NEW YORK (Reuters Health) – Obese youngsters and their doctors may be incorrectly attributing gastroesophageal reflux symptoms to asthma, researchers say.
In their pediatric asthma cohort, reflux symptoms were seven times more common in obese kids than in lean kids.
Writing online February 1 in Thorax, the researchers urge that especially for obese patients, “questionnaires that query symptoms that are more specific to asthma (‘whistling in the chest’) may improve the accuracy of symptom monitoring,” and newer portable spirometers for home use might also improve management.
Helping patients distinguish gastroesophageal reflux disease (GERD) from true lower airway symptoms will reduce medication overuse and side effects, unnecessary escalation of controller drugs and unnecessary usage for asthma, Dr. Jason E. Lang of Nemours Children’s Hospital in Orlando, Florida and colleagues say.
In previous research, Dr. Lang’s group had found that while obese and lean children with asthma had similar lung function, the obese kids were more likely to self-medicate with short-acting beta-agonists.
Of the 56 children in this new study, 23 were obese, 12 were overweight, and 21 were lean. All were between the ages of 10 and 17 and recruited between 2008 and 2010.
Symptoms and quality of life were assessed with validated tools, including the modified Asthma Control Questionnaire (ACQ6), the Asthma Control Test, the Pediatric Asthma Quality of Life Questionnaire, and the Pediatric Caregiver’s Asthma Quality of Life Questionnaire. Patients were also evaluated with the GERD Symptom Assessment Questionnaire (GSAQ), lung spirometry, FENO maneuvers, and a methacholine challenge.
The research team also attempted to replicate the GERD and asthma quality of life questionnaire results in a separate cohort of 306 children with severe asthma and no previous reflux disease.
The odds of reporting several GERD symptoms were more than seven times greater in the obese group (OR=7.7, p for interaction=0.004).
Asthma symptoms were tied to GERD scores in obese children (r=0.815, p<0.0001) but not in lean children (r=0.291, p=0.200; p for interaction=0.003). Objective tests linked higher GERD scores to higher FEV1-percent predicted (p=0.003), lower airway resistance (R10, p=0.025), improved airway reactance, (X10, p=0.005), but far worse asthma control as recorded on the Asthma Control Questionnaire (p=0.007).
In an interview, Dr. Lang suggested to Reuters Health that the symptom misattribution may be an effect of the “short doctor-patient visit.” He explained: “The underlying message for doctors and nurses is that we need to ask about specific asthma and specific reflux symptoms. We need to not jump to conclusions and thoroughly assess symptoms.”
Dr. Deepa Rastogi, a pediatric pulmonologist at the Children’s Hospital of Montefiore and the Albert Einstein College of Medicine, Bronx, New York told Reuters Health in an interview, “This is a very well-conducted study with outcomes of interest to all of us. It really shows us that it is worthwhile to look for disease entities other than asthma.”
She added, “Using objective measures and patient self report, we may do better at treatment.”
Is there a place for proton pump inhibitors if GERD underlies the asthma-like symptoms?
“Once we all realize that misattribution can be a problem, we can focus more carefully on making the right diagnosis of the symptoms and can employ other confirmatory testing like using spirometry or response to albuterol (rescue inhalers),” Dr. Lang said. “If the child truly has GER that is causing pain and discomfort, the GER should absolutely be evaluated and a discussion needs to occur weighing the risks and benefits of GER medicines.”
He continued, “Some patients who learn their chest symptoms are likely from GER and it’s not causing too many problems may elect to not treat and adopt proven lifestyle interventions. On the other hand, if GER are more bothersome or leading to coughing, then lifestyle changes plus intermittent use of an anti-GER may be the right choice. I am concerned about the side-effects of long-term use of PPIs since which we have shown that PPI appears to worsen asthma control in patients who are slow metabolizers of the drug.”