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[Dysphagia] Pediatric aspiration problems
Re the comment about ongoing exchange about aspiration - at the risk of being repetitive, some types of aspiration are harmless BUT no aspiration can ever be considered in isolation. A full and complete history is essential to determine what is being aspirated, how much, how often for how long and, most importantly, how resistant to infection is the patient.
Shelley <ShelleyBautista@hotmail.com> wrote:FLAVOR00-NONE-0000-0000-0000000000004.0; No. Mikey had a g-tube placed June 2003 and a fundoplication done October 2004.
Shelley
-------Original Message-------
From: Irene Campbell-Taylor
Date: 12/03/04 17:00:34
To: Buckie,Marcia; Shelley; dysphagia@b9.com
Subject: RE: [Dysphagia] Pediatric aspiration problems
Perhaps I missed the information but was a fundoplication performed at the time the G-tube was inserted?
"Buckie,Marcia" <mbuckie@dmc.org> wrote:
Thank you so much for your informative reply. What is interest to me is you son's positive response to not having aspiration during p.o. speaks to the ongoing exchange we have had on this list about whether this type of aspiration is even harmful, and in your son's case, it clearly was. MPB
-----Original Message-----
From: dysphagia-bounces@b9.com [mailto:dysphagia-bounces@b9.com]On
Behalf Of Shelley
Sent: Tuesday, November 23, 2004 11:42 AM
To: dysphagia@b9.com
Subject: RE: [Dysphagia] Pediatric aspiration problems
What I don't understand is the many parent-members of the listserv over the
years who have had their children's recurrent respiratory infections
disappear when a PEG is placed. If reflux is more common with PEG, than why
is there improvement?
Marcia
You are still decreasing the total amount of foreign material being
aspirated.
Being one of those parents, I thought I would reply...at least my thoughts
with regards to my son's case.
I think there is dramatic improvement because the amount being aspirated is
significantly reduced by the placement of the gtube (PEG or button type).
When you place the gtube and eliminate orally those things being aspirated
you DO decrease the opportunity for aspiration in a major major way. That
can make a huge difference in a chronic aspirator. Additionally, in my son's
case, reflux from the gtube was not immediate. It developed over the course
of a year and slowly built up to severe. We must have been 4-5 months reflux
free or at least so mild there was no impact. It gave my little one a
perfect opportunity to heal those messed up lungs. The results were very
dramatic. Now when he aspirates reflux or orally he recovers much much
quicker, usually without medical intervention.
With regards to my son, pnuemonitis doesn't cause quite the same symptoms as
an infection does. There is no fever for one and he rarely wheezes. Also
because he is/was no longer chronically aspirating, his symptoms don't get
as severe or last as long as they did before. If I had not spent a year
documenting respirations, retractions, oxygen saturation and lung noises as
heard by a stethascope, it might be difficult for me to pick up on when he
has aspirated reflux. A lot of homes don't have a pulse oximeter. There have
been occassions when my little one is tired, a little pale and maybe having
very mild retractions. If that is all I could see or determine, I might
conclude he wasn't feeling well in an ambiguos sort of way or just tired.
Especially when he obviously felt better in the morning or later in the day.
After listening to his lungs with a stethoscope and hearing decreased
breathe sounds in the right lung with faint crackles, counting respirations
and noting a mild increase, checking his oxygen saturation and finding it at
95, I would more correctly conclude he aspirated reflux. Pnuemonitis will
also clear up without the aid of antibiotics. When my son actually vomits or
has a significant reflux event, his respiratory symptoms are much more
pronounced and last longer, but it takes steroids to clear him up and not
antibiotics. If he has had a significant aspiration episode, he will
gradually get as bad as he is going too (equivalent to a moderate asthma
attack) and either get better or plateau. If he plateaus, we do oral
steroids and he clears with time, otherwise we do nothing. He does not keep
getting worse and worse and worse to the hospitalization point as one would
with unchecked pneumonia or other infection. My point: the respiratory
symptoms might not be as noticiable, especially if you were used to dealing
with respiratory symptoms that landed you in the hospital...these milder
ones might go unnoticed.
Shelley
(Mikey's Mom)
Background if you need/want it. A more detailed background is somewhere in
the archives May-June of 2003.
At 18 months of age my son began having sudden sporadic episodes of
respiratory distress. They continued to become more and more frequent and
chronic in nature. Reflux was ruled out at that time by a 24 ph study
(double probe), endoscopy, scinitscan and the fact there were no symptoms.
Eventually he was constantly experiencing symptoms of respiratory distress,
it never abated and gradually got worse and constant. (Elevated respirations
decreased oxygen saturation, dusky episodes, crackles and decreased breathe
sounds in his lungs.) In just a few months, he was on oxygen. There was not
a day that went by he was symptom free.
Finally a year later, a modified barium swallow study showed he had
laryngeal penetration with thick purees and thin purees with 80% of his
swallows. They concluded it was chronic silent micro aspiration and that
made sense to me as it seemed to fit any patterns I had noted over the
previous year. That combined with his clinical history led to a gtube for
fluid replacement and the unsafe textures were totally eliminated from his
diet. That was June 2003. His respiratory improvements were extremely
dramatic after the unsafe textures were eliminated. The symptoms were
totally gone. He began swallowing therapy and still attends 2 days a week.
He is slowly making progress. It appears the problem is more neurological in
nature and not muscle strength or discoordination.
Since the introduction of the gtube, he has either begun refluxing or it
amplified an exisiting mild reflux problem. At any rate, a year later, he
constantly silently refluxes. (Confirmed by 24 hour ph and endoscopy). We
did a Nissen Fundoplication a month ago to control/stop the reflux. The
quality of his lungs is different when he aspirates reflux than when he
aspirates food products. It is worse with reflux and I can usually tell the
difference...especially when I know he has snuck a drink of something or
vomited. Sometimes when he sneaks drinks, his symptoms aren't appreciable
(increased respiration and retracting for a couple of hours) and don't
panic" me, but I know repeated and prolonged episodes will send us right
back to were a couple of years ago. If you listen to his lungs with a
stethoscope before swallowing something liquid, he is clear. Afterwards, you
can often hear it gurgling in his lungs.
Anyway, he has since had another swallow study that shows the same
penetration, but not quite as often, I can't remember the %. Maybe 60%.
It seems all to easy to assign recurrent respiratory problems in children to
direct aspiration of oropharyngeal contents while the majority are actually
due to aspirated reflux (pneumonitis). It seems that a great deal of
emphasis os placed on "negative" Gi examinations, even pH monitoring. Little
et al, found startling results on double probe pH monitorint in which while
few children showed reflux on the lower probe, many showed reflux at the
upper probe. This seems to be counter-intuitive but must be kept in mind as
an explanation for recurrent respiratory problems that appear to be due to
direct aspiration but may not be:
Diagnosis of Pediatic Laryngopharyngeal Reflux
by Double-Probe pH Monitoring:
Why The Pharyngeal Probe is Essential
J.P. Little, MD *, B.L. Matthews, MD *, M.S. Glock, MD **,
Jamie Koufman, MD *, D. Berry, MD **, and W. Chwals, MD ***
I found this article very interesting because during my son's double probe ph study, the upper probe frequently showed a lower pH for longer periods of time than the lower probe. His GI found it a bit baffling, but his swallowing therapist did not. She grasped the impact of that immediately. :)_______________________________________________
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Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
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Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
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