61.8%) had normal findings, 7 patients (31.8%) were diagnosed with an airway abnormality including: 3 cases of laryngeal cleft (type I), 2 cases of laryngomalacia, 1 case of subglottic stenosis, 1 case of vocal fold nodules. In 5 cases (22.7%), GERD coexisted with larynx abnormalities.
Conclusions. All the children with recurrent croup should be diagnosed for both gastroesophageal reflux disease and laryngeal abnormalities. Therefore, ENT specialists, as well as gastroenterologists, should take part in diagnostic procedures to reveal primary conditions responsible for recurrent croup.
INTRODUCTION
Croup is a common respiratory tract disease in children. It presents with an acute onset, hoarseness, inspiratory stridor, barking cough and respiratory distress (1). These symptoms are caused by the inflammation and narrowing of the subglottic area of the larynx, which is the narrowest part of the respiratory tract in children (2, 3). Infectious croup is typically caused by viruses, especially during fall and winter (4). It primarily affects children between 6 months and 3 years of age, with the peak incidence at two years of age (5). It is unusual for healthy children to have more than one episode of croup per year (6). However, when the croup-like episodes occur more than two times in a year, it is referred to as recurrent croup and its presence should alert clinician to investigate underlying reasons for it (tab. 1) (7).
Tab. 1. Risk factors for recurrent croup in children (11)
CongenitalCongenital subglottic stenosis
Congenital cardiovascular abnormality
Tracheo-oesophageal fistula
Laryngotracheal cleft
Tracheobronchomalacia
Vocal cord paralysis
Congenital tracheal stenosis
Congenital goitre
TraumaticAcquired subglottic stenosis
Subglottic cyst
Airway foreign body
InflammatoryGastroesophageal reflux disease
Asthma
Allergy
InfectiousViral
Bacterial
TumorSubglottic haemangioma
Lymphangioma
Thyroid neoplasm
Recurrent respiratory papillomatosis
Thymoma
Lymphoma
Mediastinal mass
Frequent croup episodes can be caused by a disease that narrows respiratory tract (6). Several recent studies have shown an association between recurrent croup and gastroesophageal reflux disease (GERD), laryngeal abnormalities, allergy, atopy, airway hyperreactivity and asthma (tab. 2) (8-10).
Tab. 2. Diseases and symptoms related to GERD in children (16)
Upper respiratory tractLower respiratory tractDigestive tract
– subglottic
– stenosis
– laryngomalacia
– vocal cord
– nodules
– recurrent croup
– recurrent otitis media
– chronic rhinitis
– asthma
– recurrent
– papillomatosis
– wheezing
– eosinophilic esophagitis
– swallowing
– dysfunction
– vomiting
– burping
Moreover, antireflux therapy in GERD-positive cases can successfully reduce the number and duration of croup-like episodes (11).
AIM
The aim of this study was to explore the relationship between recurrent croup and gastroesophageal reflux disease in children with the history of at least one episode of severe croup.
MATERIAL AND METHODS
The study was conducted on a group of pediatric patients with recurrent croup admitted to the Department of Pediatric Otolaryngology of Medical University of Warsaw between January 2013 and February 2016. Recurrent croup was defined as more than 2 episodes of croup-like syndrome per year. All children were admitted to the hospital due to an episode of severe croup (more than 6 points in Westley Croup Score) at least once in their lifetime. In most cases, the leading symptoms of croup episodes included inspiratory stridor, barking cough and inspiratory dyspnea. In the Department, each patient was treated using the same scheme, including i.v. steroids combined with nebulized steroids and adrenaline. The collected medical data included age, sex, symptoms, medical history, the number of croup episodes and hospitalizations for croup, as well as the number of emergency visits. All patients undergone rigid endoscopic laryngoscopy to inspect the airways from epiglottis to trachea. Reflux finding score (RFS) was then given based on the endoscopic examination. All the patients were investigated for GERD using 24-hour, single probe esophageal pH monitoring, which was placed at the level of the 2nd vertebra above the diaphragm (based on the X-ray scan). Based on the results of the examination, Reflux Index (RI) was calculated and acid gastroesophageal reflux disease was diagnosed or excluded. Children with diagnosed GERD were enlisted for the outpatient reflux treatment. They all subsequently achieved symptom-free status.
RESULTS

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Piśmiennictwo
1. Bjornson CL, Johnson DW: Croup. Lancet 2008; 371: 329-339. 2. Cooper T, Kuruvilla G, Persad R et al.: Atypical croup:association with airway lesions, atopy, and esophagitis. Otolaryngol Head Neck Surg 2012 Aug;147(2): 209-214. 3. Harless J, Ramaiah R, Bhananker SM: Pediatric airway management. Int J Crit Illn Inj Sci 2014 Jan-Mar; 4(1): 65–70. 4. Knutson D, Aring A: Viral croup. Am Fam Physician 2004 Feb 1; 69(3):535-540. 5. Rittichier KK, Ledwith CA: Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics 2000 Dec; 106(6):1344-1348. 6. Joshi V, Malik V, Mirza O et al.:Fifteen-minute consultation: structured approach to management of a child with recurrent croup. Arch Dis Child Educ Pract Ed 2014 Jun; 99(3): 90-93. 7. Farmer TL, Wohl DL: Diagnosis of recurrent intermittent airway obstruction ("recurrent croup") in children. Ann Otol Rhinol Laryngol 2001 Jul; 110(7 Pt 1): 600-605. 8. Arslan Z, Cipe FE, Ozmen S et al.: Evaluation of allergic sensitization and gastroesophageal reflux disease in children with recurrent croup. Pediatr Int 2009 Oct; 51(5): 661-665. 9. Waki EY, Madgy DN, Belenky WM et al.: The incidence of gastroesophageal reflux in recurrent croup. Int J Pediatr Otorhinolaryngol. 1995 Jul; 32(3):223-232. 10. Kwong K, Hoa M, Coticchia JM: Recurrent croup presentation, diagnosis, and management. Am J Otolaryngol 2007 Nov-Dec; 28(6): 401-407. 11. Hoa M, Kingsley EL, Coticchia JM: Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann Otol Rhinol Laryngol. 2008 Jun; 117(6): 464-469. 12. Contencin P, Narcy P: Gastropharyngeal reflux in infants and children. A pharyngeal pH monitoring study. Arch Otolaryngol Head Neck Surg 1992 Oct; 118(10): 1028-1030. 13. Hartl TT, Chadha NK: A systematic review of laryngomalacia and acid reflux. Otolaryngol Head Neck Surg 2012 Oct; 147(4): 619-626. Epub 2012 Jun 27. 14. Rankin I, Wang SM, Waters A et al.: The management of recurrent croup in children. J Laryngol Otol 2013 May;127(5): 494-500. 15. Greifer M, Santiago MT, Tsirilakis K et al.: Pediatric patients with chronic cough and recurrent croup: the case for a multidisciplinary approach. Int J Pediatr Otorhinolaryngol 2015 May; 79(5): 749-752. 16. Venkatesan NN, Pine HS, Underbrink M.: Laryngopharyngeal reflux disease in children. Pediatr Clin North Am 2013 Aug; 60(4): 865-78. doi: 10.1016/j.pcl.2013.04.011.
otrzymano: 2016-10-14
zaakceptowano do druku: 2016-11-29

Adres do korespondencji:
*Lidia Zawadzka-Głos
Department of Pediatric Otolaryngology Medical University of Warsaw
63A Żwirki i Wigury Str., 02-091 Warsaw, Poland
tel.: +48 (22) 317-97-21
e-mail: laryngologia@litewska.edu.pl

New Medicine 4/2016
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