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Gastroesophageal reflux (GERD) is the upward movement of stomach’s
contents, including acid, into the esophagus and sometimes into or out of the
mouth. GERD is also referred to as acid reflux. Most infants occasionally
spit up after a meal, but frequent vomiting among infants may be caused by
gastroesophageal reflux. Older children also can be affected by gastroesophageal
reflux.
What are the symptoms of GERD in infants and children?
The most common symptoms are:
- frequent or recurrent vomiting
- frequent or persistent cough
- heartburn, gas, abdominal pain, or colicky behavior
- regurgitation and re-swallowing
Other symptoms are sometimes blamed on gastroesophageal reflux. In many
cases, however, it is not clear whether reflux actually causes the symptoms. In
young infants and children, some problems that may be blamed on gastroesophageal
reflux include:
- Colic
- Feeding problems
- Recurrent choking or gagging
- Poor growth
- Breathing problems
- Recurrent wheezing
- Recurrent pneumonia
What causes GERD in infants and children?
Most of the time, reflux in infants is due the incoordination of the
gastrointestinal tract. Many infants with the condition are otherwise healthy;
however, some infants can have problems affecting their nerves, brain or
muscles.
In older children, the causes of GERD are often the same as those seen in
adults. Anything that causes the muscular valve between the stomach and
esophagus (the lower esophageal sphincter or LES) to relax, or
anything that increases the pressure below the LES, can be the cause of GERD.
Factors that can play such a role include obesity, overeating, certain foods,
some beverages, and specific medications. There also appears to be an inherited
component to GERD, as it is more common in some families than in others.
Will my baby outgrow infantile GERD?
Yes. Most babies outgrow infantile GERD. However, reflux can occur in older
children. In either case, the problem usually can be managed easily.
How is GERD in infants and children diagnosed?
Usually, parents provide enough details for the doctor to make a diagnosis.
Sometimes, however, further tests are recommended. They include:
- Barium swallow or upper GI series—This is a special
X-ray test that uses barium to highlight the esophagus, stomach and upper
part of the small intestine. This test may identify certain problems such as
any obstructions or narrowing in these areas. It is not a highly sensitive
or specific test for reflux.
- PH probe—This is currently considered the best test to
diagnose reflux, but it does not always manage to detect the disease. In
this test, a thin tube with a probe at the tip is placed through the nose
into the esophagus. The tip, usually positioned at the lower part of the
esophagus, measures levels of stomach acids. The frequency of reflux is
monitored over a prolonged period of time, usually 24 hours.
- Upper GI endoscopy—This procedure uses an endoscope (a
thin, flexible, lighted tube) that allows the doctor to look directly inside
the esophagus, stomach and upper part of the small intestine. Pinch biopsies
of the esophagus obtained at the time of endoscpy may determine the presence
of reflux.
- Gastric emptying study— During this test, the child
drinks milk or eats food mixed with a radioactive chemical. This chemical is
followed through the gastrointestinal tract using a special camera.
What are the treatments for acid reflux in infants and children?
There are a variety of lifestyle measures you can try:
For infants:
- Elevating the head of the baby's crib or bassinet
- Holding the baby upright for 30 minutes after a feeding
- Thickening bottle feedings with cereal (do not do this without
a doctor's supervision)
- Changing feeding schedules
- Trying solid food
For older children:
- Elevating the head of the child’s bed
- Keeping the child upright for at least two hours after eating
- Serving several small meals throughout the day, rather than two
or three large meals
- Limiting foods and beverages that seem to worsen your child’s
reflux; these foods typically include acid-containing foods, caffeinated
beverages, citrus products, tomato products, chocolate and licorice
- Encouraging your child to get regular exercise
- Avoiding non-steroidal or aspirin-containing medications
If the reflux is severe or doesn't get better, your doctor may recommend
medicines to treat the reflux.
Medications for GERD
Medications to lessen gas include antacids that contain simethicone (i.e.,
Mylicon). Medications to neutralize or decrease stomach acid include:
- Antacids such as Mylanta and Maalox
- Acid blockers such as Pepcid, Tagamet or Zantac
- Proton-pump inhibitors (PPIs)—These products reduce
the production of acid by blocking the enzyme in the wall of the stomach
that produces acid; PPIs include the brand names Axid, Nexium, Prevacid and
Prilosec
Researchers aren't sure whether decreasing stomach acid lessens reflux in
infants.
For the most part, medicines that decrease intestinal gas or neutralize
stomach acid (antacids) are very safe. At high doses, antacids can cause some
side effects, such as diarrhea or constipation. Chronic use of very high doses
of antacids may be associated with an increased risk of rickets (thinning of the
bones).
Serious side effects from medications that inhibit the production of stomach
acid are quite uncommon. A small number of children may develop some sleepiness
when they take Zantac, Pepcid, Axid, or Tagamet. There are other side effects of
PPIs and H2 blockers (drugs which block histamine2; histamines
signal the stomach to make acids). These side effects include abdominal pain,
diarrhea, nausea, vomiting, headaches and laboratory abnormalities. As with any
medications, there are a number of additional rare side effects.
Medications to improve intestinal coordination
- Reglan
- Erythromycin
- Propulsid
Reglan (metoclopramide) is a medication that increases the pressure of
the LES and helps speed up the digestion process. However, it is associated with
many side effects, some of which can be serious. Reglan also can be associated
with a number of drug interactions and may increase the risk of seizures in
patients who have seizures.
Erythromycin is an antibiotic. It is usually used to treat bacterial
infections. One common side effect of erythromycin is that it causes strong
stomach contractions. This side effect is advantageous when the drug is used to
treat reflux; however, the side effect is not lasting. Erythromycin has not been
shown to be effective in the long term for treatment of GERD.
Propulsid (cisapride) was voluntarily withdrawn from the U.S. market in
2000. However, it is still available with extremely limited access. The drug
works by increasing the pressure of the lower esophageal sphincter (LES) and
increasing emptying of the stomach and the rate that food moves through the
intestines. The drug is very effective for treating childhood reflux. However,
the drug was associated with abnormal heart rhythms.
Surgery for GERD
Surgery is not often used to treat GERD in children. When it is necessary,
the Nissen fundoplication is the most often performed surgery.
During this procedure, the top part of the stomach is wrapped around the lower
esophagus. This procedure forms a cuff that contracts and closes off the
esophagus when the stomach contracts, preventing reflux. In some patients, a pyloroplasty
to improve gastric emptying may be performed at the same time. A pyloroplasty is
a surgical procedure in which the lower portion of the stomach, the pylorus,
is cut and re-sutured to relax the muscle and widen the opening into the
intestine. The Nissen fundoplication procedure is usually effective, but it is
not without risk. Discuss the potential risks and benefits of this operation
with your child's doctor.
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