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Original Article |

Extraesophageal Reflux in Pediatric Patients With Upper Respiratory Symptoms FREE

Kristina W. Rosbe, MD; Margaret A. Kenna, MD; Andrew D. Auerbach, MD, MPH
[+] Author Affiliations

From the Departments of Otolaryngology–Head & Neck Surgery (Dr Rosbe) and Medicine (Dr Auerbach), University of California, San Francisco; and Department of Otolaryngology and Communication Disorders, The Children's Hospital, Boston, Mass (Dr Kenna). The authors have no relevant financial interest in this article.


Arch Otolaryngol Head Neck Surg. 2003;129(11):1213-1220. doi:10.1001/archotol.129.11.1213.
Text Size: A A A
Published online

Objective  To systematically review published literature describing the association between reflux and upper airway symptoms in children.

Design  Structured MEDLINE search of English-language articles published since 1966.

Subjects  We selected articles examining reflux in conjunction with stridor, apnea, sudden infant death syndrome, life-threatening events, and laryngomalacia. Studies that focused on lower airway symptoms or adults were excluded.

Outcome Measures  Articles were abstracted for patient factors, elements of study design, methods of reflux diagnosis, and definition of pathologic reflux.

Results  Ninety-nine articles were identified, 56 of which specifically examined reflux and upper respiratory symptoms in children. Of these, 10 compared reflux incidence in symptomatic patients and a set of predetermined control patients, while the remainder reported prevalence data only. Overall, symptomatic patients were diagnosed with reflux frequently, with a range from 27% to 100%. In studies that attempted to compare patients with controls, only 2 provided statistical comparisons of the patient groups, and none adjusted for confounding owing to study design. There was marked heterogeneity in methods used to diagnose reflux in the studies reviewed, with only 34% using dual-channel pH testing; definitions of pathologic reflux were also variable.

Conclusions  Evidence seems to support the hypothesis that reflux is associated with upper airway symptoms in children. However, the strength of this correlation and the risk of upper airway symptoms attributable to reflux are difficult to determine given the limitations of available literature. Future research studies should seek standard reflux testing methods, clear comparison groups, and more rigorous statistical methods.

CONSULTATION FOR upper respiratory symptoms in children is common for the pediatric otolaryngologist. In the past, gastroesophageal reflux has been considered closely associated with stridor and other upper respiratory symptoms in children. However, to our knowledge, the evidence behind this assumption and the impact of treatment on symptoms has not been previously summarized. Although some symptoms are relatively benign and can be followed expectantly (ie, stridor from laryngomalacia without failure to thrive or significant respiratory distress), other upper airway symptoms such as respiratory distress secondary to subglottic stenosis preventing extubation in a newborn or an acute life-threatening respiratory event require more immediate investigation.

Reflux is considered a risk factor for many upper respiratory symptoms in children.1 Additionally, otitis media, chronic sinusitis, lymphoid hyperplasia, hoarseness, laryngeal edema, or nodules have all been associated with reflux.214 Therefore, identifying and treating coexistent reflux could improve outcomes while eliminating the need for invasive procedures in this population of children.

Laryngopharyngeal reflux is a more recently identified clinical entity. In contrast to gastroesophageal reflux, laryngopharyngeal reflux involves gastric acid reflux through the upper esophageal sphincter into the pharynx rather than across the lower esophageal sphincter.15,16 As a result, laryngopharyngeal reflux can only be diagnosed by proximal (pharyngeal) pH probe placement, a technique refined in adults in the mid-1980s, but which is still not a commonly performed diagnostic modality for children despite its proposed role as the "gold standard."15,17,18 Any episode of laryngopharyngeal reflux in adults is believed to be pathologic,1922 and few if any episodes of laryngopharyngeal reflux should be considered normal in children.2325

Laryngopharyngeal reflux has been proposed to play a key role—at least as significant as gastroesophageal reflux—in several pediatric upper airway symptoms including subglottic stenosis and acute life-threatening respiratory events. However, studies linking reflux and upper respiratory symptoms in children are heterogeneous, representing a wide range of research designs, sample sizes, definitions of reflux, and treatment protocols. Thus, the purpose of this study was to systematically review the literature with the aim of determining the strength of the available data supporting the link between reflux and upper respiratory symptoms in children.

We searched MEDLINE, the electronic bibliography database of the US National Library of Medicine, using the Medical Subject Heading (MeSH) terms gastroesophageal reflux, aspiration, esophagitis;peptic in combination with key title and text words including stridor, apnea, ALTE (acute life-threatening respiratory event), SIDS (sudden infant death syndrome), and laryngomalacia. To identify additional studies, we examined reference lists from published guidelines and book chapters in our topic area, as well as reference lists of our initially identified articles.1,26

We then excluded non–English-language articles, those not including an abstract, those that focused solely on lower airway symptoms (such as asthma), and those that studied adults only. Articles that met these criteria were then abstracted by trained reviewers (K.W.R. and A.D.A.) for key outcomes and elements of study design. Because of the recognized difficulties in quality scoring of trials, we did not score studies meeting our inclusion criteria. However, abstraction forms for each article included key elements pertaining to trial design, such as reporting of important confounders or biases, comparability of the patient groups, and methods for matching patient groups or accounting for bias. Because 24-hour dual-channel pH probe monitoring is considered the gold standard diagnostic test for reflux, we abstracted all articles for whether this test was part of outcome measurements.2730 Finally, we also specifically abstracted articles for their definition of reflux.

Or analytic plan sought to distinguish articles that could be used to determine prevalence from articles that could allow estimation of risk for symptoms attributable to reflux. To this end, we split articles into 2 groups: (1) articles that reported prevalence of reflux within a defined subset of symptomatic patients and (2) articles that compared incidence of reflux in a symptomatic population with that in a predefined control group or those that attempted to match—via study design or statistical methods—reflux incidence in symptomatic and asymptomatic patients. Although all articles were reviewed for diagnostic modalities, this smaller subset of articles was then abstracted for elements that would allow estimation of the strength of the association between reflux and upper respiratory symptoms in children.

OVERVIEW

We initially identified 99 articles, 43 of which were excluded because they studied animals, enrolled adults, or focused on lower airway symptoms, yielding a core list of 56 articles that examined reflux and upper respiratory symptoms in children. We then excluded 2 studies that enrolled asymptomatic patients and reported population normative data only31,32 and 3 case series that did not report explicit entry criteria.3335 Five additional studies were excluded because they involved treatment trials but did not include a control group from which conclusions regarding prevalence could be drawn.3640 Finally, we excluded studies in which reflux testing was performed so inconsistently that we could not discern which patients were tested and which were not,13 that reported results that were not clearly peer reviewed,5 that enrolled patients with reflux only,12,41 that did not report objective diagnostic data,42 and that correlated periods of apnea in patients with known reflux.43 Studies in which it was unclear whether symptoms and reflux incidences overlapped were also excluded.4446

Thus, our final group of articles reported results from patients enrolled in 35 studies published since 1979. As a group, these studies were uniformly based at academic medical centers or children's hospitals. Of these studies, 21 (60%) were performed prospectively and 14 (40%) were performed retrospectively, most often via medical record review. Of identified studies, only 12 (34%) explicitly reported results from dual-channel pH probe testing to diagnose reflux and 21 (60%) used other pH probe tests. Of additional tests, the most common modality was laryngoscopy and bronchoscopy (n = 13 [37%]), followed by barium swallow (n = 10 [29%]), gastric-emptying studies (n = 6 [17%]), and esophageal biopsy (n = 6 [17%]).

Of the 35 studies, 9 (26%) included subjects with multiple upper airway symptoms, 13 (37%) included subjects with apnea or a history of an acute life-threatening respiratory event, and 4 (11%) included subjects with laryngomalacia. Three studies (8%) examined patients with nasal obstruction or patients presenting with stridor from croup or subglottic stenosis. Sinusitis was the presenting symptom in 2 studies (6%), and hoarseness was the presenting symptom in 1 study (3%). Twenty-five articles reported data regarding prevalence only, and 10 attempted to compare reflux incidence in symptomatic patients with that of a control group.

STUDIES REPORTING REFLUX PREVALENCE IN PATIENTS WITH UPPER AIRWAY SYMPTOMS

Twenty-five articles reported the prevalence of reflux in patients with upper airway symptoms (Table 1). These articles displayed a range of definitions of reflux, with most defining pathologic reflux as various combinations of duration of esophageal acidity and severity of acidity. However, these definitions were inconsistent and ranged from rigorous, previously validated guidelines for diagnosis of reflux 47,52 to those with less apparent justification.55,65

Table Graphic Jump LocationTable 1. Studies Reporting Prevalence of Reflux in Patients With Upper Airway Symptoms4750,2,3,5154,29,31,55,8,5659,9,10,6063,24,6469

The most common symptom examined was apnea, which was a focus of investigation in 8 (32%) of these 25 identified studies, 4 (50%) of which involved premature infants. These 4 articles reported a range between 33% and 100% in reflux prevalence in premature patients with apnea compared with a range between 25% and 100% in full-term infants with reflux. A higher reflux prevalence was noted in studies that provided results of proximal pH probe testing29,66; lower prevalence of reflux was noted in studies that performed pH probe testing of shorter duration or that reported distal results only. A similarly broad range in reflux prevalence was noted for other upper airway symptoms, with most articles reporting prevalence of reflux in excess of 50%.

STUDIES COMPARING CONTROL AND SYMPTOMATIC PATIENTS

Ten articles reported prevalence of reflux in patients with upper airway symptoms and attempted to compare these patients with a control patient group (Table 2). Control groups were generally defined as asymptomatic patients or patients with symptoms not related to the upper respiratory tract. Few studies attempted any matching based on age, comorbidities (ie, prematurity), or other clinical factors, and only 2 studies 74,78 reported any baseline information describing these factors in their patient groups. In addition, few studies reported any specific rationale for case finding or choice of controls. Similar to the studies reporting prevalence only, these articles used variable methods to diagnose reflux, with only 3 using dual-channel pH probe testing for even a proportion of patients.

Table Graphic Jump LocationTable 2. Studies Comparing Incidence of Reflux in Control and Symptomatic Patients.7072,23,73,17,7478

Prevalence of reflux in symptomatic groups in these articles was similar to those seen in prevalence studies, with a range between 27% and 100%. Overall, most articles suggested an excess of reflux in symptomatic patients, with 7 (70%) of 10 using statistical methods to compare symptomatic patients with controls. However, other than the articles by See et al78 and Newman et al,74 none of these articles reported more than age and sex information regarding their patients, and none attempted to account for biases in their study design using statistical methods.

The results of our systematic review suggest that, although it is highly likely that reflux is associated with upper airway symptoms in children, the strength of this correlation is very difficult to determine. The available literature comprises studies largely derived from referral centers, most of which have substantial methodologic flaws related to inconsistent methods used for diagnosing reflux, biased patient populations, and limited statistical methods.

THE DIAGNOSIS OF REFLUX

There is general agreement that the 24-hour dual-channel pH probe with 1 channel in the esophagus and 1 channel in the pharynx is the diagnostic study of choice for reflux.18,79,80 Although reproducibility of pediatric 24-hour dual-channel pH probe results has been questioned81 and false-negative rates up to 20% have been reported, few other testing modalities have similar discriminative power. Barium swallow, scintiscan, endoscopy with biopsy, and bronchial washings for lipid-laden macrophages have been used,82,83 but they demonstrate sensitivities and specificities lower than dual-channel pH probe.84,85

Investigators have tried alternate diagnostic testing to aid diagnosis of reflux. Laryngoscopy and bronchoscopy findings—especially arytenoid edema, postglottic edema, and lingual tonsillar hypertrophy—have been demonstrated to correlate with acid exposure.45,54 However, few data exist to correlate laryngoscopy and bronchoscopy findings with pH probe results. Esophageal biopsy is promising, but also has not been compared with dual-channel pH probe testing, nor has its safety and feasibility compared with alternate testing modalities been proven.64,68 Also, studies using esophageal biopsy did not provide any information about pharyngeal acid exposure or laryngopharyngeal reflux.

Most studies we reviewed did not use dual-channel pH probe testing for diagnosis of reflux, and most used single-probe tests. Many studies combined results from multiple reflux tests, considering a patient to have reflux if he or she had just 1 positive diagnostic test result. Such "pooled positivity criterion" further muddies the diagnostic waters in that sequential testing may magnify the imprecision of individual tests. That is, if one orders a panel of 20 tests, each of which is 95% accurate, one can expect to have at least 1 false-positive test result and an inflated prevalence estimate. In contrast, many of the tests used for reflux have sensitivities far lower than 95% for detection of pathologic reflux, raising the possibility that these studies underestimate true prevalence.

Even within the studies that used pH probe testing, we observed a moderate amount of variability in the diagnostic criteria for reflux in terms of duration and severity of acid exposure. Although individual studies generally adhered to a published definition, across studies several criteria were used, limiting our ability to directly compare results. Even when appropriate diagnostic testing is performed, not all positive results necessarily mandate treatment. Some amount of reflux, especially in premature or newborn infants, may be physiologic and not pathologic. Comparison of different age groups would then reflect the natural history of improvement with age rather than true prevalence rates of pathologic reflux.

SHOULD CLINICIANS TREAT FIRST AND ASK QUESTIONS LATER?

Many consider treatment for reflux a necessary first step in the management of various airway symptoms. In an uncontrolled trial, patients with choanal atresia who received reflux therapy formed less granulation tissue and needed fewer revision procedures.3 Another investigator found that aggressive empiric treatment of reflux in patients with subglottic stenosis led to symptomatic improvement and eliminated the need for surgical intervention.9 However, other studies showing no impact of reflux treatment on airway surgery for subglottic stenosis have refuted this finding.86

Results from our systematic review suggest a reason for these apparently conflicting findings from clinical trials, since it is likely that an uncertain link between reflux and specific upper airway symptoms leads to uncertain clinical response. Empiric reflux treatment, especially when a low-risk approach is chosen, is likely to provide more benefit than risk as a first step. However, clinicians should be aware that little high-quality evidence exists to direct them to groups of patients who are most likely to benefit.

The studies we reviewed, although suggesting higher incidence of reflux in patients with upper airway symptoms, do not yet provide ample evidence to determine the magnitude of a causal link. Such a determination will require a study design using an appropriate control group, perhaps chosen on the basis of comorbidities or stage of development rather than site of care (ie, pediatric intensive care unit or referral for reflux tests on the basis of an alternate diagnosis). Admittedly, the identification and selection of controls may be difficult, but in the absence of an ideal group, adherence to standards of reporting that clinicians can use to make decisions about treatment should be the minimal standard. For example, many of the studies in our review were based at tertiary care centers and were likely subject to substantial referral bias. Few studies provided any patient information other than age or sex, making it nearly impossible to discern whether results from these studies could be used by non–tertiary care-based clinicians.8789 In addition to being potentially helpful in multivariable models by producing adjusted results, detailed information about patients' comorbidities would be useful for clincians simply seeking to apply evidence to their practices.

Our systematic review of studies examining the association between reflux and upper airway symptoms reveals that the literature has substantial shortcomings in terms of study design, reporting of results, methods to account for bias, and standard definitions of reflux. Although reflux plays an important role in some children with upper airway symptoms, the magnitude of this risk remains unclear. Future studies addressing these shortcomings will be required to provide the evidence for clinicians faced with these often challenging patients.

Corresponding author and reprints: Kristina W. Rosbe, MD, Department of Otolaryngology–Head & Neck Surgery, University of California, San Francisco, 400 Parnassus Ave, Suite A730, San Francisco, CA 94143-0342 (e-mail: krosbe@itsa.ucsf.edu).

Submitted for publication August 26, 2002; final revision received February 12, 2003; accepted March 12, 2003.

This study was presented at the American Society of Pediatric Otolaryngology; May 5, 2003; Nashville, Tenn.

Rudolph  CDMazur  LJLiptak  GS  et al Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr.2001;32:S1-S31.
PubMed
Belmont  JRGrundfast  K Congenital laryngeal stridor (laryngomalacia): etiologic factors and associated disorders. Ann Otol Rhinol Laryngol.1984;93:430-437.
PubMed
Beste  DJConley  SFBrown  CW Gastroesophageal reflux complicating choanal atresia repair. Int J Pediatr Otorhinolaryngol.1994;29:51-58.
PubMed
Bothwell  MRParsons  DSTalbot  ABarbero  GJWilder  B Outcome of reflux therapy on pediatric chronic sinusitis. Otolaryngol Head Neck Surg.1999;121:255-262.
PubMed
Contencin  PMaurage  CPloyet  MJSeid  ABSinaasappel  M Gastroesophageal reflux and ENT disorders in childhood. Int J Pediatr Otorhinolaryngol.1995;32:S135-S144.
PubMed
Gaynor  EB Otolaryngologic manifestations of gastroesophageal reflux. Am J Gastroenterol.1991;86:801-808.
PubMed
Gaynor  EB Laryngeal complications of GERD. J Clin Gastroenterol.2000;30:S31-S34.
PubMed
Gumpert  LKalach  NDupont  CContencin  P Hoarseness and gastroesophageal reflux in children. J Laryngol Otol.1998;112:49-54.
PubMed
Halstead  LA Gastroesophageal reflux: a critical factor in pediatric subglottic stenosis. Otolaryngol Head Neck Surg.1999;120:683-688.
PubMed
Herbst  JJMinton  SDBook  LS Gastroesophageal reflux causing respiratory distress and apnea in newborn infants. J Pediatr.1979;95:763-768.
PubMed
Kenna  MA The effect of gastroesophageal reflux on the pediatric airway. Int Anesthesiol Clin.1992;30:83-91.
PubMed
Nielson  DWHeldt  GPTooley  WH Stridor and gastroesophageal reflux in infants. Pediatrics.1990;85:1034-1039.
PubMed
Waki  EYMadgy  DNBelenky  WMGower  VC The incidence of gastroesophageal reflux in recurrent croup. Int J Pediatr Otorhinolaryngol.1995;32:223-232.
PubMed
Yellon  RF The spectrum of reflux-associated otolaryngologic problems in infants and children. Am J Med.1997;103:125S-129S.
PubMed
Postma  GNBelafsky  PCAviv  JEKoufman  JA Laryngopharyngeal reflux testing. Ear Nose Throat J.2002;81:14-18.
PubMed
Bach  KKMcGuirt  WF  JrPostma  GN Pediatric laryngopharyngeal reflux. Ear Nose Throat J.2002;81:27-31.
PubMed
Little  JPMatthews  BLGlock  MS  et al Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring of 222 children. Ann Otol Rhinol Laryngol Suppl.1997;169:1-16.
PubMed
Postma  GN Ambulatory pH monitoring methodology. Ann Otol Rhinol Laryngol Suppl.2000;184:10-14.
PubMed
Amin  MRPostma  GNJohnson  PDigges  NKoufman  JA Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg.2001;125:374-378.
PubMed
Koufman  JSataloff  RTToohill  R Laryngopharyngeal reflux: consensus conference report. J Voice.1996;10:215-216.
PubMed
Ulualp  SOToohill  RJ Laryngopharyngeal reflux: state of the art diagnosis and treatment. Otolaryngol Clin North Am.2000;33:785-802.
PubMed
Maronian  NCAzadeh  HWaugh  PHillel  A Association of laryngopharyngeal reflux disease and subglottic stenosis. Ann Otol Rhinol Laryngol.2001;110:606-612.
PubMed
Contencin  PNarcy  P Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis. Int J Pediatr Otorhinolaryngol.1991;22:249-256.
PubMed
Phipps  CDWood  WEGibson  WSCochran  WJ Gastroesophageal reflux contributing to chronic sinus disease in children: a prospective analysis. Arch Otolaryngol Head Neck Surg.2000;126:831-836.
PubMed
Zalzal  GHTran  LP Pediatric gastroesophageal reflux and laryngopharyngeal reflux. Otolaryngol Clin North Am.2000;33:151-161.
PubMed
Putnam  PE Gastroesophageal Reflux. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996.
Richter  JEBradley  LADeMeester  TRWu  WC Normal 24-hr ambulatory esophageal pH values: influence of study center, pH electrode, age, and gender. Dig Dis Sci.1992;37:849-856.
PubMed
Vincent  DA  JrGarrett  JDRadionoff  SLReussner  LAStasney  CR The proximal probe in esophageal pH monitoring: development of a normative database. J Voice.2000;14:247-254.
PubMed
Conley  SFWerlin  SLBeste  DJ Proximal pH-metry for diagnosis of upper airway complications of gastroesophageal reflux. J Otolaryngol.1995;24:295-298.
PubMed
Cucchiara  SStaiano  AGobio Casali  LBoccieri  APaone  FM Value of the 24 hour intraoesophageal pH monitoring in children. Gut.1990;31:129-133.
PubMed
Vandenplas  YSacre-Smits  L Continuous 24-hour esophageal pH monitoring in 285 asymptomatic infants 0-15 months old. J Pediatr Gastroenterol Nutr.1987;6:220-224.
PubMed
Vandenplas  YGoyvaerts  HHelven  RSacre  L Gastroesophageal reflux, as measured by 24-hour pH monitoring, in 509 healthy infants screened for risk of sudden infant death syndrome. Pediatrics.1991;88:834-840.
PubMed
Burton  DMPransky  SMKatz  RMKearns  DBSeid  AB Pediatric airway manifestations of gastroesophageal reflux. Ann Otol Rhinol Laryngol.1992;101:742-749.
PubMed
Bauman  NMSandler  ADSmith  RJ Respiratory manifestations of gastroesophageal reflux disease in pediatric patients. Ann Otol Rhinol Laryngol.1996;105:23-32.
PubMed
van den Abbeele  TBruhier  NNarcy  P Severe laryngeal manifestations of gastroesophageal reflux in children. Pediatr Pulmonol Suppl.1997;16:237-238.
PubMed
Ewer  AKJames  METobin  JM Prone and left lateral positioning reduce gastro-oesophageal reflux in preterm infants. Arch Dis Child Fetal Neonatal Ed.1999;81:F201-F205.
PubMed
Jolley  SGHerbst  JJJohnson  DGMatlak  MEBook  LS Surgery in children with gastroesophageal reflux and respiratory symptoms. J Pediatr.1980;96:194-198.
PubMed
Kimball  ALCarlton  DP Gastroesophageal reflux medications in the treatment of apnea in premature infants. J Pediatr.2001;138:355-360.
PubMed
Krishnamoorthy  MMintz  ALiem  TApplebaum  H Diagnosis and treatment of respiratory symptoms of initially unsuspected gastroesophageal reflux in infants. Am Surg.1994;60:783-785.
PubMed
Suskind  DLZeringue  GP  IIIKluka  EAUdall  JLiu  DC Gastroesophageal reflux and pediatric otolaryngologic disease: the role of antireflux surgery. Arch Otolaryngol Head Neck Surg.2001;127:511-514.
PubMed
Walsh  JKFarrell  MKKeenan  WJLucas  MKramer  M Gastroesophageal reflux in infants: relation to apnea. J Pediatr.1981;99:197-201.
PubMed
Wenzl  TGSilny  JSchenke  SPeschgens  THeimann  GSkopnik  H Gastroesophageal reflux and respiratory phenomena in infants: status of the intraluminal impedance technique. J Pediatr Gastroenterol Nutr.1999;28:423-428.
PubMed
Menon  APSchefft  GLThach  BT Apnea associated with regurgitation in infants. J Pediatr.1985;106:625-629.
PubMed
Boix-Ochoa  JLafuenta  JMGil-Vernet  JM Twenty-four hour esophageal pH monitoring in gastroesophageal reflux. J Pediatr Surg.1980;15:74-78.
PubMed
Carr  MMNguyen  APoje  CPizzuto  MNagy  MBrodsky  L Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease. Laryngoscope.2000;110:1560-1562.
PubMed
Jolley  SGHalpern  LMTunell  WPJohnson  DGSterling  CE The risk of sudden infant death from gastroesophageal reflux. J Pediatr Surg.1991;26:691-696.
PubMed
Andze  GOBrandt  MLSt Vil  DBensoussan  ALBlanchard  H Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring. J Pediatr Surg.1991;26:295-300.
PubMed
Euler  ARByrne  WJ Twenty-four-hour esophageal intraluminal pH probe testing: a comparative analysis. Gastroenterology.1981;80:957-961.
PubMed
Arad-Cohen  NCohen  ATirosh  E The relationship between gastroesophageal reflux and apnea in infants. J Pediatr.2000;137:321-326.
PubMed
Barrington  KJTan  KRich  W Apnea at discharge and gastro-esophageal reflux in the preterm infant. J Perinatol.2002;22:8-11.
PubMed
Wiener  GJKoufman  JAWu  WCCooper  JBRichter  JECastell  DO Chronic hoarseness secondary to gastroesophageal reflux disease: documentation with 24-h ambulatory pH monitoring. Am J Gastroenterol.1989;84:1503-1508.
PubMed
Bouchard  SLallier  MYazbeck  SBensoussan  A The otolaryngologic manifestations of gastroesophageal reflux: when is a pH study indicated? J Pediatr Surg.1999;34:1053-1056.
PubMed
Carr  MMNguyen  ANagy  MPoje  CPizzuto  MBrodsky  L Clinical presentation as a guide to the identification of GERD in children. Int J Pediatr Otorhinolaryngol.2000;54:27-32.
PubMed
Carr  MMNagy  MLPizzuto  MPPoje  CPBrodsky  LS Correlation of findings at direct laryngoscopy and bronchoscopy with gastroesophageal reflux disease in children: a prospective study. Arch Otolaryngol Head Neck Surg.2001;127:369-374.
PubMed
Giannoni  CSulek  MFriedman  EMDuncan  NO  III Gastroesophageal reflux association with laryngomalacia: a prospective study. Int J Pediatr Otorhinolaryngol.1998;43:11-20.
PubMed
Halpern  LMJolley  SGTunell  WPJohnson  DGSterling  CE The mean duration of gastroesophageal reflux during sleep as an indicator of respiratory symptoms from gastroesophageal reflux in children. J Pediatr Surg.1991;26:686-690.
PubMed
Jolley  SGJohnson  DGHerbst  JJPena  AGarnier  R An assessment of gastroesophageal reflux in children by extended pH monitoring of the distal esophagus. Surgery.1978;84:16-24.
PubMed
Jolley  SGHerbst  JJJohnson  DGMatlak  MEBook  LS Esophageal pH monitoring during sleep identifies children with respiratory symptoms from gastroesophageal reflux. Gastroenterology.1981;80:1501-1506.
PubMed
Jolley  SGTunell  WPCarson  JASmith  EIGrunow  J The accuracy of abbreviated esophageal pH monitoring in children. J Pediatr Surg.1984;19:848-854.
PubMed
Marino  AJAssing  ECarbone  MTHiatt  IMHegyi  TGraff  M The incidence of gastroesophageal reflux in preterm infants. J Perinatol.1995;15:369-371.
PubMed
Matthews  BLLittle  JPMcGuirt  WF  JrKoufman  JA Reflux in infants with laryngomalacia: results of 24-hour double-probe pH monitoring. Otolaryngol Head Neck Surg.1999;120:860-864.
PubMed
McMurray  JSHolinger  LD Otolaryngic manifestations in children presenting with apparent life-threatening events. Otolaryngol Head Neck Surg.1997;116:575-579.
PubMed
Paton  JYMacfadyen  UWilliams  ASimpson  H Gastro-oesophageal reflux and apnoeic pauses during sleep in infancy—no direct relation. Eur J Pediatr.1990;149:680-686.
PubMed
Stroh  BCFaust  RARimell  FL Results of esophageal biopsies performed during triple endoscopy in the pediatric patient. Arch Otolaryngol Head Neck Surg.1998;124:545-549.
PubMed
Veereman-Wauters  GBochner  AVan Caillie-Bertrand  M Gastroesophageal reflux in infants with a history of near-miss sudden infant death. J Pediatr Gastroenterol Nutr.1991;12:319-323.
PubMed
Vijayaratnam  VLin  CHSimpson  PTolia  V Lack of significant proximal esophageal acid reflux in infants presenting with respiratory symptoms. Pediatr Pulmonol.1999;27:231-235.
PubMed
Walner  DLStern  YGerber  MERudolph  CBaldwin  CYCotton  RT Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg.1998;124:551-555.
PubMed
Yellon  RFCoticchia  JDixit  S Esophageal biopsy for the diagnosis of gastroesophageal reflux-associated otolaryngologic problems in children. Am J Med.2000;108:131S-138S.
PubMed
Zalesska-Krecicka  MKrecicki  TIwanczak  BBlitek  AHorobiowska  M Laryngeal manifestations of gastroesophageal reflux disease in children. Acta Otolaryngol.2002;122:306-310.
PubMed
de Ajuriaguerra  MRadvanyi-Bouvet  MFHuon  CMoriette  G Gastroesophageal reflux and apnea in prematurely born infants during wakefulness and sleep. AJDC.1991;145:1132-1136.
PubMed
Bibi  HKhvolis  EShoseyov  D  et al The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia. Chest.2001;119:409-413.
PubMed
Carr  MMPoje  CPEhrig  DBrodsky  LS Incidence of reflux in young children undergoing adenoidectomy. Laryngoscope.2001;111:2170-2172.
PubMed
Contencin  PNarcy  P Gastropharyngeal reflux in infants and children: a pharyngeal pH monitoring study. Arch Otolaryngol Head Neck Surg.1992;118:1028-1030.
PubMed
Newman  LJRusse  JGlassman  MS  et al Patterns of gastroesophageal reflux (GER) in patients with apparent life-threatening events. J Pediatr Gastroenterol Nutr.1989;8:157-160.
PubMed
Sondheimer  JM Continuous monitoring of distal esophageal pH: a diagnostic test for gastroesophageal reflux in infants. J Pediatr.1980;96:804-807.
PubMed
Spitzer  ARBoyle  JTTuchman  DNFox  WW Awake apnea associated with gastroesophageal reflux: a specific clinical syndrome. J Pediatr.1984;104:200-205.
PubMed
Sacre  LVandenplas  Y Gastroesophageal reflux associated with respiratory abnormalities during sleep. J Pediatr Gastroenterol Nutr.1989;9:28-33.
PubMed
See  CCNewman  LJBerezin  S  et al Gastroesophageal reflux-induced hypoxemia in infants with apparent life-threatening event(s). AJDC.1989;143:951-954.
PubMed
Sarani  BGleiber  MEvans  SR Esophageal pH monitoring, indications, and methods. J Clin Gastroenterol.2002;34:200-206.
PubMed
Strobel  CTByrne  WJAment  MEEuler  AR Correlation of esophageal lengths in children with height: application to the Tuttle test without prior esophageal manometry. J Pediatr.1979;94:81-48.
PubMed
Mahajan  LWyllie  ROliva  LBalsells  FSteffen  RKay  M Reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients. Pediatrics.1998;101:260-263.
PubMed
Ahrens  PNoll  CKitz  RWilligens  PZielen  SHofmann  D Lipid-laden alveolar macrophages (LLAM): a useful marker of silent aspiration in children. Pediatr Pulmonol.1999;28:83-88.
PubMed
Gonzalez Fernandez  FArguelles Martin  FRodriguez de Quesada  BGonzalez Hachero  JValls Sanchez de Puerta  AGentles  M Gastroesophageal scintigraphy: a useful screening test for GE reflux. J Pediatr Gastroenterol Nutr.1987;6:217-219.
PubMed
Tolia  VKuhns  LKauffman  RE Comparison of simultaneous esophageal pH monitoring and scintigraphy in infants with gastroesophageal reflux. Am J Gastroenterol.1993;88:661-664.
PubMed
Tolia  VCalhoun  JAKuhns  LRKauffman  RE Lack of correlation between extended pH monitoring and scintigraphy in the evaluation of infants with gastroesophageal reflux. J Lab Clin Med.1990;115:559-563.
PubMed
Zalzal  GHChoi  SSPatel  KM The effect of gastroesophageal reflux on laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg.1996;122:297-300.
PubMed
Jaeschke  RGuyatt  GHSackett  DLfor the Evidence-Based Medicine Working Group Users' guides to the medical literature, III: how to use an article about a diagnostic test, B: what are the results and will they help me in caring for my patients? JAMA.1994;271:703-707.
PubMed
McAlister  FAStraus  SEGuyatt  GHHaynes  RBfor the Evidence-Based Medicine Working Group Users' guides to the medical literature, XX: integrating research evidence with the care of the individual patient. JAMA.2000;283:2829-2836.
PubMed
Richardson  WSWilson  MCGuyatt  GHCook  DJNishikawa  Jfor the Evidence-Based Medicine Working Group Users' guides to the medical literature, XV: how to use an article about disease probability for differential diagnosis. JAMA.1999;281:1214-1219.

Figures

Tables

Table Graphic Jump LocationTable 1. Studies Reporting Prevalence of Reflux in Patients With Upper Airway Symptoms4750,2,3,5154,29,31,55,8,5659,9,10,6063,24,6469
Table Graphic Jump LocationTable 2. Studies Comparing Incidence of Reflux in Control and Symptomatic Patients.7072,23,73,17,7478

References

Rudolph  CDMazur  LJLiptak  GS  et al Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr.2001;32:S1-S31.
PubMed
Belmont  JRGrundfast  K Congenital laryngeal stridor (laryngomalacia): etiologic factors and associated disorders. Ann Otol Rhinol Laryngol.1984;93:430-437.
PubMed
Beste  DJConley  SFBrown  CW Gastroesophageal reflux complicating choanal atresia repair. Int J Pediatr Otorhinolaryngol.1994;29:51-58.
PubMed
Bothwell  MRParsons  DSTalbot  ABarbero  GJWilder  B Outcome of reflux therapy on pediatric chronic sinusitis. Otolaryngol Head Neck Surg.1999;121:255-262.
PubMed
Contencin  PMaurage  CPloyet  MJSeid  ABSinaasappel  M Gastroesophageal reflux and ENT disorders in childhood. Int J Pediatr Otorhinolaryngol.1995;32:S135-S144.
PubMed
Gaynor  EB Otolaryngologic manifestations of gastroesophageal reflux. Am J Gastroenterol.1991;86:801-808.
PubMed
Gaynor  EB Laryngeal complications of GERD. J Clin Gastroenterol.2000;30:S31-S34.
PubMed
Gumpert  LKalach  NDupont  CContencin  P Hoarseness and gastroesophageal reflux in children. J Laryngol Otol.1998;112:49-54.
PubMed
Halstead  LA Gastroesophageal reflux: a critical factor in pediatric subglottic stenosis. Otolaryngol Head Neck Surg.1999;120:683-688.
PubMed
Herbst  JJMinton  SDBook  LS Gastroesophageal reflux causing respiratory distress and apnea in newborn infants. J Pediatr.1979;95:763-768.
PubMed
Kenna  MA The effect of gastroesophageal reflux on the pediatric airway. Int Anesthesiol Clin.1992;30:83-91.
PubMed
Nielson  DWHeldt  GPTooley  WH Stridor and gastroesophageal reflux in infants. Pediatrics.1990;85:1034-1039.
PubMed
Waki  EYMadgy  DNBelenky  WMGower  VC The incidence of gastroesophageal reflux in recurrent croup. Int J Pediatr Otorhinolaryngol.1995;32:223-232.
PubMed
Yellon  RF The spectrum of reflux-associated otolaryngologic problems in infants and children. Am J Med.1997;103:125S-129S.
PubMed
Postma  GNBelafsky  PCAviv  JEKoufman  JA Laryngopharyngeal reflux testing. Ear Nose Throat J.2002;81:14-18.
PubMed
Bach  KKMcGuirt  WF  JrPostma  GN Pediatric laryngopharyngeal reflux. Ear Nose Throat J.2002;81:27-31.
PubMed
Little  JPMatthews  BLGlock  MS  et al Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring of 222 children. Ann Otol Rhinol Laryngol Suppl.1997;169:1-16.
PubMed
Postma  GN Ambulatory pH monitoring methodology. Ann Otol Rhinol Laryngol Suppl.2000;184:10-14.
PubMed
Amin  MRPostma  GNJohnson  PDigges  NKoufman  JA Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg.2001;125:374-378.
PubMed
Koufman  JSataloff  RTToohill  R Laryngopharyngeal reflux: consensus conference report. J Voice.1996;10:215-216.
PubMed
Ulualp  SOToohill  RJ Laryngopharyngeal reflux: state of the art diagnosis and treatment. Otolaryngol Clin North Am.2000;33:785-802.
PubMed
Maronian  NCAzadeh  HWaugh  PHillel  A Association of laryngopharyngeal reflux disease and subglottic stenosis. Ann Otol Rhinol Laryngol.2001;110:606-612.
PubMed
Contencin  PNarcy  P Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis. Int J Pediatr Otorhinolaryngol.1991;22:249-256.
PubMed
Phipps  CDWood  WEGibson  WSCochran  WJ Gastroesophageal reflux contributing to chronic sinus disease in children: a prospective analysis. Arch Otolaryngol Head Neck Surg.2000;126:831-836.
PubMed
Zalzal  GHTran  LP Pediatric gastroesophageal reflux and laryngopharyngeal reflux. Otolaryngol Clin North Am.2000;33:151-161.
PubMed
Putnam  PE Gastroesophageal Reflux. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996.
Richter  JEBradley  LADeMeester  TRWu  WC Normal 24-hr ambulatory esophageal pH values: influence of study center, pH electrode, age, and gender. Dig Dis Sci.1992;37:849-856.
PubMed
Vincent  DA  JrGarrett  JDRadionoff  SLReussner  LAStasney  CR The proximal probe in esophageal pH monitoring: development of a normative database. J Voice.2000;14:247-254.
PubMed
Conley  SFWerlin  SLBeste  DJ Proximal pH-metry for diagnosis of upper airway complications of gastroesophageal reflux. J Otolaryngol.1995;24:295-298.
PubMed
Cucchiara  SStaiano  AGobio Casali  LBoccieri  APaone  FM Value of the 24 hour intraoesophageal pH monitoring in children. Gut.1990;31:129-133.
PubMed
Vandenplas  YSacre-Smits  L Continuous 24-hour esophageal pH monitoring in 285 asymptomatic infants 0-15 months old. J Pediatr Gastroenterol Nutr.1987;6:220-224.
PubMed
Vandenplas  YGoyvaerts  HHelven  RSacre  L Gastroesophageal reflux, as measured by 24-hour pH monitoring, in 509 healthy infants screened for risk of sudden infant death syndrome. Pediatrics.1991;88:834-840.
PubMed
Burton  DMPransky  SMKatz  RMKearns  DBSeid  AB Pediatric airway manifestations of gastroesophageal reflux. Ann Otol Rhinol Laryngol.1992;101:742-749.
PubMed
Bauman  NMSandler  ADSmith  RJ Respiratory manifestations of gastroesophageal reflux disease in pediatric patients. Ann Otol Rhinol Laryngol.1996;105:23-32.
PubMed
van den Abbeele  TBruhier  NNarcy  P Severe laryngeal manifestations of gastroesophageal reflux in children. Pediatr Pulmonol Suppl.1997;16:237-238.
PubMed
Ewer  AKJames  METobin  JM Prone and left lateral positioning reduce gastro-oesophageal reflux in preterm infants. Arch Dis Child Fetal Neonatal Ed.1999;81:F201-F205.
PubMed
Jolley  SGHerbst  JJJohnson  DGMatlak  MEBook  LS Surgery in children with gastroesophageal reflux and respiratory symptoms. J Pediatr.1980;96:194-198.
PubMed
Kimball  ALCarlton  DP Gastroesophageal reflux medications in the treatment of apnea in premature infants. J Pediatr.2001;138:355-360.
PubMed
Krishnamoorthy  MMintz  ALiem  TApplebaum  H Diagnosis and treatment of respiratory symptoms of initially unsuspected gastroesophageal reflux in infants. Am Surg.1994;60:783-785.
PubMed
Suskind  DLZeringue  GP  IIIKluka  EAUdall  JLiu  DC Gastroesophageal reflux and pediatric otolaryngologic disease: the role of antireflux surgery. Arch Otolaryngol Head Neck Surg.2001;127:511-514.
PubMed
Walsh  JKFarrell  MKKeenan  WJLucas  MKramer  M Gastroesophageal reflux in infants: relation to apnea. J Pediatr.1981;99:197-201.
PubMed
Wenzl  TGSilny  JSchenke  SPeschgens  THeimann  GSkopnik  H Gastroesophageal reflux and respiratory phenomena in infants: status of the intraluminal impedance technique. J Pediatr Gastroenterol Nutr.1999;28:423-428.
PubMed
Menon  APSchefft  GLThach  BT Apnea associated with regurgitation in infants. J Pediatr.1985;106:625-629.
PubMed
Boix-Ochoa  JLafuenta  JMGil-Vernet  JM Twenty-four hour esophageal pH monitoring in gastroesophageal reflux. J Pediatr Surg.1980;15:74-78.
PubMed
Carr  MMNguyen  APoje  CPizzuto  MNagy  MBrodsky  L Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease. Laryngoscope.2000;110:1560-1562.
PubMed
Jolley  SGHalpern  LMTunell  WPJohnson  DGSterling  CE The risk of sudden infant death from gastroesophageal reflux. J Pediatr Surg.1991;26:691-696.
PubMed
Andze  GOBrandt  MLSt Vil  DBensoussan  ALBlanchard  H Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring. J Pediatr Surg.1991;26:295-300.
PubMed
Euler  ARByrne  WJ Twenty-four-hour esophageal intraluminal pH probe testing: a comparative analysis. Gastroenterology.1981;80:957-961.
PubMed
Arad-Cohen  NCohen  ATirosh  E The relationship between gastroesophageal reflux and apnea in infants. J Pediatr.2000;137:321-326.
PubMed
Barrington  KJTan  KRich  W Apnea at discharge and gastro-esophageal reflux in the preterm infant. J Perinatol.2002;22:8-11.
PubMed
Wiener  GJKoufman  JAWu  WCCooper  JBRichter  JECastell  DO Chronic hoarseness secondary to gastroesophageal reflux disease: documentation with 24-h ambulatory pH monitoring. Am J Gastroenterol.1989;84:1503-1508.
PubMed
Bouchard  SLallier  MYazbeck  SBensoussan  A The otolaryngologic manifestations of gastroesophageal reflux: when is a pH study indicated? J Pediatr Surg.1999;34:1053-1056.
PubMed
Carr  MMNguyen  ANagy  MPoje  CPizzuto  MBrodsky  L Clinical presentation as a guide to the identification of GERD in children. Int J Pediatr Otorhinolaryngol.2000;54:27-32.
PubMed
Carr  MMNagy  MLPizzuto  MPPoje  CPBrodsky  LS Correlation of findings at direct laryngoscopy and bronchoscopy with gastroesophageal reflux disease in children: a prospective study. Arch Otolaryngol Head Neck Surg.2001;127:369-374.
PubMed
Giannoni  CSulek  MFriedman  EMDuncan  NO  III Gastroesophageal reflux association with laryngomalacia: a prospective study. Int J Pediatr Otorhinolaryngol.1998;43:11-20.
PubMed
Halpern  LMJolley  SGTunell  WPJohnson  DGSterling  CE The mean duration of gastroesophageal reflux during sleep as an indicator of respiratory symptoms from gastroesophageal reflux in children. J Pediatr Surg.1991;26:686-690.
PubMed
Jolley  SGJohnson  DGHerbst  JJPena  AGarnier  R An assessment of gastroesophageal reflux in children by extended pH monitoring of the distal esophagus. Surgery.1978;84:16-24.
PubMed
Jolley  SGHerbst  JJJohnson  DGMatlak  MEBook  LS Esophageal pH monitoring during sleep identifies children with respiratory symptoms from gastroesophageal reflux. Gastroenterology.1981;80:1501-1506.
PubMed
Jolley  SGTunell  WPCarson  JASmith  EIGrunow  J The accuracy of abbreviated esophageal pH monitoring in children. J Pediatr Surg.1984;19:848-854.
PubMed
Marino  AJAssing  ECarbone  MTHiatt  IMHegyi  TGraff  M The incidence of gastroesophageal reflux in preterm infants. J Perinatol.1995;15:369-371.
PubMed
Matthews  BLLittle  JPMcGuirt  WF  JrKoufman  JA Reflux in infants with laryngomalacia: results of 24-hour double-probe pH monitoring. Otolaryngol Head Neck Surg.1999;120:860-864.
PubMed
McMurray  JSHolinger  LD Otolaryngic manifestations in children presenting with apparent life-threatening events. Otolaryngol Head Neck Surg.1997;116:575-579.
PubMed
Paton  JYMacfadyen  UWilliams  ASimpson  H Gastro-oesophageal reflux and apnoeic pauses during sleep in infancy—no direct relation. Eur J Pediatr.1990;149:680-686.
PubMed
Stroh  BCFaust  RARimell  FL Results of esophageal biopsies performed during triple endoscopy in the pediatric patient. Arch Otolaryngol Head Neck Surg.1998;124:545-549.
PubMed
Veereman-Wauters  GBochner  AVan Caillie-Bertrand  M Gastroesophageal reflux in infants with a history of near-miss sudden infant death. J Pediatr Gastroenterol Nutr.1991;12:319-323.
PubMed
Vijayaratnam  VLin  CHSimpson  PTolia  V Lack of significant proximal esophageal acid reflux in infants presenting with respiratory symptoms. Pediatr Pulmonol.1999;27:231-235.
PubMed
Walner  DLStern  YGerber  MERudolph  CBaldwin  CYCotton  RT Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg.1998;124:551-555.
PubMed
Yellon  RFCoticchia  JDixit  S Esophageal biopsy for the diagnosis of gastroesophageal reflux-associated otolaryngologic problems in children. Am J Med.2000;108:131S-138S.
PubMed
Zalesska-Krecicka  MKrecicki  TIwanczak  BBlitek  AHorobiowska  M Laryngeal manifestations of gastroesophageal reflux disease in children. Acta Otolaryngol.2002;122:306-310.
PubMed
de Ajuriaguerra  MRadvanyi-Bouvet  MFHuon  CMoriette  G Gastroesophageal reflux and apnea in prematurely born infants during wakefulness and sleep. AJDC.1991;145:1132-1136.
PubMed
Bibi  HKhvolis  EShoseyov  D  et al The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia. Chest.2001;119:409-413.
PubMed
Carr  MMPoje  CPEhrig  DBrodsky  LS Incidence of reflux in young children undergoing adenoidectomy. Laryngoscope.2001;111:2170-2172.
PubMed
Contencin  PNarcy  P Gastropharyngeal reflux in infants and children: a pharyngeal pH monitoring study. Arch Otolaryngol Head Neck Surg.1992;118:1028-1030.
PubMed
Newman  LJRusse  JGlassman  MS  et al Patterns of gastroesophageal reflux (GER) in patients with apparent life-threatening events. J Pediatr Gastroenterol Nutr.1989;8:157-160.
PubMed
Sondheimer  JM Continuous monitoring of distal esophageal pH: a diagnostic test for gastroesophageal reflux in infants. J Pediatr.1980;96:804-807.
PubMed
Spitzer  ARBoyle  JTTuchman  DNFox  WW Awake apnea associated with gastroesophageal reflux: a specific clinical syndrome. J Pediatr.1984;104:200-205.
PubMed
Sacre  LVandenplas  Y Gastroesophageal reflux associated with respiratory abnormalities during sleep. J Pediatr Gastroenterol Nutr.1989;9:28-33.
PubMed
See  CCNewman  LJBerezin  S  et al Gastroesophageal reflux-induced hypoxemia in infants with apparent life-threatening event(s). AJDC.1989;143:951-954.
PubMed
Sarani  BGleiber  MEvans  SR Esophageal pH monitoring, indications, and methods. J Clin Gastroenterol.2002;34:200-206.
PubMed
Strobel  CTByrne  WJAment  MEEuler  AR Correlation of esophageal lengths in children with height: application to the Tuttle test without prior esophageal manometry. J Pediatr.1979;94:81-48.
PubMed
Mahajan  LWyllie  ROliva  LBalsells  FSteffen  RKay  M Reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients. Pediatrics.1998;101:260-263.
PubMed
Ahrens  PNoll  CKitz  RWilligens  PZielen  SHofmann  D Lipid-laden alveolar macrophages (LLAM): a useful marker of silent aspiration in children. Pediatr Pulmonol.1999;28:83-88.
PubMed
Gonzalez Fernandez  FArguelles Martin  FRodriguez de Quesada  BGonzalez Hachero  JValls Sanchez de Puerta  AGentles  M Gastroesophageal scintigraphy: a useful screening test for GE reflux. J Pediatr Gastroenterol Nutr.1987;6:217-219.
PubMed
Tolia  VKuhns  LKauffman  RE Comparison of simultaneous esophageal pH monitoring and scintigraphy in infants with gastroesophageal reflux. Am J Gastroenterol.1993;88:661-664.
PubMed
Tolia  VCalhoun  JAKuhns  LRKauffman  RE Lack of correlation between extended pH monitoring and scintigraphy in the evaluation of infants with gastroesophageal reflux. J Lab Clin Med.1990;115:559-563.
PubMed
Zalzal  GHChoi  SSPatel  KM The effect of gastroesophageal reflux on laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg.1996;122:297-300.
PubMed
Jaeschke  RGuyatt  GHSackett  DLfor the Evidence-Based Medicine Working Group Users' guides to the medical literature, III: how to use an article about a diagnostic test, B: what are the results and will they help me in caring for my patients? JAMA.1994;271:703-707.
PubMed
McAlister  FAStraus  SEGuyatt  GHHaynes  RBfor the Evidence-Based Medicine Working Group Users' guides to the medical literature, XX: integrating research evidence with the care of the individual patient. JAMA.2000;283:2829-2836.
PubMed
Richardson  WSWilson  MCGuyatt  GHCook  DJNishikawa  Jfor the Evidence-Based Medicine Working Group Users' guides to the medical literature, XV: how to use an article about disease probability for differential diagnosis. JAMA.1999;281:1214-1219.

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