Gastroesophageal Reflux in Infants and Children Treatment

The burping, heartburn, and spitting up associated with GERD are the result of acidic stomach contents moving backward into the esophagus (called reflux). This can happen because the muscle that connects the esophagus with the stomach (the esophageal sphincter) relaxes at the wrong time or doesn’t properly close.

Many people have reflux regularly and it’s not usually a cause for concern. But with GERD, reflux occurs more often and causes noticeable discomfort.

After nearly all meals, GERD causes heartburn, also known as acid indigestion, which feels like a burning sensation in the chest, neck, and throat.

In babies with GERD, breast milk or formula regularly refluxes into the esophagus, and sometimes out of the mouth. Sometimes babies regurgitate forcefully or have “wet burps.”

Most babies outgrow GERD between the time they are 1 and 2 years old. But in some cases, GERD symptoms persist. Kids with developmental or neurological conditions, such as cerebral palsy, are more at risk for GERD and can have more severe, lasting symptoms.

Symptoms of GERD

Heartburn is the most common symptom of GERD in kids and teens. It can last up to 2 hours and tends to be worse after meals. In infants and young children, GERD can lead to problems during and after feeding, including:

  • frequent regurgitation or vomiting, especially after meals
  • choking or wheezing, if the contents of the reflux get into the windpipe and lungs
  • wet burps or wet hiccups
  • spitting up that continues beyond the first year of life (when it typically stops for most babies)
  • irritability or inconsolable crying after eating
  • refusal to eat, at all or in limited amounts
  • failure to gain weight

These symptoms may be worse if a baby lies down or is placed on in a car seat after a meal.

Clinical Manifestations

INFANTS

Infants with GER regurgitate without any secondary signs or symptoms of inadequate growth, esophagitis, or respiratory disease. Infants with GER are thriving and represent the majority of infants who present to the physician with this condition.

Patients with GERD may manifest persistent regurgitation with secondary poor weight gain and failure to thrive.

Failure to thrive occurs when caloric intake is less than ongoing losses. Other infants may manifest signs of esophagitis, including persistent irritability, pain, feeding problems, and iron deficiency anemia.

A subset of infants may demonstrate significant reflux by esophageal pH monitoring but will not have symptoms of regurgitation, known as “silent” GERD. All infants with GERD, therefore, do not visibly regurgitate, and the majority of infants who regurgitate do not have GERD.

A variety of respiratory symptoms occur in infants. Apnea with cyanotic episodes may occur secondary to upper airway stimulation by pharyngeal regurgitation, as previously described. Instead of a pure obstructive apnea pattern, a mixed pattern of both obstructive and central types generally predominates.

A well-defined relationship between apnea secondary to GERD and an apparent life-threatening event has not been established.10 Another sign of upper airway disease is recurrent stridor.

Lower airway symptoms secondary to bronchoconstriction and airway inflammation include wheezing and chronic cough. Aspiration of refluxate may lead to pneumonia, especially in infants with neurologic impairment.

Finally, abnormal hyperextension of the neck with torticollis (Sandifer’s syndrome) may be seen solely in infants with more severe GERD. This movement is perhaps a protective mechanism of an infant with acidic reflux causing esophagitis.

CHILDREN

After infancy, more classic symptoms of esophagitis predominate, including lower chest pain, heartburn (pyrosis), odynophagia, dysphagia, and signs of anemia and esophageal obstruction from stricture formation. With the exception of apnea, older children experience respiratory symptoms similar to infants.

Complications of reflux esophagitis may be seen, including signs of peptic stricture and Barrett’s esophagus, which is the progressive replacement of distal eroded squamous mucosa with metaplastic gastric epithelium.

Barrett’s esophagus may increase the risk of esophageal adenocarcinoma in adulthood, but the risk is much lower in children.

Complications of GERD

Some children develop complications from GERD. The constant reflux of stomach acid can lead to:

  • breathing problems (if the stomach contents enter the trachea, lungs, or nose)
  • redness and irritation in the esophagus, a condition called esophagitis
  • bleeding in the esophagus
  • scar tissue in the esophagus, which can make it difficult to swallow

Because these complications can make eating painful, GERD can interfere with proper nutrition. So if your child isn’t gaining weight as expected or is losing weight, it’s important to talk with your doctor.

Diagnosing GERD

In older kids, doctors usually can diagnose GERD by doing a physical exam and hearing about the symptoms. Try to keep track of the foods that seem to bring on symptoms in your child — this information can help the doctor determine what’s causing the problem.

In younger children and babies, doctors might run these tests to diagnose GERD or rule out other problems:

Barium swallow. This is a special X-ray that can show the refluxing of liquid into the esophagus, any irritation in the esophagus, and abnormalities in the upper digestive tract.

For the test, the child must swallow a small amount of a chalky liquid (barium). This liquid appears on the X-ray and shows the swallowing process.

24-hour impedance-probe study. This is considered the most accurate way to detect reflux and the number of reflux episodes. A thin, flexible tube is placed through the nose into the esophagus. The tip rests just above the esophageal sphincter to monitor the acid levels in the esophagus and to detect any reflux that occurs.

Milk scans. This series of X-ray scans tracks a special liquid as the child swallows it. The scans can show whether the stomach is slow to empty liquids and whether the refluxed liquid is being inhaled into the lungs.

Upper endoscopy. In this test, doctors directly look at the esophagus, stomach, and a portion of the small intestines using a tiny fiberoptic camera.

During the procedure, doctors may also biopsy or take a small sample of the lining of the esophagus to rule out other problems and determine whether GERD is causing other complications.

Diagnostic Evaluation

In most cases of GER, no diagnostic study is required. Although scintigraphy may best quantify gastric emptying or aspiration, it is not as commonly used as the upper GI examination (barium fluoroscopy), the esophageal 24-hour pH probe, or the endoscopy with esophageal biopsy.

No single definitive study can diagnose GERD. Consultation with a pediatric gastroenterologist may be necessary to select the most appropriate study for individual patients. Table 4 describes the benefits and limitations of each study.

Treating GERD

Treatment for GERD depends on the type and severity of the symptoms.

In babies, doctors sometimes suggest lightly thickening the formula or breast milk with rice cereal to reduce reflux. Making sure the baby is in a vertical position (seated or held upright) during feedings can also help.

Older kids often get relief by avoiding foods and drinks that seem to trigger GERD symptoms, including:

  • citrus fruits
  • chocolate
  • foods with caffeine
  • fatty and fried foods
  • garlic and onions
  • spicy foods
  • tomato-based foods and sauces
  • peppermint

Doctors may recommend raising the head of a child’s bed 6 to 8 inches to minimize reflux that occurs at night. They may also try to address other conditions that can contribute to GERD symptoms, including obesity and certain medications — and in teens, smoking and alcohol consumption.

If these measures don’t help relieve the symptoms, the doctor may also prescribe medication, such as H2 blockers, which can help block the production of stomach acid, or proton pump inhibitors, which reduce the amount of acid the stomach produces.

Medications called prokinetics are sometimes used to reduce the number of reflux episodes by helping the lower esophageal sphincter muscle work better and the stomach empty faster.

In rare cases, when medical treatment alone doesn’t help and a child is failing to grow or develops other complications, a surgical procedure called fundoplication might be an option.

This involves creating a valve at the top of the stomach by wrapping a portion of the stomach around the esophagus.

Management

Conservative treatment for mild symptoms of GER involves thickened feedings and positional changes in infants, and dietary modification in children. Healthy infants who regurgitate without signs of GERD may be managed by thickening feedings with up to one tablespoon of dry rice cereal per 1 oz of formula.

Thickened feeding reduces regurgitation and fussiness, and increases daily caloric intake.

Smaller, more frequent feedings are recommended in older infants and children. Furthermore, avoidance of foods and behaviors that decrease lower esophageal sphincter tone should be initiated.

This includes excessive intake of caffeinated, acidic, and alcoholic beverages in children and cigarette smoking in adolescents.

Completely upright and prone positioning is beneficial in infants with GERD. These select infants may be exempt from the American Academy of Pediatrics’ statement against prone positioning for sleep.17 Soft bedding materials should be avoided in this setting.

Prone positioning is not routinely recommended as first-line management of simple regurgitation without evidence of GERD. Placing these infants in the supine position is routinely recommended.

Seated positioning should be minimized because it provokes reflux by increasing intra-abdominal pressure.

Parents must be assured that most infants with regurgitation and GER respond well to conservative management. Parents should be informed of the widespread prevalence of functional GER in infancy, especially among one- to four-month-olds.

Observation of feeding behavior and the interaction between the parent and child is important, and revised instructions on feeding techniques may be necessary.

Because an allergy to cow’s milk may manifest with symptoms similar to those of GER, a two week trial of casein hydrolysate formula may be considered if patients do not show improvement with conservative measures.

Caution should be exercised in changing from traditional lactose-based formula to soy formula, because up to 20 percent of infants who have milk protein allergy also demonstrate sensitivity to soy formula.

When to Call the Doctor

If your child is experiencing GERD symptoms, talk with your doctor. With proper diagnosis and treatment, kids can get relief and avoid longer-term health problems.

Source & More Info: Kid Health and American Family Physician

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