Gastroesophageal Reflux Disease (Pediatric)
Gastroesophageal reflux is when the contents of the stomach flow back into the esophagus. (The esophagus is a long tube of muscle that connects the mouth to the stomach.)
If the reflux is serious, it can cause:
- Damage to the lining of the esophagus from the stomach acid that is spit up. Without treatment this damage can be severe and possibly lead to cancer.
- Poor nutrition because food is being spit up instead of being digested
- Getting the spit up food into the lungs or airways. This can lead to forms of asthma or pneumonia
- A narrowing of the esophagus (strictures)
When a baby often spits up food to the point where it isn't getting enough to eat and thrive, a doctor should be called in. The doctor can check whether the baby has gastroesophageal reflux or another condition that is causing the problem.
Signs that a child may have gastroesophageal reflux include:
- A peculiar arching movement. This happens in some infants because of the painful burning sensation when the stomach fluid remains in the esophagus. Sometimes this movement is mistaken for a neurological problem.
- Failure to grow and gain weight
- Frequent cough or coughing fits at night
- Frequent sore throats in morning
- Frequent upper respiratory infections (colds)
- Frequent vomiting
- Rattling in the chest
- Refusal to eat or fussiness at meals
- Sour taste in the mouth
When the spit up food reaches the back of throat as the infant is breathing, the material can be inhaled into the windpipe and lungs. The infant will cough in response. Sometimes this may be mistaken for asthma or bronchitis for years before the real cause is discovered. The inhaled material may also cause an infection that leads to pneumonia. It may also be a cause of sudden infant death syndrome (SIDS).
When the spit up food reaches the back of the throat at the same time that the baby breathes, the material is aspirated into the windpipe and lungs. The aspirated material may cause a chemical or bacterial pneumonia. A child can be thought to have reactive airway disease, asthma, or bronchitis for some years before the real reason - reflux - is found.
Causes and Risk Factors for Gastroesophageal Reflux in Children
Gastroesophageal reflux disease happens because of several factors including:
- The angle of where the esophagus joins the stomach. (This is called the angle of His.)
- How toned the muscles are at the lower end of the esophagus
- The length of the esophagus inside the abdomen
- A pinching effect of the fibers of the diaphragm where they separate to allow the esophagus to pass from the abdomen to the chest. )The diaphragm itself is a thin muscle below the lungs and heart that separates the abdomen from the chest.)
- Other factors such as having a hiatal hernia.
Certain foods - chocolate, peppermint and high-fat foods - seem to make the muscle that is supposed to close the mouth of the stomach where it joins the esophagus stay open longer. Other foods, such as citrus fruit and tomatoes, cause the stomach to make more acid.
Diagnosing Gastroesophageal Reflux in Children
Gastroesophageal reflux can be hard to diagnose. Several other diseases have similar symptoms. It is very important to get a correct diagnosis. Only then can the proper treatment be given.
Several tests are used to diagnose gastroesophageal reflux, including:
- An upper gastrointestinal (GI) contrast study. This is the most frequent test done to diagnose reflux. This test shows the anatomy of the digestive tract and any possible hiatal hernias or problems such as an ulcer. An upper GI contrast study is a snapshot in time. Reflux may not be seen at that particular moment. Just because the test doesn't show the reflux doesn't mean that the reflux isn't present.
- A 24-hour pH probe study. This involves putting a small tube that measures acid levels down the esophagus. When reflux occurs, a wave of acid washes over the probe, which measures a drop in pH. This study is done over a period of time. The study can tell how often reflux occurs and how long the reflux episodes are. This text is helpful in distinguishing between normal and abnormal reflux.
- Chest X-ray. This is used to look for signs of inhaled food or pneumonia.
- Esophageal manometric studies. These are designed to measure the pressure of the muscle that holds the lower end of the esophagus shut (the lower esophageal sphincter).
- Upper GI endoscopy. This involves examining the insides of the esophagus, stomach and duodenum (where the stomach and small intestine join) using a tiny scope (an endoscope). This test can show whether there are narrowings (strictures), abnormal structures, tumors or infections. Endoscopy also allows the doctor to take samples, if needed, for looking at under a microscope (a biopsy).
- Bronchoscopy. This is an examination of the airways of the lungs using an endoscope. Tissue biopsies may be done as well to check for signs of reflux. This test is usually only done when other tests haven't shown reflux is present, but the baby still has symptoms.
- Nuclear medicine scan. This test involves feeding the baby or child milk that has a small amount of radioactive material in it. A scanner is used to see what happens inside the child's body. It can show how fast the milk leaves the stomach, whether there are problems with stomach movement or problems in the lower part of the digestive tract and whether milk is being inhaled into the lungs.
Treating Gastroesophageal Reflux Disorder in Children
Often a baby will outgrow GERD, usually by around eight months. If not, medical or surgical treatments may be needed.
There are several effective options for treating gastroesophageal reflux in children. How a child is treated for gastroesophageal reflux disease will depend on many factors, including:
- The child's age, general health and medical history
- How severe the disease is
- How well the child tolerates certain medicines, procedures or therapies
- What the long-term outlook is for the disease
- The preferences of the parents
Treatment approaches for reflux that don't involve surgery include:
- Medicines to help lower the amount of acid the stomach makes. This will cut down on the amount of heartburn associated with the reflux. These medicines include cimetidine (Tagament), ranitidine (Zantac), omeprazole (Prilosec) and lansoprazole (Prevacid). These medicines have to be taken daily.
- Medicines to help the stomach empty faster. If there is less food in the stomach, there is less reflux. An example of this type of medicine is metoclopramide (Reglan). It is usually taken three to four times a day before meals or feedings and at bedtime.
- Nutritional supplements. Because it can be hard for a baby or child to get enough nourishment when they have reflux, a doctor may recommend adding rice cereal to baby formula or adding prescription supplements to formula or breast milk to increase calories.
- Tube feedings. When a baby has a condition that makes them tired such as heart disease or is premature, they may fall asleep before they take in enough food. Other babies can't tolerate a normal amount of food in the stomach without vomiting. In these cases, a tube can be placed in the nose and guided through the esophagus and into the stomach. Formula or breast milk is given through the tube. Tube feeding can be done instead of or in addition to normal feeding.
Some changes in diet and lifestyle can also be helpful. Examples include avoiding or limiting fried or fatty foods, peppermint, chocolate, drinks with caffeine such as colas, tea or Mountain Dew, citrus fruit and juice and tomato products. Eating small amounts of food at a time and eating more often can also help. Not letting a child lie down or go to bed right after a meal can be helpful. Having dinner at least two hours before bedtime will lessen reflux. Babies should be placed on their tummies with their tummies with their chests elevated after eating. It can be helpful to hold a baby in a sitting position for about 30 minutes after being fed.
If medical treatment doesn't successfully treat the reflux, surgery is an option. Clear signs that surgery should be done include:
- Loss of weight and inadequate nutrition
- Pain that keeps coming back and interferes with daily living
- Damage to the esophagus or tooth damage
- Respiratory problems such as asthma, pneumonia or ongoing ear infections
- Any life-threatening event from breathing fluid into the lungs.
If surgery is needed, a procedure called fundoplication can be done by Cedars-Sinai Pediatric Surgical Services. Whenever possible, this procedure is done using minimally invasive techniques