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Gastroesophageal Reflux in Children

(Gastroesophageal Reflux Disease [GERD])

By William J. Cochran, MD, Associate, Department of Pediatrics GI and Nutrition;Clinical Professor, Department of Pediatrics, Geisinger Clinic, Danville, PA;Temple University School of Medicine

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Gastroesophageal reflux is the backward movement of food and acid from the stomach into the esophagus and sometimes into the mouth.

  • Reflux may be caused by the infant’s position during feeding; overfeeding; exposure to caffeine, nicotine, and cigarette smoke; a food intolerance or allergy; or an abnormality of the digestive tract.

  • Infants may vomit, spit up excessively, have feeding or breathing problems, and also appear irritable.

  • Tests that help doctors diagnose the disorder include a barium study, an esophageal pH probe, a gastric emptying scan, and endoscopy.

  • Treatment options include thickened or hypoallergenic formula for feedings, special positioning, frequent burping, histamine-2 blockers, proton pump inhibitors, and, in certain cases, metoclopramide and surgery.

Nearly all infants have episodes of gastroesophageal reflux, which are characterized by wet burps, burping up, or spitting up. Wet burps typically occur shortly after eating and are considered normal. Reflux typically worsens in the first several months of life, peaks around 6 to 7 months of age, and then gradually lessens. Nearly all infants with reflux outgrow it by about 18 months of age.

Gastroesophageal reflux becomes known as gastroesophageal reflux disease (GERD) when it

  • Interferes with feeding and growth

  • Damages the esophagus (esophagitis)

  • Leads to breathing difficulties (such as coughing, wheezing, or stopping breathing)

  • Continues beyond infancy into childhood

Causes

Healthy infants have reflux for many reasons. The circular band of muscle at the junction of the esophagus and stomach (the lower esophageal sphincter) normally keeps stomach contents from entering the esophagus (see Overview of the Esophagus). In infants, this muscle may be underdeveloped, or it may relax at inappropriate times, allowing stomach contents to move backward (reflux) into the esophagus. Being held flat during feeding or lying down after feeding promotes reflux because gravity is no longer able to help keep material in the stomach from flowing back up the esophagus. Overfeeding and chronic lung diseases predispose infants to reflux because they increase pressure in the stomach. Cigarette smoke (as secondhand smoke) and caffeine (in beverages or breast milk) relax the lower esophageal sphincter, allowing reflux to occur more readily. Caffeine and nicotine (in breast milk) also stimulate acid production, so any reflux that does occur is more acidic.

A food allergy or intolerance, most commonly milk allergy, also can contribute to reflux, but this is a less common cause.

Inherited disorders of metabolism, such as galactosemia and hereditary fructose intolerance, and anatomic abnormalities, such as narrowing of the esophagus, partial blocking of the stomach (pyloric stenosis), or abnormal positioning of the intestines (malrotation), can initially mimic reflux because they cause repeated episodes of vomiting. However, these abnormalities are more serious and can progress to vomiting and other symptoms of obstruction, such as abdominal pain, listlessness, and dehydration.

Symptoms

In infants, the most obvious symptoms of gastroesophageal reflux are

  • Vomiting

  • Excessive spitting up (regurgitation)

In young children, the most common symptoms are

  • Chest pain

  • Abdominal pain

  • Sometimes heartburn (a burning pain behind the breastbone)

In adolescents, the most common symptom is the same as in adults:among adults

  • Heartburn

Complications of reflux

In some infants, reflux causes complications and becomes known as GERD. Such complications include

  • Irritability due to stomach discomfort

  • Feeding problems that can result in poor growth

  • “Spells” of twisting and posturing that may be confused with seizures

Less commonly, small amounts of acid from the stomach may enter the windpipe (aspiration). Acid in the windpipe and breathing passages may result in coughing, wheezing, stopping breathing (apnea), or pneumonia. Many children with asthma also have reflux. Ear pain, hoarseness, hiccups, and sinusitis also can occur as a result of GERD. If the esophagus is significantly irritated (esophagitis), there may be some bleeding, resulting in iron deficiency anemia. In others, esophagitis can cause scar tissue, which can narrow the esophagus (stricture).

Diagnosis

  • Barium study

  • Esophageal pH probe or impedance probe

  • Gastric emptying scan

  • Upper endoscopy

Tests are often not needed to diagnose gastroesophageal reflux in infants or older children who simply have mild symptoms such as frequent spit-ups (in infants) and heartburn (in older children). However, if symptoms are more complicated, various tests can be done.

A barium study is the most common test. The child swallows barium, a liquid that outlines the digestive tract when x-rays are taken. Although this test can help the doctor diagnose gastroesophageal reflux, it more importantly helps the doctor identify some of the possible causes of the reflux.

An esophageal pH probe is a thin flexible tube with a sensor at the tip that measures the degree of acidity (pH). Doctors pass the tube through the child’s nose, down the throat, and into the end of the esophagus. The tube is usually left in place for 24 hours. Normally, children do not have acid in their esophagus, so if the sensor detects acid, it is a sign of reflux. Doctors sometimes use this test to see whether children with symptoms such as coughing or breathing difficulties have reflux.

An impedance probe is very similar to the esophageal pH probe but it can detect both acid and nonacid reflux. This probe is used in children who are taking drugs that suppress stomach acid to see whether they still have reflux, to see whether the reflux is associated with other symptoms, and to confirm that the drugs are working to lessen acid reflux.

In a gastric emptying scan (milk scan), the child drinks a beverage that contains a small amount of mildly radioactive material. This material is harmless to the child. A special camera or scanner that is highly sensitive to radiation can detect where the material is in the child’s body. The camera can see how rapidly the material leaves the stomach and whether there is reflux, aspiration, or both.

In upper endoscopy, the child is sedated, and a small flexible tube with a camera on the end (endoscope) is passed through the mouth into the esophagus and stomach. Doctors may do upper endoscopy if they need to see whether the reflux has caused damage to the esophagus (esophagitis), an ulcer, or irritation or if they need to obtain a sample for a biopsy. Endoscopy can also help determine whether the symptoms of reflux are not due to something else such as an allergy, infection, or celiac disease. Bronchoscopy is a similar test in which doctors use an endoscope to examine the voice box (larynx) and airways. Bronchoscopy can help doctors decide whether reflux is a likely cause of lung or breathing problems.

Treatment

  • For wet burps in infants, thickened formula, special positioning, and frequent burping

  • For food intolerance or allergy in infants, possibly special formula

  • Other measures to reduce reflux

  • Sometimes drugs

  • Rarely surgery

Treatment of reflux depends on the child’s age and symptoms.

For infants who just have wet burps, doctors reassure parents that there is nothing more serious happening. They may recommend no treatment or may suggest measures such as thickening formula for feedings, special positioning, and frequent burping. Formula can be thickened by adding 1 to 3 teaspoons of rice cereal per ounce of formula. The nipple may have to be cross-cut to allow the formula to flow. Infants with reflux should be fed in an upright or semi-upright position and then maintained in an upright, nonsitting position for 20 to 30 minutes after eating (sitting, as in an infant seat, increases stomach pressure and is not helpful). In addition, burping the infant after every 1 to 2 ounces can help decrease pressure in the stomach by expelling the air the infant swallows.

Infants with a food intolerance or allergy may benefit from a hypoallergenic formula.

The head of the crib or bed can be raised 6 inches (about 15 centimeters) to help reduce nighttime reflux. Infants should be secured in a sling fitted over the mattress or wedge to keep them from rolling or sliding down to a horizontal position on the lower end of the crib.

Older children also should avoid eating 2 to 3 hours before bedtime, drinking carbonated beverages and those that contain caffeine, taking certain drugs (such as those with anticholinergic effects), eating certain foods (such as chocolate or fatty foods), and overeating.

All children should be kept away from caffeine and tobacco smoke.

Drugs for reflux

If changes in feeding and positioning do not control symptoms, doctors may prescribe drugs. Several types of drugs are available for reflux:

  • Those that neutralize acid

  • Those that suppress acid production

  • Those that improve the movement of the digestive tract

Antacids are drugs that neutralize stomach acid. These drugs work quickly to relieve symptoms such as heartburn.

For children with more severe disease, acid-suppressing drugs are required. By reducing stomach acid, these drugs lessen symptoms and allow the esophagus to heal. There are two types of acid-suppressing drugs, histamine-2 (H2) blockers and proton pump inhibitors (PPIs). H2 blockers do not suppress acid production quite as much as PPIs.

Promotility drugs stimulate the movement of contents through the stomach and intestines. These drugs (such as erythromycin) may help increase the speed at which the stomach empties. Improved gastric emptying should decrease stomach pressure, making reflux less likely to occur.

Surgery for reflux

Rarely, reflux does not respond to nonsurgical treatment and is so severe that doctors recommend surgery. The most common surgical procedure is a fundoplication. In fundoplication, the surgeon wraps the top of the stomach around the lower end of the esophagus to make that junction tighter and decrease reflux.

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