From the Pediatric Literature

Acid Suppression Use in Children with Laryngomalacia

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Laryngomalacia often is diagnosed in infants, and acid suppression therapy generally is prescribed due to concerns that acidic gastroesophageal reflux disease (GERD) can cause upper airway damage. Acid suppression therapy (via proton pump inhibitors or PPIs) often is used to prevent supraglottoplasty in patients with laryngomalacia. Since most cases of laryngomalacia resolve over time without surgical intervention, the authors of this study evaluated the effectiveness of acid suppression therapy to prevent potential supraglottoplasty. Patients with laryngomalacia were identified over a one-year period at a tertiary children’s hospital in the United States. These patients were evaluated for existing co-morbidities, severity of laryngomalacia, use of acid suppression medication, swallowing function (evaluated by both feeding evaluation and video swallow study), risk of hospitalization for respiratory disease, and risk of supraglottoplasty. 

A total of 236 patients were diagnosed with laryngomalacia during this study period, and 52% of patients had mild laryngomalacia with the remainder of the patients having either moderate-to-severe laryngomalacia or severity not being classified. It was noted that 55% of patients were on some type of acid suppression therapy (27% using H2-receptor antagonist therapy; 11% using PPI use; 17% using both), and no significant difference existed between acid suppression medication regimen and laryngomalacia severity. Most acid suppression therapy prescriptions were written by primary care physicians. No patient underwent pH-impedance testing for gastroesophageal reflux, and 10% of patients underwent esophagogastroduodenoscopy (for which only one patient was found to have microscopic esophagitis). A total of 40% of patients underwent a clinical feeding evaluation and 36% of patients had a video swallow study performed. Patients with moderate-to-severe laryngomalacia were more likely to undergo a clinical feeding evaluation or video swallow study. A clinical feeding evaluation led to a change in medical management in 72% of patients while a video swallow study led to a change in medical management in 61% of patients (including use of thickening agents or changing nipple flow). Supraglottoplasty occurred in 10% of these patients and repeat video swallow study testing showed an improvement in swallowing function in the patients that underwent surgery.

Univariate and multivariate analysis demonstrated that acid suppression use was significantly associated with an increased risk of hospitalization and an increased number of days in the hospital with respiratory disease (regardless of type of acid suppression therapy used). On the other hand, use of thickening agents significantly decreased the number of days that patients were hospitalized for respiratory disease. Of note, patients with an abnormal clinical swallow evaluation and/or video swallow study had no increase in hospitalizations, and no increased risk of hospitalization was noted regardless of laryngomalacia severity. It was noted that 40% of patients with severe laryngomalacia required surgery compared to 8% of patients with mild laryngomalacia and to 15% of patients with laryngomalacia not specified. However, acid suppression use was associated with an increased risk of progression to eventual supraglottoplasty regardless of laryngomalacia severity while thickening use was not associated with progression to this type of surgical intervention. Finally, acid suppression use was significantly associated with a more rapid progression to supraglottoplasty while thickener use was significantly associated with a increased time before performing supraglottoplasty regardless of laryngomalacia severity.  This is an extremely important study demonstrating that acid suppression therapy may be detrimental to outcomes in patients with laryngomalacia. The reason for this finding is not clear although effects on the gastric and pulmonary microbiome should be considered for further studies. Finally, thickening agent use in pediatric patients with laryngomalacia may be protective.

Duncan D, Larson K, Davidson K, Williams N, Liu E, Watters K, Rahbar R, Rosen R. Acid suppression does not improve laryngomalacia outcomes but treatment for oropharyngeal dysphagia might be protective. Journal of Pediatrics 2021; 238: 42-49.

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