Reflux Aspiration in Children With Neurodisability--A Significant Problem, but Can We Measure It?

J Pediatr Surg. 2012 Feb;47(2):291-8. doi: 10.1016/j.jpedsurg.2011.11.019.


Recurrent respiratory problems are common in children with severe neurodisability, and respiratory deterioration is a leading cause of premature death in this group. Although the etiology is multifactorial, recurrent pulmonary aspiration is thought to play a significant role. Gastroesophageal reflux is known to be common, as is oral-motor discoordination. Differentiating direct aspiration of food and saliva and gastric reflux aspiration is difficult and presents a challenge in managing patients and assessing their suitability for surgical antireflux procedures. This is particularly the case when children present with predominantly respiratory symptoms, where there may be direct aspiration, reflux aspiration, neither, or both. A clinical biomarker to identify and quantify reflux aspiration would therefore be useful in surgical assessment and may also be applicable as an outcome measure for clinical trials of antireflux surgery. In this review, we discuss the evidence base behind existing and potentially novel biomarkers of aspiration in bronchoalveolar lavage fluid. We highlight the limitations of the lipid-laden macrophage index, particularly with regard to its specificity and interrater/intrarater reliability. We discuss the laboratory methods available to measure promising new biomarkers (pepsin and bile acids) and highlight their potential advantages and disadvantages. Finally, to understand how aspiration causes clinical signs and symptoms in our patients, we need to study the effect of aspirated substances on the lung, and here we review the available in vivo and in vitro literature.

Publication types

  • Review

MeSH terms

  • Animals
  • Bile Acids and Salts / adverse effects
  • Bile Acids and Salts / analysis*
  • Biomarkers
  • Blotting, Western / methods
  • Brain Damage, Chronic / complications*
  • Brain Damage, Chronic / physiopathology
  • Bronchoalveolar Lavage Fluid / chemistry*
  • Bronchoalveolar Lavage Fluid / cytology
  • Child
  • Enzyme-Linked Immunosorbent Assay / methods
  • Fundoplication
  • Gastroesophageal Reflux / complications
  • Gastroesophageal Reflux / surgery
  • Gastrostomy
  • Humans
  • Lipids / analysis
  • Macrophages / chemistry
  • Macrophages / pathology*
  • Mass Spectrometry
  • Patient Selection
  • Pepsin A / analysis*
  • Respiratory Aspiration / complications
  • Respiratory Aspiration / diagnosis*
  • Respiratory Aspiration / physiopathology
  • Respiratory Aspiration / surgery
  • Respiratory Mucosa / drug effects
  • Respiratory Tract Diseases / etiology
  • Respiratory Tract Diseases / pathology
  • Respiratory Tract Diseases / prevention & control
  • Saliva
  • Staining and Labeling


  • Bile Acids and Salts
  • Biomarkers
  • Lipids
  • Pepsin A