Gastroesophageal Reflux in Children

Overview

• What is gastroesophageal reflux?

  Gastroesophageal reflux is the bringing up or regurgitation of stomach contents or acid into the esophagus (the swallowing tube). Almost everyone refluxes at some point during the day especially after meals. What distinguishes normal reflux from pathologic or abnormal reflux is how often reflux occurs and if it causes symptoms or damage to the esophagus. Reflux is being increasingly recognized in children and adolescents. Although the symptoms in teenagers may be similar to those seen in adults, the symptoms in infants and younger children may differ enough so that they are not recognized as being due to reflux.

Symptoms

• Is it normal if my infant spits up?

  Almost all infants reflux or regurgitate a portion of their feeding at one time or another. What distinguishes normal regurgitation from abnormal regurgitation is how often the reflux occurs, if it is associated with discomfort, and if it results in other complications. These complications include poor weight gain known as “failure to thrive”, breathing difficulties such as infrequent breaths or apnea, asthma symptoms such as wheezing, or a hoarse voice or cry. Other complications of reflux are aspiration, which is when the refluxed stomach contents reach the lungs, pneumonia due to aspiration, or inflammation of the esophagus called esophagitis. Spitting up blood or material that looks like old “coffee grounds” is rarely seen and requires immediate evaluation by a physician.

  Reflux symptoms in infants tend to improve as they get older, usually by 12 to 15 months of age. This is because as infants get older their stomach is able to empty quicker and their esophagus lengthens, therefore there is less material in the stomach to regurgitate. Infants who reflux or regurgitate will not necessarily have problems with reflux as they get older or as adults.

• Is vomiting in my baby always due to gastroesophageal reflux?

  There are a number of reasons, other than reflux, that a baby may vomit. Babies may be allergic to the milk or soy protein that they are getting in their formula, or proteins in their mother’s diet if they are breast fed and this can result in irritability, vomiting, poor weight gain and blood in the bowel movements. This is treated with a change to a specialized formula where the proteins are broken down to make them less allergenic (allergy causing). Babies can be born with problems where the intestine is not formed or positioned properly or is blocked. These types of problems are usually found in the immediate newborn period but can present later in some infants. A combination of x-rays and or endoscopy (looking at the lining of the stomach and upper intestine and/or colon with a long tube with a video camera at the tip) is usually helpful to make this diagnosis.

  Between 4-8 weeks of age infants can develop a condition known as pyloric stenosis. This results in significant and forceful vomiting and is usually associated with poor weight gain and possibly weight loss. Parents of infants with this problem describe their child’s vomiting as projectile. Pyloric stenosis is currently treated with surgery. There are other non-gastrointestinal causes of vomiting in infants and young children including hormonal problems, kidney problems and problems with increased pressure on the brain. These are unusual conditions but patients should be tested for these problems if their physician feels that their symptoms are not typical or they are not responding to treatment for their reflux.

• What are the symptoms of reflux in older children and adolescents?

  Reflux symptoms in children are variable. Children may be unable to communicate typical reflux symptoms such as heartburn. They may complain of generalized abdominal pain, frequently around the area of the belly button and on occasion may complain of chest pain. Often children will report a feeling that they need to throw up and on occasion will describe that they get a taste in their mouth as if they have thrown up. Other children will report that they feel that the food is coming back up and that they then re-swallow it. Occasionally they will report a feeling that food is not going down correctly or feels like it is getting stuck. Some patients may complain of asthma symptoms such as cough or wheezing that are worsened by reflux. Even though children may not relate reflux symptoms to eating, obtaining a dietary history for foods and medicines that may trigger or worsen reflux is important.

Diagnosis

• How is the diagnosis of reflux made?

  Reflux is usually diagnosed based on symptoms and physical examination. X-rays are generally not helpful in diagnosing abnormal reflux although they are often used to exclude other problems that may mimic reflux. Performing an upper intestinal endoscopy with biopsies can be helpful to determine if inflammation of the esophagus is present. The test currently considered most helpful in making the diagnosis of acid reflux is a pH/ impedance probe. This probe is a small tube inserted through the nose into the esophagus that continuously measures how often acid is being regurgitated into the esophagus. There are normal expected values for both children and adults.

Treatment

• What are treatment choices for children and adolescents with gastroesophageal reflux?

  There are many medications available to treat gastroesophageal reflux. Many of these medications have been used successfully to treat children. Dosages of medication must be modified for a child’s weigh and they require monitoring to reduce possible long-term side effects. The most common medications reduce or turn off the production of acid in the stomach. They include H2 blockers and proton pump inhibitors (PPis). Other medications include agents that help empty the stomach. Diet is an important part of reflux management and children and teenagers with reflux should avoid the products listed below. Medications such as aspirin, ibuprofen, nonsteroidal anti-inflammatory medicines (NSAIDs) and alcohol based products should be avoided if possible in children with reflux. Rarely a surgical procedure called a fundoplication (or wrap) is required for severe reflux. This procedure is usually reserved for patients with severe symptoms or complications of reflux that do not respond to standard medications and dietary treatment. 

  Foods to avoid if you have reflux

  Spicy, acidic or tomato based foods
  Fatty foods
  Citrus products including citrus juices
  Apple juice
  Caffeinated drinks – cola, tea, coffee, hot chocolate
  Chocolate and licorice

Author(s) and Publication Date(s)

Marsha H. Kay, MD, FACG The Cleveland Clinic, Cleveland, OH, and Annette E. Whitney, MD, Digestive Health Associates of Texas, Dallas, TX – Updated December 2012.

Marsha H. Kay, MD, The Cleveland Clinic, Cleveland, OH, and Vasundhara Tolia, MD, Children's Hospital of Michigan, Detroit, MI – Published September 2004.

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