An increased lipid content in alveolar macrophages of bronchoalveolar lavage (BAL) fluid is thought to be a useful indicator for recurrent pulmonary aspiration. To assess whether pulmonary diseases unrelated to aspiration can raise the lipid content in alveolar macrophages, we evaluated Oil-Red-O-stained smears of BAL fluid in 18 children aged 3-15 years undergoing elective surgery for nonpulmonary illnesses under general anesthesia and in 18 children aged 1-16 years who had pulmonary diseases without clinical evidence of aspiration (pneumonia, exogenous allergic alveolitis, or cystic fibrosis). A semiquantitative lipid-laden macrophage (LLM) index was determined for each patient. LLM indices in children without pulmonary disease were higher than those published for healthy adults. In children with pulmonary diseases but without evidence of aspiration, a significantly higher LLM index was observed compared to controls. The LLM indices of children with pulmonary diseases were similar to those published by other authors for children with pulmonary aspiration. We conclude that an elevated LLM index in alveolar macrophages of BAL can be found in a variety of pulmonary diseases in which there is no clinical evidence of aspiration and is therefore unlikely to be a specific parameter for silent pulmonary aspiration.