Andrey Nailor, M.D.·Published 26 January 2012·16 min read
Key points
Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus.
The symptoms of gastroesophageal reflux depend upon the child's age.
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.
Gastroesophageal reflux (GER) is the medical term for spitting up.
Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The esophagus carries food from the mouth to the stomach.
When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has gastroesophageal reflux disease. Heartburn that occurs more than twice a week may be considered gastroesophageal reflux disease (GERD).
The main symptoms are persistent heartburn and acid regurgitation. Some people have gastroesophageal reflux disease (GERD) without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. Gastroesophageal reflux disease (GERD) can also cause a dry cough and bad breath.
Gastroesophageal reflux disease (GERD) in Children Studies* show that gastroesophageal reflux disease is common and may be overlooked in infants and children. Acid reflux is a normal process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause bothersome symptoms or problems.
However, some people with acid reflux have troublesome symptoms, including heartburn, vomiting, or pain with swallowing. In this case, the problem is called gastroesophageal reflux disease (GERD). Treatments for GERD are available and can help to reduce symptoms.
This article discusses the symptoms, causes, diagnosis, and treatment of children and adolescents with gastroesophageal reflux disease. Gastroesophageal reflux in infants and adults is discussed separately.
Children's immature digestive systems are usually to blame, and most infants grow out of gastroesophageal reflux disease (GERD) by the time they are 1 year old. Still, you should talk to your child's doctor if the problem occurs regularly and causes discomfort. Your doctor may recommend simple strategies for avoiding reflux, like burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. If your child is older, the doctor may recommend avoiding sodas that contain caffeine, chocolate and peppermint, spicy foods like pizza, acidic foods like oranges and tomatoes and fried and fatty foods. [Jung AD. Gastroesophageal reflux in infants and children. American Family Physician. 2001;64(11):1853 - V1860.]
Avoiding food 2 to 3 hours before bed may also help. The doctor may recommend that the child sleep with head raised. If these changes do not work, the doctor may prescribe medicine for your child. In rare cases, a child may need surgery. What causes gastroesophageal reflux disease? No one knows why people get gastroesophageal reflux disease. A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus.
Written and revised by
Andrey Nailor, M.D.
Our doctors write and review articles for accuracy and keep them up to date.
health.am provides general information, not medical advice. Always consult a qualified health professional about your own health.
When a hiatal hernia is present, it is easier for the acid to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.
Other factors that may contribute to gastroesophageal reflux disease include alcohol use, overweight, pregnancy and smoking
Heartburn and acid indigestion can be pretty painful at times. If it's difficult for you to imagine the pain and discomfort for yourself, try to grasp the concept that it's not so uncommon for infants and young children to experience as well. It's normal for a baby to spit up sometimes throughout the day, but it should be monitored and if it's associated with other symptoms you child could be suffering from GERD.
Acid reflux in young children and infants is caused in the same way as in adults. It's the act of the stomach's contents backing into their throats and mouths. The same malfunction of the lower esophageal sphincter (LES) is responsible, and usually it's because of an infants' immature digestive system. The good news about this is that most physicians will agree that they will grow out of it by age one. In older children it's virtually the same as adults. Anything that causes that sphincter muscle to relax or puts undue pressure abdomen will cause this failure. You should restrict or limit your child's intake of caffeine laden and carbonated drinks, fatty and greasy foods, and if your child is showing sings of being overweight seek guidance from your doctor on if a diet is in need.
It is fairly well known that food allergies in young children can cause gastrointestinal problems like vomiting or diarrhea, but it is less common for such food allergies to cause acid reflux. This is rare but possible side effect to food allergies.
If your infant shows signs of acid reflux you can do several things to ease her discomfort. Hold the bottle at and angle, and make sure she is not totally horizontal. Try not feed large quantities at a time, I know this is hard when they are hungry but smaller portions make it easier to digest. If she's at a stage where she's eating solid foods, try only one food at a time and make sure that you give it a few days before moving on, this will give you enough time to know what is causing a reaction if any. Once you know what food is causing such reaction it's best to avoid it. This may make things a little inconvenient, but it's worth it, and most will grow out of this stage.
ACID REFLUX SYMPTOMS
The symptoms of gastroesophageal reflux depend upon the child's age.
Preschool - Symptoms of acid reflux in preschool-age children can include:
Vomiting or feeling stomach acid or food in the throat or mouth Less commonly, there can be wheezing, particularly in children with asthma Lack of interest in eating (because of pain with eating) Weight loss
Older children and adolescents - The most common symptoms of GERD in older children and adolescents include many of the symptoms listed above, plus:
Tasting stomach acid in the throat Nausea Pain or burning in the upper chest (heartburn) Discomfort or pain with swallowing Feeling that food gets stuck while swallowing
Children who do not talk may pound their chest when they feel the heartburn. Pain usually happens after meals, may awaken the child from sleep, and may be worse with stress or when lying down. Pain can last minutes to hours.
In all age groups, constipation can cause some of the symptoms of GERD, such as upset stomach, heartburn, and nausea. Treating constipation can relieve these problems.
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Also, certain foods can be associated with reflux events, including citrus fruits, chocolate, drinks with caffeine, fatty and fried foods, garlic and onions, mint flavorings, spicy foods, tomato-based foods, like spaghetti sauce, chili, and pizza
Several treatment options are available for children with acid reflux. The "best" treatment depends upon your child's age, the type and severity of symptoms, and how your child responds to treatment.
Lifestyle changes — Lifestyle changes, such as raising the head of the bed and losing weight, are commonly recommended for adults with GERD. These changes might be helpful for some, but not all, children with mild symptoms of acid reflux.
Lifestyle changes are not recommended as the ONLY treatment for a child with moderate or severe symptoms of GERD. Call your child's healthcare provider before beginning any treatment for acid reflux.
Avoid certain foods — Certain foods, including caffeine, chocolate, and peppermint, can relax the muscle in the esophagus, allowing acid to reflux. Acidic foods and drinks, including colas, orange juice, and spicy foods, may also cause more symptoms. Foods that are high in fat, such as pizza and french fries, may also increase reflux by slowing stomach emptying. These foods should be avoided if they seem to cause more symptoms, and particularly if the child is overweight. Raise the head of the bed 6 to 8 inches — Although some people only have heartburn for the two to three hours after meals, others wake up at night with heartburn. Raising the head of the bed might help to reduce nighttime heartburn. This raises the head and shoulders higher than the stomach, allowing gravity to prevent acid from backing up into the esophagus.
You can raise the head of the bed with blocks of wood under the legs of the head of the bed or a foam wedge under the mattress. However, it is not helpful to use extra pillows; this can cause an unnatural bend in the body that increases pressure on the stomach, worsening acid reflux.
Weight loss — In significantly overweight children, losing weight might help reduce reflux. If you are worried about your child's weight, consult a doctor or nurse for advice on helping the child to lose weight.
Stay away from tobacco smoke — Smoking or being around tobacco smoke reduces the amount of saliva in the mouth and throat, which can worsen reflux. Saliva helps to neutralize acid. Tobacco smoke also provokes coughing, causing frequent episodes of acid reflux in the esophagus.
Parents and adolescents who smoke are encouraged to quit. Avoid lying down after eating — Lying down with a full stomach makes it easier for acid to reflux. By eating three or more hours before bedtime, you are less likely to have acid reflux while sleeping. Also avoid eating before exercising.
Chew gum — Chewing gum can increase the amount of saliva you make, which can help to neutralize stomach acid that has entered the esophagus. However, gum is not recommended for children who are less than four years old.
How is gastroesophageal reflux disease treated? If you have had heartburn or any of the other symptoms for a while, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your gastroesophageal reflux disease is, treatment may involve one or more of the following lifestyle changes and medications or surgery. Your doctor may also advise you to change your lifestyle, such as stop smoking, stop drinking alcohol, control weight (if needed), eating small meals, wearing loose-fitting clothes, avoiding lying down for 3 hours after a meal and raising the head of your bed 6-8 inches higher.
Medications include (1) Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Riopan, (2) Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. (3) H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. (4) Proton pump inhibitors - omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), (5) Prokinetics, helps strengthen the sphincter and makes the stomach empty faster-bethanechol (Urecholine) and metoclopramide (Reglan).
Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production.
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What if symptoms persist?
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.
A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus- called stricture - ulcers, hiatal hernia, and other problems will.
Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm gastroesophageal reflux disease (GERD).
The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found.
In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with gastroesophageal reflux disease (GERD) symptoms but no esophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux. Surgery Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.
Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for gastroesophageal reflux disease (GERD). The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.
This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown. Implant Recently the FDA approved an implant that may help people with gastroesophageal reflux disease D who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the esophagus. It is injected during endoscopy. The implant is approved for people who have gastroesophageal reflux disease and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.
What are the long-term complications of gastroesophageal reflux disease (GERD)? Sometimes gastroesophageal reflux disease (GERD) can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer.
Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by gastroesophageal reflux disease (GERD).
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Points to Remember Heartburn, also called acid indigestion, is the most common symptom of gastroesophageal reflux disease (GERD). Anyone experiencing heartburn twice a week or more may have gastroesophageal reflux disease (GERD).
You can have gastroesophageal reflux disease (GERD) without having heartburn. Your symptoms could be excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the mouth, or pain in the chest.
In infants and children, gastroesophageal reflux disease may cause repeated vomiting, coughing, and other respiratory problems. Most babies grow out of gastroesophageal reflux disease by their first birthday.
If you have been using antacids for more than 2 weeks, it is time to see a doctor. Most doctors can treat gastroesophageal reflux disease. Or you may want to visit an internist - a doctor who specializes in internal medicine - or a gastroenterologist - a doctor who treats diseases of the stomach and intestines.
For most people who believe they are suffering from acid reflux, their treatment will begin with simple lifestyle changes in an attempt to cure the problem. Losing weight, stopping smoking, and avoiding acidic foods will be where they start. Elevating the head of the bed, as well as using standard antacids before meals will also be used before starting a more formal treatment. Once prescription only medications, Prilosec and Prevacid, are available now over-the-counter which will help most people with their symptoms if they continue after attempting the above mentioned practices. Doctors still have more powerful prescription only medications as well as having surgery as an option to treat those that still need help.
There are many options for acid reflux help available to those that need it. You can often attempt to cure your symptoms yourself with the above mentioned practices. If in doubt though always seek the advise of your family doctor who may recommend you see a specialist if they feel it is necessary.
Doctors usually recommend lifestyle and dietary changes to relieve heartburn. Many people with gastroesophageal reflux disease (GERD) also need medication. Surgery may be an option.
GASTROESOPHAGEAL REFLUX OVERVIEW
Gastroesophageal reflux (GER) is the medical term for spitting up. It occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Because the stomach naturally produces some acid, reflux is sometimes called acid reflux; other terms include regurgitation and spilling.
Reflux is a normal process that occurs in healthy infants, children, and adults. Most infants have brief episodes, during which they spit up milk or formula through the mouth or nose. Uncomplicated reflux does not usually bother the infant, has a low risk of long-term complications, and does not usually require treatment.
In contrast, a few infants with gastroesophageal reflux disease (GERD) are irritable, gain weight slowly, develop recurrent pneumonia, or spit up blood. Infants with these signs and symptoms usually require further testing and may require treatment. Although most infants with gastroesophageal reflux disease improve as they grow, some children have symptoms later in childhood.
This topic review discusses the symptoms, causes, diagnosis, and treatment of infants with gastroesophageal reflux and gastroesophageal reflux disease. Gastroesophageal reflux disease in older children and adolescents is discussed separately.
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WHEN TO SEEK HELP
Infants with acid reflux who also have the following signs or symptoms should be evaluated by a healthcare provider:
Bloody stools, severe diarrhea, recurrent vomiting, or vomiting blood Recurrent pneumonia Delayed weight gain The infant has cried for more than two hours Refusing to eat or drink anything for a prolonged period The infant is under three months of age and has forceful vomiting after each feed, but still appears hungry Behavior changes, including lethargy or decreased responsiveness
CAUSES OF GERD
No one knows why some people who have heartburn develop gastroesophageal reflux disease. Several factors may be involved, and research is under way on many levels.
Risk factors - what makes some people get gastroesophageal reflux disease but not others - are being explored, as is gastroesophageal reflux disease 's role in other conditions such as asthma and bronchitis.
The role of hiatal hernia in gastroesophageal reflux disease (GERD) continues to be debated and explored. It is a complex topic because some people have a hiatal hernia without having reflux, while others have reflux without having a hernia.
Much research is needed into the role of the bacterium Helicobacter pylori. Our ability to eliminate H. pylori has been responsible for reduced rates of peptic ulcer disease and some gastric cancers. At the same time, gastroesophageal reflux disease (GERD), Barrett's esophagus, and cancers of the esophagus have increased. Researchers wonder whether having H. pylori helps prevent gastroesophageal reflux disease (GERD) and other diseases. Future treatment will be greatly affected by the results of this research.
### Resource for this article: The National Digestive Diseases Information Clearinghouse (NDDIC) 2 Information Way Bethesda, MD 20892 - 3570, Email: nddic@info.niddk.nih.govAugust 2, 2005.
References
Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965. Gibbons TE, Gold BD. The use of proton pump inhibitors in children: a comprehensive review. Paediatr Drugs 2003; 5:25. Diaz DM, Gibbons TE, Heiss K, et al. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol 2005; 100:1844.
