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
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.
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)
|Congenital||Congenital subglottic stenosis|
Congenital cardiovascular abnormality
Vocal cord paralysis
Congenital tracheal stenosis
|Traumatic||Acquired subglottic stenosis|
Airway foreign body
|Inflammatory||Gastroesophageal reflux disease|
Recurrent respiratory papillomatosis
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 tract||Lower respiratory tract||Digestive tract|
|– subglottic |
– vocal cord
– recurrent croup
– recurrent otitis media
– chronic rhinitis
|– eosinophilic esophagitis|
Moreover, antireflux therapy in GERD-positive cases can successfully reduce the number and duration of croup-like episodes (11).
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.
22 children between 1.5 year to 7.5 years of age were examined and their medical records were analyzed. The mean age at their first stay in our Department was 4.25 ± 1.85 years, with the youngest child being 22 months old and the oldest being 89 months old, and the mean age at the first croup episode was 7.8 ± 5.9 months. The male-to-female ratio was 2.1:1. The mean BMI was 16 ± 2 kg/m2. All the patients had had a history of at least one emergency room visit, as well as one hospital admission due to a croup episode. Sixteen children (72.7%) had had croup episodes more than three times a year and eight children (36.3%) had been hospitalized for croup more than once in their lifetime. Two children (9%) had a history of ICU hospitalization and one of them had been intubated in infancy (4.5%). Four children (18.1%) had had low birth weight and five children (22.7%) had been born prematurely before the completion of 37 weeks of gestational age. Seven patients (31.8%) had had at least one comorbidity: 2 children were diagnosed with atopic dermatitis, 4 – with allergy and asthma and 1 – with epilepsy.
An acid GER disease was found in fourteen patients (63,6%) and the mean RI in this group of children was of 11,6%, with RI > 4.5% being considered as positive. The mean BMI of patients diagnosed with GERD was 16 for both sexes and BMI was higher than 17 in only two children. Parents or legal guardians of children diagnosed with GERD were asked about their children’s dietary habits. 85% of children “very often” consumed a type of food that is considered unhealthy (full-fat cheese, white bread, sweets, fast-food and snacks). Only in 3 cases, the parents admitted to carefully avoiding saturated fats and high-calorie snacks and replacing it with a healthy diet: vegetables, fruit and dairy.
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