Gastroesophageal Reflux Disease (GERD) / Heartburn
Gastroesophageal reflux disease (GERD) is a digestive disorder that is caused by gastric acid flowing from the stomach into the esophagus.
Gastroesophageal refers to the stomach and esophagus, and reflux means to flow back or return. Gastroesophageal reflux (GER) is the return of acidic stomach juices, or food and fluids, back up into the esophagus.
GER is very common in infants, though it can occur at any age. It is the most common cause of vomiting during infancy.
GERD is often the result of conditions that affect the lower esophageal sphincter (LES). The LES, a muscle located at the bottom of the esophagus, opens to let food in and closes to keep food in the stomach. When this muscle relaxes too often or for too long, acid refluxes back into the esophagus, causing vomiting or heartburn.
Everyone has gastroesophageal reflux from time to time. If you have ever burped and had an acid taste in your mouth, you have had reflux. The lower esophageal sphincter occasionally relaxes at inopportune times, and usually, all your child will experience is a bad taste in the mouth, or a mild, momentary feeling of heartburn.
Infants are more likely to have the lower esophageal sphincter (LES) relax when it should remain shut. As food or milk is digesting, the LES opens and allows the stomach contents to go back up the esophagus. Sometimes, the stomach contents go all the way up the esophagus and the infant or child vomits. Other times, the stomach contents only go part of the way up the esophagus, causing heartburn, breathing problems, or, possibly, no problems at all.
Some foods seem to affect the muscle tone of the lower esophageal sphincter, allowing it to stay open longer than normal. These include, but are not limited to, the following:
- high-fat foods
Other foods increase acid production in the stomach, including:
- citrus foods
- tomatoes and tomato sauces
Some infants and children who have gastroesophageal reflux may not vomit, but may still have stomach contents move up the esophagus and spill over into the windpipe (the trachea), which can cause asthma, and or pneumonia.
Infants and children with GERD who vomit frequently may not gain weight and grow normally. Inflammation (esophagitis) or ulcers (sores) can form in the esophagus due to contact with stomach acid. These can be painful and also may bleed, leading to anemia (too few red blood cells in the bloodstream). Esophageal narrowing (stricture) and Barrett's esophagus (abnormal cells in the esophageal lining) are long-term complications from inflammation.
Heartburn, also called acid indigestion, is the most common symptom of GERD. Heartburn is described as a burning chest pain that begins behind the breastbone and moves upward to the neck and throat. It can last as long as two hours and is often worse after eating. Lying down or bending over can also result in heartburn. Most children younger than 12 years of age who are diagnosed with GERD will experience a dry cough, asthma symptoms, or trouble swallowing, instead of heartburn.
The following are other common symptoms of GERD. However, each child may experience symptoms differently. Symptoms may include:
- refusal to eat
- fussiness around mealtimes
- frequent vomiting
- frequent cough
- coughing fits at night
- frequent upper respiratory infections (colds)
- rattling in the chest
- frequent sore throats in the morning
- sour taste in the mouth
The symptoms of GERD may resemble other conditions or medical problems. Consult your child's physician for a diagnosis.
Your child's physician will perform a physical examination and obtain a medical history. Diagnostic procedures that may be done to help evaluate GERD include:
- chest x-ray - a diagnostic test to look for evidence of aspiration.
- upper GI (gastrointestinal) series - a diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an x-ray) is swallowed. X-rays are then taken to evaluate the digestive organs.
- endoscopy - a test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Tissue samples from inside the digestive tract may also be taken for examination and testing.
- esophageal manometric studies - a test that helps determine the strength of the muscles in the esophagus. It is useful in evaluating gastroesophageal reflux and swallowing abnormalities. A small tube is guided into the nostril, then passed into the throat, and finally into the esophagus. The pressure the esophageal muscles produce at rest is then measured.
- pH monitoring - this measures the acidity inside the esophagus. It is helpful in evaluating GERD. A thin plastic tube is placed into a nostril, guided down the throat, and then into the esophagus. The tube stops just above the lower esophageal sphincter, which is at the connection between the esophagus and the stomach. The end of the tube inside the esophagus contains a sensor that measures pH, or acidity. The other end of the tube outside the body is connected to a monitor that records the pH levels for a 24- to 48-hour period. Normal activity is encouraged during the study, and a diary is kept of symptoms experienced, or activity that might be suspicious for reflux, such as gagging or coughing. It is also recommended to keep a record of the time, type, and amount of food eaten. The pH readings are evaluated and compared with the patient's activity for that time period.
- gastric emptying studies
Specific treatment will be determined by your child's physician based on the following:
- your child's age, overall health, and medical history
- the extent of the disease
- your child's tolerance for specific medications, procedures, or therapies
- the expectations for the course of the disease
- your opinion or preference
In many cases, GERD can be relieved through diet and lifestyle changes, under the direction of your child's physician. Some ways to better manage GERD symptoms include the following:
- Ask your child's physician to profile any of the medications he/she is taking - some may irritate the lining of the stomach or esophagus.
- Watch your child's food intake - limit fried and fatty foods, peppermint, chocolate, drinks with caffeine (such as colas, Mountain Dew`#8482;, and tea), citrus fruit and juices, and tomato products.
- Offer your child smaller portions at mealtimes, and include small snacks in-between meals if your child is hungry. Avoid letting your child overeat. Allow him/her to let you know when he/she is hungry or full.
- If your child is overweight, consult his/her physician to set weight loss goals.
- Do not allow your child to lie down or go to bed right after a meal. Serve the evening meal early - at least two hours before bedtime. Always remember to check with your infant's doctor before elevating the head of the crib if he or she has been diagnosed with gastroesophageal reflux. this is for safety reasons and to reduce the risk for SIDS and other sleep-related infant deaths.
- After feedings, hold your infant in an upright position for 30 minutes.
- If bottle-feeding, keep the nipple filled with milk so your infant does not swallow too much air while eating. Try different nipples to find one that allows your baby's mouth to make a good seal with the nipple during feeding.
- Adding rice cereal to feeding may be beneficial for some infants.
- Burp your baby several times during bottle or breast feeding. Your child may reflux more often when burping with a full stomach.
Treatment may include:
If needed, your child's physician may prescribe medications to help with reflux. There are medications which help decrease the amount of acid the stomach makes, which, in turn, will cut down on the heartburn associated with reflux. One group of this type of medication is called "H2-blockers." Medications in this category include cimetidine (Tagamet`#174;) and ranitidine (Zantac®). Another group of medications is called "proton-pump inhibitors." Medications in this category include omeprazole (Prilosec®) and lansoprazole (Prevacid®). These medications are taken daily to prevent excess acid secretion in the stomach.
Another type of medicine your child's physician may prescribe helps the stomach empty faster. If food does not remain in the stomach as long as usual, there may be less chance of reflux occurring. A medicine in this category that can be prescribed is metoclopramide (Reglan®). This medicine is usually taken three to four times a day, before meals or feedings and at bedtime.
- calorie supplements
Some infants with reflux will not be able to gain weight due to frequent vomiting. Your child's physician may recommend the following:
- adding rice cereal to baby formula
- providing your infant with more calories by adding a prescribed supplement (such as Polycose™ or Moducal™) to formula or breast milk to make the milk higher in calories than normal
- change formula to milk/soy free formula if allergy is suspected
- tube feedings
Some babies with reflux have other conditions that make them tired, such as congenital heart disease or prematurity. In addition to having reflux, these babies may not be able to drink very much without becoming sleepy. Other babies are not able to tolerate a normal amount of formula in the stomach without vomiting, and would do better if a small amount of milk was given continuously. In both of these cases, tube feedings may be recommended. Formula or breast milk is given through a tube that is placed in the nose, guided through the esophagus, and into the stomach (nasogastric tube). Nasogastric tube feedings can be given in addition to or instead of what a baby takes from a bottle. Nasoduodenal tubes can also be used to bypass the stomach.
In severe cases of reflux, a surgical procedure called fundoplication may be performed. Your physician may recommend this operation if your child is not gaining weight due to vomiting, has frequent respiratory problems, or has severe irritation in the esophagus. This procedure is usually done laparoscopically, which means that pain in minimized and the recovery time is faster after surgery. Small incisions are made in the abdomen, and a small tube with a camera on the end is placed into one of the incisions to look inside. The surgical instruments are placed through the other incisions while the surgeon looks at a video monitor to see the stomach and other organs. The top portion of the stomach is wrapped around the esophagus, creating a tight band that greatly decreases reflux.
Many infants who vomit will "outgrow it" by the time they are about a year old, as the lower esophageal sphincter becomes stronger. For others, medications, lifestyle, and diet changes can minimize reflux, vomiting, and heartburn.
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