Content uploaded by Müge Özçelik Korkmaz
Author content
All content in this area was uploaded by Müge Özçelik Korkmaz on Dec 09, 2020
Content may be subject to copyright.
The Role of Nutritional and Dietary Habits in Etiology in
Pediatric Vocal Fold Nodule
*M€
uge
€
Oz¸celik Korkmaz, and
†
Arzu T€
uz€
uner, *Adapazari, and yAnkara, Turkey
Summary: Objectives. In pediatric pediatric vocal fold nodule (VFN) patients, different causes have been
suggested in the development of the vocal cord nodule, including laryngopharyngeal reflux (LPR). It is known
that the content of consumed foods, obesity, and other dietary behaviors are among the risk factors for the devel-
opment of reflux. The aim of this study was to evaluate dietary and food consumption habits in pediatric VFN
patients.
Methods. This prospective-controlled study included 50 children with VFNs (age range 5−14 years) and 50 age-
matched children without any voice disorders as a control group. BMI values of each participant were evaluated
according to age-percentile range. The voice usage habits and personality structure of all the children were ques-
tioned. All patients underwent laryngeal examination and voice analysis. The Turkish Pediatric Voice Handicap
Index (t-PVHI) and Child Voice Handicap Index-10 (t-CVHI) were completed by patients or their parents. The
examination findings of all patients were evaluated with the reflux finding score (RFS), and their complaints were
questioned with the reflux symptom index (RSI). In addition, eating and drinking at night, fast eating and exces-
sive food consumption habits and the frequency of consumption of packaged foods defined as junk food, carbon-
ated beverage were questioned. The data obtained were compared statistically between the two groups.
Results. There was no significant difference between the study and control groups in terms of age, gender distri-
bution, median BMI value, voice usage habits, and personality structure. In the study group, t-PVHI, t-CVHI, jit-
ter, schimmer values, the mean RFS, and RSI scores were significantly higher than those of the control group.
The number of children with high consumption of junk food and carbonated drinks was higher in the study
group. There was no significant difference between the two groups in terms of dietary habits.
Conclusion. Food consumption habits may play a role in childhood voice problems in this population.
Key Words: Pediatric−Vocal fold−Nodule−Laryngopharyngeal reflux−Nutrition−Junk food.
INTRODUCTION
Vocal symptoms are common among the pediatric popula-
tion and vocal fold nodules (VFN) are the most common
cause of childhood dysphonia.
1
These nodules present in
35%−78% of cases of pediatric voice disorders, with higher
rates in males (21.6%) than females (11.7%).
2
The most
common symptoms are dysphonia or aphonia, difficulty in
speaking, straining (breathiness), and short maximum pho-
nation time (MPT). Many factors, including laryngophar-
yngeal reflux (LPR), allergy, sinusitis, and chronic cough
may play a role in the development of VFN. In addition,
the etiological causes of VFN in children include shouting,
loud talking, screaming, or sporting activities.
3
Studies have
emphasized that attention deficit/hyperactivity-related
behavioral disorders are more common in children with
VFN and therefore, behavioral changes in these children
should be evaluated.
4,5
The role of LPR in the etiology is
not yet certain, although it is also among the etiological
causes.
6
The diagnosis of LPR may not always be easy in
either adults or children. In the case of GERD, the 24-hour
pH of double probe esophagus monitoring is generally con-
sidered the gold standard for diagnosis, but laryngeal exam-
ination and symptom questioning are also methods used in
the diagnosis of LPR.
7
The nutritional habits of children
are known to be changing and the consumption of foods,
referred to as junk food, and beverages with high acid and
sugar content is becoming more common in this age group
nowadays. Additionally, fast and hasty eating habits are
increasing nowadays. Consequently, there are studies show-
ing the relationship between such eating habits and behav-
ioral disorders such as hyperactivity, in addition to obesity
and cardiovascular diseases.
8,9
It is also possible that there
are changes in gastric acid content and this increases the
incidence of LPR in children who consume more than nor-
mal processed foods with sugar, salt, saturated, and trans-
fatty content, because LPR is closely connected to the effect
of gastric acid and pepsin on the pharyngeal, laryngeal, and
nasopharyngeal mucosa.
10
Therefore, processed fatty, spicy
or sweet snacks, chocolate, biscuits, chips and carbonated
sugary drinks have the potential to have a negative impact
on reflux development and voice health for children. It is
also a known fact that fast-eating, over-eating, food and
beverage consumption before bedtime are associated with
reflux.
11
However, there is no study in the literature on the
relationship between dieatry habits and pediatric dysphonia
or VFN.
The aim of this study is to compare the food consumption
and eating habits of children with VFN with a non-VFN
Accepted for publication September 14, 2020.
Conflicts of interest: The authors declare that they have no competing interests.
Financial disclosure information: No financial disclosures.
From the *Sakarya University Training and Research Hospital, Adapazari,
Sakarya, Turkey; and the yBa¸skent University Medical Faculty Ankara Hospital,
Ankara, Turkey.
Address correspondence and reprint requests to: M€
uge
€
Oz¸celik Korkmaz, Department
of Otorhinolayngology, Sakarya University Training and Research Hospital, Korucuk
Neighborhood, Adapazar{, Sakarya, 54290, Turkey. E-mail: ozcelikmuge@gmail.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.09.007
ARTICLE IN PRESS
control group. We also wanted to compare the LPR-related
laryngeal examination findings and symptoms in both
groups, considering that this could be related to LPR.
MATERIAL METHODS
Study Design and Participants
Approval for this prospective-controlled study was obtained
from the ethics Committee of Sakarya University Faculty
of Medicine. Children aged 6−15 years who were admitted
to our outpatient clinic with the complaint of hoarseness,
roughness in the voice or breathy voice were enrolled.
Among these, children who allowed adequate imaging with
flexible endoscopic laryngeal examination and had bilateral
VFN were included in the study group. Children were
excluded from the study if they had an active upper respira-
tory tract infection, chronic obstructive lung disease, were
taking medication of inhaler steroids or antireflux, had a
history of laryngeal surgery or other benign laryngeal
lesions (cyst, sulcus, polyp, etc) any speech or cognitive dis-
order. Regardless of the etiology, children with any known
gastroenterological disease in infancy and childhood and
treated (medical or surgery) for this purpose were excluded
from the study.
A control group was formed among of 50 volunteers who
applied to our otolaryngology clinic for any reason (snoring,
open mouth sleep, etc.) other than voice or speech com-
plaints and underwent satisfying flexible endoscopic laryn-
geal examination. Exclusion criteria (infection, medication,
etc) in the study group were also accepted here, in addition
those with VFNs were excluded. While selecting the control
group, it was attempted to make the group as heterogeneous
as possible to eliminate confounding factors, so care was
taken not to have individuals from any particular sociocul-
tural group or environment. In addition, age and gender dis-
tribution in the study group was taken into consideration.
Written informed consent forms were obtained from the
children and their parents included in the control and study
group.
Examination and evaluation of personality
We performed a questionnaire study to examine demo-
graphic and personality characteristics (age, gender weight,
height, speaking habits, etc.) The parents were asked to
score their children’s speaking level between 0 and 7, and
were questioned as to whether they were in the habit of
shouting/speaking loudly, which was evaluated as present
(1)/none (0). The personality structure of the children was
defined as active-irritable (1) or normal-calm (0). BMI was
calculated as weight in kilograms divided by height in
square meters (kg/m
2
) and BMI percentile for age was
assessed using the Center for Disease Control growth charts
overweight and obesity were defined as a BMI at or above
the 85th percentile and below the 95th percentile and at or
above 95th percentile for children of the same age and sex.
12
A detailed ENT examination was applied, including
visualization of vocal folds and the larynx with a flexible
endoscope (0°, 3.4 mm, Olympus). The reflux finding score
(RFS), which was developed by Belafsky et al
13
based on
the findings of fiber-optic laryngoscopy, evaluates the eight
most common laryngoscopic LPR findings: subglottal
edema, ventricular obliteration, erythema or hyperemia,
vocal fold edema, generalized laryngeal edema, posterior
commissure hypertrophy, granuloma or granulation tissue
formation, and excess mucus in the larynx (Figure 1). Each
item is categorized as present or absent, and if present, by
severity and location. During the examination, the LPR
findings were evaluated in detail and scored according to
the RFS. Examinations were performed and recorded by a
single doctor. The recorded images were evaluated and
scored by both authors, both of whom have more than
10 years of experience. In addition, the children were evalu-
ated using the reflux symptom index (RSI) for symptoms
associated with reflux. The RSI, developed by Belafsky
et al
14
is a self-administered, nine-item instrument for assess-
ment of LPR symptoms. The scale for each item ranges
from 0 (no problem) to 5 (severe problem) and the maxi-
mum total score is 45. Parents helped their children to com-
plete the questionnaire (Figure 2). The children themselves
and/or their families were asked to complete the Turkish
Pediatric Voice Handicap Index (t-PVHI)
15
and the Turkish
Children Voice Handicape Index-10 (t-CVHI)
16
forms. The
t-PVHI scale consists of three parts: functional-physcial-
emotional.
Eating and food consumption habits
Nutritional and eating habits of children in their daily rou-
tines were evaluated by asking their parents under 4 head-
ings. Accordingly, if there were a habits of late night eating/
drinking (2 hours before bedtime), fast eating (less than 20
minutes for each meal) and over-eating, it was evaluated
presented (1) or none (0). In terms of food consumption
habits, the frequency were questioned of weekly processed
food, determined as junk food (rich in sugar, salt, saturated,
and trans-fatty acids with low nutritional value such as salty
snacks, potato crisps, fried foods, fatty foods, biscuits, cook-
ies, cakes, chocolate, ice cream, and candies), and sugar-
sweetened/carbonated beverages (cola, ice tea, boxed juice,
FIGURE 1. Reflux Symptom Index.4 Score range, 0−45. A score
of 0 indicates no problem; a score of 5 or more, a severe problem.
ARTICLE IN PRESS
2Journal of Voice, Vol. &&, No. &&, 2020
soda etc). According to the grouping based on previous
studies, the parents were asked about the amount of junk
food and carbonated drinks consumed weekly by their chil-
dren. Those who consumed 0−2 items per week were scored
as 0, those who consumed 2−4 items were scored 1, and
those who consumed more than 4 items were scored as 2 .
The consumption of carbonated beverages was similarly
questioned and those who drank 0−2 glasses a week were
scored as 0, those who consumed 2−4 glasses were 1 and
those who consumed more than 4 glasses were scored 2.
Voice analysis
The voice analysis was performed after a 15-minute rest
period taking into account that the child could have been
very active beforehand, and to avoid vocal abuse just before
the test, as these factors could affect the voice analysis nega-
tively. Voice analysis was performed in a quiet room; the
subjects phonated only the vowel “/a/”for at least 5 seconds
in the acoustic voice analysis while sitting in an upright posi-
tion, with a dynamic ATB USB microphone (Shure Incor-
porated, Chicago, Illinois) 15 cm away from the mouth.
Audacity multitrack audio editor program for Windows
were used for the voice recordings. The recordings were
made at a sampling frequency of 44.1 kHz and 16-bit .wave
file format. The vowel /a/ was recorded for longer than 3
seconds in each patient. MPT was measured. Voice analyses
were performed using the Praat v4.1 software for Windows
(version 5.1.37, Boersma & Wee-nink, 2010). In the voice
samples, calculations were made of fundamental frequency
(Fo), % jitter, % shimmer, and noise-harmonic ratio
(NHR). The data of the study group were compared with
the control group in respect of age, gender, BMI, RSI, RFS,
t-PVHI, t-CHVI, MPT, and the acoustic parameters (Fo, %
jitter, % shimmer, NHR).
Statistical analysis
Data obtained in the study were analyzed statistically using
IBM SPSS Statistics 21.0 software (SPSS, IBM, Armonk,
New York). Continuous variables were presented as mean
§standard deviation or median (minimum−maximum) val-
ues. Frequency and percentage values were used to specify
categorical variables. The normality distribution of the data
was analyzed with the Kolmogorov-Smirnov test. For con-
tinuous variables, the differences between the two groups
were analyzed using the Independent Samples ttest or the
Mann-Whitney U-test. Relationships between categorical
variables were compared with the Pearson Chi-square test
(A value of P0.05 for all).
RESULTS
General data
Each group comprised 50 children in the age range of
6−15 years. The study group included 32 (64%) males and
18 (36%) females with a mean age of 9.5 §2.2 years. The
control group included 30 (60%) males and 20 (40%)
females with a mean age of 9.6 §2.2 years There was no sig-
nificant difference in the male-to-female ratio, median BMI
values and mean age between the groups (P>0.05 for all).
Although there were no obese children in both the study
and control groups, 9 (18%) of the participants in the study
group and 7 (14%) of the control group were overweight
and there was no significiant difference (P>0.05). The dura-
tion of dysphonia was between 5 and 36 months (mean: 12
§6.7 months) in the study group. The mean of speaking
level was 5 §8.5 (range: 3−7) in the study group and 4.2 §
7 (range: 3−7) in the control group, with no statistically sig-
nificant difference determined between the 2 groups (P>
0.05). The number of children with the habit of shouting/
speaking loudly habit was 28 (56%) in the study group and
20 (40%) in the control group. When evaluated in terms of
personality structure, 28 (56%) of the families in the study
group stated that their child had an active-irritable personal-
ity structure, while 22 (44%) families stated that their chil-
dren had a normal-calm personality structure. In the
control group, these rates were 16 (32%) and 34 (68%),
respectively. There was no statistically significant difference
between the two groups in terms of personality structure
and the habit of shouting/speaking loudly (P>0.05,
P>0.05; Table 1).
LPR findings and acoustic parameters
The mean RFS was 7.5 §3 in the study group and 3 §2
(range: 0−11) in the control group, and the difference was
FIGURE 2. Reflux Finding Score.5 Score range, 0 (no abnormal
findings) to 100 (worst possible score).
ARTICLE IN PRESS
M€
uge
€
Oz¸celik Korkmaz and Arzu T€
uz€
uner Dietary Habits in Pediatric Nodule 3
statistically significant (P= 0.00). In the RFS, the most com-
mon examination findings were erythema/hyperemia in ary-
tenoids and mild or moderate posterior commissure
hypertrophy, followed by vocal fold edema, thick endolar-
yngeal mucus, and pseudosulcus, respectively. The mean
RSI value was 9 §3.5 in the study group and this was signif-
icantly higher than that of the control group (P= 0.023).The
most common complaints were hoarseness and excess throat
mucus or postnasal drip. In the study group, the median t-
PVHI scores were functional domain 11, physical domain
19, and emotional domain 10. In the control group, the
median scores were functional domain 1, physical domain
2, and emotional domain 0. The median t-CVHI score was
13 in the study group and 0 in the control group. The
median scores of the three domains and the total t-PVHI
scores were significantly higher in the study group than in
the control group (P= 0.000; Table 2) The acoustic parame-
ters of the study group were determined as mean MPT: 7 §
2.5 seconds, mean Fo value: 248 §41, mean % shimmer:
4.72 §1.8, mean % jitter: 1.9 §78.5 and mean NHR: 0.15
§0.0. In the control group, these values were MPT: 7.2 §
2.8 seconds, mean Fo: 252 §43, mean % shimmer: 2.84 §
0.1, mean % jitter: 0.82 §0.8 and mean NHR: 0.13 §0.0.
A statistically significant difference was determined between
the groups in respect of the % jitter and shimmer values of
the acoustic parameter data (Pvalues <0.05; Table 2).
Eating and food consumption habits
The late night eating/drinking habit was present in 23 (46%)
patients in the study group and in 22 (44%) children in the
control group. In terms of eating speed, while 11 (22%) of
the participants in the study group had fast eating habit, 8
(16%) children in the control group had fast eating habit.
While only 8 (16%) of the parents of participants in the
study group stated that their children over-eating, this value
was 3 (4%) in the control group. There was no statistically
significant difference between the study group and the
TABLE 1.
Baseline Characteristics of Children in Study and Control Group
Parameters Study Group (n = 50) Control Group (n = 50) P
Age (mean) 9,58 §2,19 9,62 §2,17 0.64*
Gender (n/%)
Male 32 (64) 30 (60) 0.45*
Female 18 (36) 20 (40)
BMI (median) 15,9 §2,4 15,6 §2,5 0.78
Overweight children (n/%)) 9 (18) 7 (14) 0.95
†
Speaking Level (mean) 4.80 §8.57 4.24 §7.14 0.67*
Shouting habit (yes) 28 (56) 20 (40) 0.21
†
Active-irritable (yes) 28 (56) 16 (32) 0.31
†
* t Test and the Mann-Whitney U-test were used.
†
Pearson Chi-square and Fisher’s exact test were used.
BMI, body mass index.
TABLE 2.
Comparison of Results of Voice Analysis and Perceptual Survey Datas Between Two Groups
Parameters Study Group (n = 50) Control Group (n = 50) P
t-PVHI (median)
Functional 11 1 0.00*
Physical 19 2 0.00*
Emotional 10 0 0.00*
t-CVHI (median) 13 0 0.00*
RFS 7,512 §2,805 3,054 §1,79 0.00*
RSI 9,23 §3,46 4,56 §2,86 0.02*
MPT 6.8 §2.4 7.2§2.8 0.67*
Fo 246.8 §73.61 252.34 §43.24 0.48*
%Shim 4.721 §1.83 2.843 §0.09 0.00*
%Jitter 1.903 §78.4 0.825 §0,77 0.00*
NHR 0.149 §0.005 0.13 §0.014 0. 56*
* t Test and the Mann-Whitney U-test were used.
Fo, fundamental frequency; NHR, noise-harmonic ratio; RFS, reflux finding score; RSI, reflux symptom index; t-PVHI, Turkish pediatric voice handicape index;
t-CVHI, Turkish children voice handicape index.
The values were statistically significantly higher in the study group compared to the control group.
ARTICLE IN PRESS
4Journal of Voice, Vol. &&, No. &&, 2020
control group in respect of night eating, fast eating and
over-eating habits (Pvalues >0.05; Table 3).
The junk food consumption habits of the study group
were determined as 0−2 items a week (0) in 4 (8%) cases,
2−4 items per week (1) in 12 (24%) cases and more than 4
items per week (2) in 34 (68%) cases. The number of patients
who scored 2 points was higher in the study group than the
control group. The consumption of carbonated beverages in
the study group was determined as 0/1−2 glasses per week
(0) in18 (36%) cases, 2−4 glasses per week (1) in 16 (32%)
cases and more than 4 glasses per week (2) in 16 (32%) cases.
In the control group, junk food consumption per week was
determined as 0−2 items (0) in 32 (64%) cases, 2−4 items (1)
in 13 (26%) cases and more than 4 items (2) in 5 (10%) cases.
The consumption of carbonated beverages per week was
determined as 0/0−2 glasses (0) in 22 (44%) cases, 2−4
glasses (1) in 25 (50%) cases and more than 4 glasses (2) in 3
(6%) cases. Junk food was consumed by statistically signifi-
cantly more children in the study group than in the control
group (P= 0.00). The rate of carbonated beverage consump-
tion was also significantly higher in the study group patients
(P= 0.00).
DISCUSSION
In the pediatric age group, the most common cause of voice
disorder is VFNs, which, unlike adults, affects both genders
equally. Although vocal hygiene practices and voice therapy
are routinely recommended, especially reducing abuse of the
voice during the treatment phase, dietary recommendations
in children may be overlooked.
17
The results of this pilot
study showed that the rate of junk food consumption in
pediatric VFN patients was higher than in children without
voice problems. Similarly, the LPR finding scores were also
found to be higher in these children. The rate of consump-
tion of foods and acidic beverages, which contain poor fat,
sugar and additives, which are defined as junk food, is
known to be gradually increasing in the daily dietary habits
of children. In Turkey, processed foods that children con-
sume frequently include salty snacks, potato crisps, fried
foods, biscuits, wafers, cakes, chocolate, cola, and candies.
Consequently, studies have shown an increase in the inci-
dence of many important diseases, particularly cardiovascu-
lar disorders, in the pediatric age group.
8,9,18
However,
there are not many studies showing the effects of dietary
and nutritional habits in ENT practice in the pediatric age
group.
The effect of dietary habits and food preferences in the
etiology of gastroesophageal reflux disease is a known fact.
In a study with preschool children in Korea, it was stated
that nutritional habits such as selective and irregular nutri-
tion, snack preference, liquid foods, and eating late at night
showed a significant correlation with GERD.
19
Junk foods,
which contain more than normal amounts of sugar, poor
fat, sodium, and various additives, can make changes in the
gastric content and acidity. Thus, there may be an increase
in chronic mucosal irritation on vocal folds associated with
LPR. As known, LPR in children may be associated with
different laryngeal disorders such as hoarsenesss, vocal fold
granuloma, laryngomalacia, subglottic stenosis, and recur-
rent papillomatosis.
20
Some studies have suggested that
LPR may have an effect on children with pediatric VFNs.
21
In a retrospective study of 337 children with hoarseness,
Block et al found co-existence of nodules and reflux in 20%
of children. They also stated that combining reflux and
speech therapy provided better healing in children with nod-
ules than those treated with a single method.
22
In the current
study group, although there was a lack of comparison of
treatment and follow-up results, the significantly higher
RFS values compared to the control group can be consid-
ered to contribute to the literature in terms of supporting
the evidence of the association of VFNs and reflux. The
results of the current study showed a significant difference
between the VFNs and control groups in respect of the con-
sumption of the above-mentioned foods, and a higher RFS
in the study group, suggesting that junk food consumption
TABLE 3.
Grouping and Comparison of the Children in Both Groups According to Dieatary and Food Consumption Habits
Dieatary and Food Consumption Habits Study Group (n, %) Control Group (n, %) P
Late night drinking/eating 23 (46) 22 (44) 0.67*
Fast eating 11 (22) 8 (16) 0.50*
Over-eating 8 (16) 3 (6) 0.11*
Junk food(package)
0 4 (8) 32 (64) 0.00*
1 12 (24) 13 (26) .086*
2 34 (68) 5 (10) 0.00*
Carbonated beverages(cup)
0 18 (36) 22 (44) 0.56*
1 16 (32) 25 (50) 0.48*
2 16 (32) 3 (6) 0.00*
* Pearson chi-square and Fisher’s exact test were used.
The values were statistically significantly higher in the study group compared to the control group.
ARTICLE IN PRESS
M€
uge
€
Oz¸celik Korkmaz and Arzu T€
uz€
uner Dietary Habits in Pediatric Nodule 5
may have negative effects on pediatric voice health. In the
development of reflux, not only the types of food consumed,
but also eating and drinking habits like fast, over-eating or
up to 2 hours before bedtime can have an effect. However,
in the current study, no significant difference was seen
between the groups in these respects. In addition, the
median BMI values and the number of overweight children
in the groups were similar. Although there are no large-
based studies investigating the prevalence of obesity in
school-age children in our country has been reported
between 9% and 27% in regional studies.
23
The rates of
overweight children in the groups were compatible with the
literature.
At present, there is no ideal diagnostic test for LPR detec-
tion in the pediatric age group. However, multichannel
impedance with pH monitoring has become the new gold
standard (MII-pH) to document both acid and nonacid
reflux.
7,24
However, this examination is quite invasive and
shows low sensitivity to LPR, with the proportion of unde-
tected diseases reaching as high as 50%. One of the most
important diagnostic tools in the diagnosis of LPR in the
pediatric age group is RFS assessment performed by fiber-
optic examination. In a retrospective study by Simons et al,
they showed that RSI may be a useful parent-proxy instru-
ment for pediatric voice patients.
25
In our study, we used
examination data (RFS) and parent-proxy symptom ques-
tioning (RSI) to evaluate possible reflux findings in children.
Similar studies have found that endoscopic examination
findings related to LPR show frequent changes due to
inflammation. The most common endoscopic examination
findings are erythema and edema in arytenoids, interaryte-
noid and postglottic regions.
20,26,27
In the current study, the
most common finding was reflux (40%) edema and ery-
thema (35%) consistent with findings in literature. Carr et al
reported pseudosulcus findings in 89% of children with a
positive LPR test, whereas in the current study only 2 chil-
dren had accompanying pseudosulcus.
28
In addition, exces-
sive food intake due to junk food diet and soft drinks may
cause behavioral changes that may result in hyperactivity or
lethargy. Studies have shown that children who consume
such foods frequently are more likely to experience behav-
ioral disorders.
8,29
Personality structure and the behavioral
characteristics of children are known to have effects on
VFNs development. In a review by Lee et al, the role of
children's personalities and psychological factors was
emphasized in the formation of VFN and it was also
suggested that the relationship between vocal use and per-
sonality should be evaluated with relevant psychiatric ques-
tionnaires and that treatment should be planned according
to these results.
30
There is also an increasing number of
studies showing that hyperactivity and attention deficit dis-
orders are more common in children with VFNs.
31
In this
respect, these types of food consumption habits and behav-
ioral changes in children can indirectly lead to increased
habits of vocal abuse. T€
uz€
uner et al also stated that environ-
mental factors such as the presence of siblings and maternal
voice disease can contribute to in the development of voice
disorders in children with VFNs.
4
Although there was no
significant difference between the study and control groups
in terms of loud use/shouting habits and personality struc-
ture of the children in the current study, the number of chil-
dren identified as aggressive/irritable in the study group was
higher in accordance with the literature.
A limitation of the current study was the lack of detailed
psychiatric and psychological evaluations of the children.
Further studies to be conducted in collaboration with the
pediatric psychiatry department will be able to provide
more detailed and objective data on the relationship
between behavioral disorders that increase voice abuse and
food consumption habits. This is a preliminary and pilot
study, important not to assign cause and effect but to
emphasize that there may be an association worth investi-
gating with a larger, more comprehensive study. Although
the data obtained support the negative effects of increasing
junk food consumption on the voice health of children, anti-
reflux treatment and diet controlled studies will be able to
provide more accurate data on this subject in future. The
methods and data presented in our study can be guiding for
this purpose.
CONCLUSION
The most well-known causes of pediatric VFNs are phono-
trauma due to loud use, shouting and sporting activities,
and these children are known to usually be irritable/aggres-
sive children. In the current study, there was no significant
difference between the control group without voice prob-
lems and this patient group in terms of character traits and
shouting habits. When the food consumption habits of these
children were examined, the consumption of junk food and
carbonated beverages was higher in the VFN patients than
in the control group, and the RFS was also higher than in
the control group. The data obtained in this pilot study sug-
gest relationships between the amount of junk food con-
sumption, LPR and VCNs. This was a pioneering study on
the relationship between food consumption habits and voice
health in children, and more detailed, controlled studies in
the future will reveal clearer results. According to the future
results, recommendations can be made to children with
VFNs to limit such foods and reduce excessive consumption
to alleviate LPR
COMPLIANCE WITH ETHICAL STANDARDS
All procedures performed in studies involving human par-
ticipants were in accordance with the ethical standards of
the national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical
standards.
INFORMED CONSENT
Informed consent was obtained from all individual partici-
pants included in the study.
ARTICLE IN PRESS
6Journal of Voice, Vol. &&, No. &&, 2020
REFERENCES
1. De Bodt MS, Ketelslagers K, Peeters T, et al. Evolution of vocal fold
nodules from childhood to adolescence. J Voice. 2007;21:151–156.
2. Kili¸c M, Okur E, Yildirim I, et al. The prevalence of vocal fold nodules
in school age children. Int J Pediatr Otorhinolaryngol. 2004;68:409–
412.
3. Martins RG, Hidalgo Ribeiro CB, Fernandes de Mello BM, et al. Dys-
phonia in children. J Voice. 2012;26:17–20.
4. Tuzuner A, Demirci S, Oguz H, et al. Pediatric vocal fold nodule
etiology: what are its usual causes in children? JVoice. 2017;31:
506–511.
5. D'Alatri L, Petrelli L, Cal
o L, et al. Vocal fold nodules in school age
children: attention deficit hyperactivity disorder as a potential risk fac-
tor. J Voice. 2015;29:287–291.
6. Martins RH, do Amaral HA, Tavares EL, et al. Voice disorders: etiol-
ogy and diagnosis. J Voice. 2016;30:761–770.
7. W»odarczyk E, Tomasz J, Raj-Koziak D, et al. Diagnosis of laryngo-
pharyngeal reflux in children with voice disorders using 24-hour pharyn-
geal pH monitoring. Int J Pediatr Otorhinolaryngol. 2019;121:188–196.
8. Wiles NJ, Northstone K, Emmett P, et al. ‘Junk food’diet and child-
hood behavioural problems: results from the ALSPAC cohort. Eur J
Clin Nutr. 2009;63:491–498.
9. Costa CS, Del-Ponte B, Assuncao MCF, et al. Consumption of ultra-
processed foods and body fat during childhood and adolescence: a sys-
tematic review. Public Health Nutr. 2018;21:148–159.
10. Leung AK, Hon KL. Gastroesophageal reflux in children: an
updated review. Drugs Context. 2019;17:212591. https://doi.org/
10.7573/dic.212591. eCollection 2019.
11. Takeshita E, Furukawa S, Sakai T, et al. Eating behaviours and preva-
lence of gastroesophageal reflux disease in japanese adult patients with
type 2 diabetes mellitus: the dogo study. Can J Diabetes. 2018;42:308–
312. https://doi.org/10.1016/j.jcjd.2017.07.007.
12. WHO Multicentre Growth Reference Study Group. WHO Child
Growth Standards based on length/height, weight and age. Acta Pae-
diatr. 2006;450:76–85.
13. Belafsky PC, Postma GN, Koufman JA. The validity and reliability of
the reflux finding score (RFS). Laryngoscope. 2001;111:1313–1317.
14. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the
reflux symptom index (RSI). J Voice. 2002;16:274–277.
15.
€
Ozkan ET, T€
uz€
uner A, Demirhan E, et al. Reliability and validity of
the Turkish pediatric Voice Handicap index. Int J Pediatr Otorhinolar-
yngol. 2015;7:680–684.
16. Tadihan
€
Ozkan E, T€
uz€
uner A, ¸C iyiltepe M, et al. Reliability and valid-
ity of the Turkish children's voice handicap index-10 (TR-CVHI-10).
Int J Pediatr Otorhinolaryngol. 2017;96:131–134.
17. Trani M, Ghidini A, Bergamini G, et al. Voice therapy in pediatric
functional dysphonia: a prospective study. Int J Pediatr Otorhinolar-
yngol. 2007;71:379–384.
18. Azemati B, Kelishadi R, Ahadi B, et al. Association between junk food
consumption and cardiometabolic risk factors in a national sample of
Iranian children and adolescents population: the CASPIAN-V study.
Eat Weight Disord. 2018;11:1–7.
19. Choi YJ, Ha EK, Jeong SJ. Dietary habits and gastroesophageal reflux
disease in preschool children. Korean J Pediatr. 2016;59:303–307.
https://doi.org/10.3345/kjp.2016.59.7.303.
20. Venkatesan NN, Pine HS, Underbrink M. Laryngopharyngeal reflux
disease in children. Pediatr Clin North Am. 2013;60:865–878.
21. Galluzzi F, Schindler A, Gaini RM, et al. The assessment of children
with suspected laryngopharyngeal reflux: an Otorhinolaringological
perspective. Int J Pediatr Otorhinolaryngol. 2015;79:1613–1619.
22. Block BB, Brodsky L. Hoarseness in children: the role of laryngophar-
yngeal reflux. Int J Pediatr Otorhinolaryngol. 2007;7:1361–1369.
23. Ercan S, Dallar YB,
€
Onen S, et al. Prevalence of obesity and associated
risk factors among adolescents in Ankara. Turkey J Clin Res Pediatr
Endocrinol. 2012;4:204–207.
24. Lightdale JR, Gremse DA. Section on gastroenterology, hepatology,
and nutrition. Gastroesophageal reflux: management guidance for the
pediatrician. Pediatrics.. 2013;131:1684–1695.
25. Simons JP, Rosen CA, Casselbrant ML, et al. Comparison of pediatric
voice outcome survey, reflux symptom index, reflux finding score, and
esophageal biopsy results. Arch Otolaryngol Head Neck Surg..
2008;134:837–841.
26. Karkos PD, Leong SC, Apostolidou MT, et al. Laryngeal manifestations
and pediatric laryngopharyngeal reflux. Am J Otol. 2006;27:200–203.
27. Lechien JR, Saussez S, Harmegnies B, et al. Laryngopharyngeal reflux
and voice disorders: a multifactorial model of etiology and pathophysi-
ology. J Voice. 2017;31:733–752.
28. Carr MM, Abu-Shamma U, Brodsky LS. Predictive value of laryngeal
pseudosulcus for gastroesophageal reflux in pediatric patients. Int J
Pediatr Otorhinolaryngol. 2005;69:1109–1112.
29. Kelishadi R, Heshmat R, Mansourian M, et al. Association of dietary
patterns with continuous metabolic syndrome in children and adoles-
cents; a nationwide propensity score-matched analysis: the CASPIAN-
V study. Diabetol Metab Syndrome.2018 52-63.
30. Lee JM, Roy N, Dietrich M. Personality, psychological factors, and
behavioral tendencies in children with vocal nodules: a systematic
review. J Voice. 2019;6:945–963.
31. Barona-Lleo L, Fernandez S. Hyperfunctional voice disorder in chil-
dren with Attention Deficit Hyperactivity Disorder (ADHD). A phe-
notypic characteristic? J Voice. 2016;30:114–119.
ARTICLE IN PRESS
M€
uge
€
Oz¸celik Korkmaz and Arzu T€
uz€
uner Dietary Habits in Pediatric Nodule 7
