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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 203-205

Childhood gastroesophageal reflux disease with laryngopharyngeal reflux and association of psychosocial risk factors

1 Department of Paediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Otolaryngology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission23-May-2022
Date of Decision02-Aug-2022
Date of Acceptance02-Aug-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Priya Jose
Department of Paediatrics, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry - 605 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_43_22

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Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are inflammatory sequelae following the backflow of stomach contents to the esophagus or larynx/pharynx, respectively, the latter most often occurring in GERD. Unlike adults, the clinical parameters of “reflux symptom index” and “reflux finding score” are not routinely done in children suspected of LPR associated with GERD. Proton-pump inhibitor (PPI) trial with a 50% reduction of symptom severity following 2–4 weeks of empirical PPI, which is then continued for 12 weeks, is considered a valuable diagnostic and therapeutic tool for GERD in children. We present our successful management of an 8-year-old child, who had primarily respiratory symptoms with no associated respiratory, cardiac, or neurological etiology. Clinical evidence of underlying LPR secondary to GERD was confirmed by otolaryngologists with Reflux Finding Score. Significant psychosocial risk factors observed during her evaluation were addressed by psychologists. PPI therapy and behavioral therapy were initiated and the child improved drastically. The association of significant psychological issues in family and the social context appears to be significant in childhood GERD. A multidisciplinary comprehensive clinical approach is the cornerstone for its successful medical management.

Keywords: Pediatric gastroesophageal reflux disease, pediatric laryngopharyngeal reflux, psychosocial factors, reflux finding score

How to cite this article:
Jose P, Ganesh S S, Deve L, Kurien M. Childhood gastroesophageal reflux disease with laryngopharyngeal reflux and association of psychosocial risk factors. J Curr Res Sci Med 2022;8:203-5

How to cite this URL:
Jose P, Ganesh S S, Deve L, Kurien M. Childhood gastroesophageal reflux disease with laryngopharyngeal reflux and association of psychosocial risk factors. J Curr Res Sci Med [serial online] 2022 [cited 2023 May 28];8:203-5. Available from: https://www.jcrsmed.org/text.asp?2022/8/2/203/364500

  Introduction Top

Abnormal involuntary backflow of gastric secretions or contents into the lower esophagus causing mucosal injury is referred to as gastroesophageal reflux disease (GERD) while that into the larynx and pharynx through the upper esophageal sphincter producing laryngeal inflammation is laryngopharyngeal reflux (LPR). Heartburn is uncommon in LPR, although chronic symptoms such as throat burning or constant clearing, dry cough, hoarseness of voice, and globus sensation can occur.[1] A correlation between the presence of LPR and the severity of GERD has also been identified.[2] Reflux symptom index (RSI), is a nine-item questionnaire that rates patients' severity of LPR symptoms on a Likert scale. The maximum score is 45, with more than 13 being diagnostic of acid reflux.[3] Reflux finding score (RFS) is a nine-item clinical severity scale based on laryngeal findings during video laryngoscopy. Scores from 0 (normal) to 26 (worst possible score) indicate the severity of inflammation. LPR is diagnosed with 95% certainty when RFS exceeds seven.[4] RSI and RFS improve the accuracy of LPR diagnosis and also evaluates its treatment efficiency.[5] We describe our experience in the management of a child with primarily respiratory symptoms. Following detailed evaluation by a pediatrician and otolaryngologists, LPR secondary to GERD was diagnosed. Associated psychosocial risk factors in this patient were an additional confounding factor.

  Case Report Top

An 8-year-old girl, first born to nonconsanguineous parents with a normal birth history presented to the pediatric outpatients with her mother who informed that patient had a recurrent cough, breathing difficulty (Grade II New York Heart Association), and chest pain for the past 18 months. She had abnormal sounds while walking, coughing, and eating. She was unable to carry out daily activities and had night awakenings with breathing difficulty. She also had a loss of appetite and weight loss for the past 12 months. She had several evaluations in various hospitals for the above symptoms. Since the age of 7, she had five episodes of respiratory infections treated with antibiotics, antihistamines, and steroid inhalers, the latest being formetrol inhaler and mometasone nasal spray for the past 5 months and 1 month, respectively.

Clinically, the patient was thinly built with normal general physical examination, respiratory and heart rate including capillary refill time. Her SpO2 was 98% at room air. Systemic examinations including complete blood count, chest radiography, electrocardiogram, and echocardiography were normal. COVID reverse transcription-polymerase chain reaction, sputum acid fast bacilli (AFB), Mantoux, and GeneXpert were negative. Transnasal awake flexible nasopharyngolaryngoscopy done under local anesthesia by otolaryngologists revealed laryngoscopic findings of RFS with a score of 11 [Table 1] and bilateral mobile vocal cords with normal subglottis. There was a pooling of saliva in both pyriform fossae. Flexible endoscopic evaluation of swallowing (FEES) was done with orange juice and observed for initiation/penetration/aspiration/residue.[6] This revealed minimal penetration and aspiration [Figure 1]. RSI on reviewing history was noted to be seven. Speech assessment revealed mild stuttering with minimal hoarseness of voice.
Table 1: Reflux finding score

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Figure 1: Penetration and aspiration of colored fluid (orange juice)

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Considering this child's relatively older onset of predominantly respiratory symptoms with laryngoscopic findings of RFS-15 and aspiration (by FEES), LPR secondary to GERD was considered. Proton-pump inhibitor (PPI) trial therapy was then initiated for 3 weeks.

During clinical evaluation, a history of parental marital issues was noted. She was referred to a child psychologist who took detailed interviews with both mother and daughter. The psychologist's opinion was that, although this child was cooperative, well-groomed with average intelligence, and responded well to instructions during the assessment; she had difficulty in learning and had inadequate visual memory. Despite her good relationship with peers, her mother, and other family members, that with her father was very strained. She had a severe emotional conflict due to parental separation and her father threatening her mother!! This strained relationship with extreme anxiety and anger toward her father had led to passive aggression and physical complaints.

With the diagnosis of LPR (as revealed by RFS score and FEES) and underlying GERD as revealed by her positive response to PPI trial therapy, her definitive treatment with PPI therapy was then continued for 9 more weeks. In the meantime, considering the significant psychological overlay to the above diagnosis, in addition to dietary modification with swallowing therapy, the child and her mother had sessions of behavioral therapy for 3 weeks. The child was guided on anxiety as well as anger management, suppression of emotion, and effective ventilation techniques. Her mother was advised on behavioral management and providing a safe, protective environment for her daughter. Repeat fiberoptic laryngoscopy 6 weeks later was normal with no aspiration.

  Discussion Top

GERD in the pediatric population and its multifaceted clinical presentation, especially when symptoms arise from the respiratory tract is indeed a challenge. A potential etiologic factor in children with an unexplained cough could be asymptomatic acid and nonacid gastroesophageal reflux. In cough-related GERD, the increased acid exposure and delayed acid clearance time typical of erosive reflux disease are absent.[7] Typical GERD symptoms can be reliably assessed in children 8–12 years of age.[8] Statistically, a significant correlation was also noted between the severity of esophagitis and RFS among children who underwent upper gastrointestinal tract endoscopy.[9]

Psychological association among children with GERD when compared to healthy ones revealed those classified as “requiring psychological or psychiatric follow-up,” were significantly more among those with GERD.[8] A nationwide survey in Germany reported two-thirds of children and adolescents being highly burdened by the COVID pandemic with significantly more mental health problems and higher anxiety levels than before the pandemic.[10] As our patient presented to us, in the recent past, the possibility of COVID-19 pandemic impact, with its economic and social risk factors confounded by school closure, the pressure of online classes, and paucity of peer interaction among children, are a reality that cannot be ignored.

  Conclusion Top

To date, diagnostic criteria of childhood GERD is a positive response of 50% reduction of symptom severity following 2–4 weeks of empirical PPI trial therapy. In addition, a multidisciplinary approach with fiberoptic laryngoscopic evaluation for RFS and swallowing (FEES) to confirm LPR along with evaluation of psychosocial risk factors, are being suggested in the management protocol of childhood GERD.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's mother has given her consent for their daughter's clinical information to be reported in the journal. The patient's mother understands that their daughter's name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991;101:1-78.  Back to cited text no. 1
Groome M, Cotton JP, Borland M, McLeod S, Johnston DA, Dillon JF. Prevalence of laryngopharyngeal reflux in a population with gastroesophageal reflux. Laryngoscope 2007;117:1424-8.  Back to cited text no. 2
Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice 2002;16:274-7.  Back to cited text no. 3
Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001;111:1313-7.  Back to cited text no. 4
Kirti YK. Reflux Finding Score (RFS) a quantitative guide for diagnosis and treatment of laryngopharyngeal reflux. Indian J Otolaryngol Head Neck Surg 2018;70:362-5.  Back to cited text no. 5
Miller CK, Willging JP. Fiberoptic endoscopic evaluation of swallowing in infants and children: Protocol, safety, and clinical efficacy: 25 years of experience. Ann Otol Rhinol Laryngol 2020;129:469-81.  Back to cited text no. 6
Borrelli O, Marabotto C, Mancini V, Aloi M, Macrì F, Falconieri P, et al. Role of gastroesophageal reflux in children with unexplained chronic cough. J Pediatr Gastroenterol Nutr 2011;53:287-92.  Back to cited text no. 7
Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, et al. Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009;49:498-547.  Back to cited text no. 8
Ugras MK, Dogan M, Pata DY, Ozkan F. Can the reflux finding score and reflux symptom index be used to evaluate the severity of esophagitis in children? J Voice 2021;35:157.e7-10.  Back to cited text no. 9
Ravens-Sieberer U, Kaman A, Erhart M, Devine J, Schlack R, Otto C. Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany. Eur Child Adolesc Psychiatry 2022;31:879-89.  Back to cited text no. 10


  [Figure 1]

  [Table 1]


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