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Overview
Gastroesophageal reflux disease (GERD) is a common problem for which infants, children, and adolescents are referred to and evaluated at GI Care for Kids. If GERD is suspected, an important first step your care provider at GI Care for Kids will take is to distinguish between gastroesophageal reflux (GER) and the disease (GERD).
GER: a Natural Digestive Response
GER, in which stomach contents come up into the esophagus during or after a meal, is a normal physiological activity that allows for decompression of the stomach. It occurs throughout life, during childhood as well as adulthood.
In infancy, GER occurs frequently for many reasons, including the frequency of feeding and positioning during or after feeds. It can result in spitting, irritability, vomiting, or coughing. GER occurs in most infants who are otherwise healthy, happy, and growing well. Older children might also complain of heartburn, regurgitation, or frequent swallowing. As long as the symptoms are short lived, not perceived as troublesome by a parent, caretaker, or children who are older than 8 years old, it is still classified as GER.
There are many reasons why infants have GER. The lower esophageal sphincter (LES) is the gate between the stomach and esophagus. In infants, reflux occurs when the LES relaxes at inappropriate times. The good news is these episodes of inappropriate LES relaxation occur less often as infants grow older. The reflux of stomach contents into the esophagus can happen when eating, crying, or otherwise straining. Less commonly, reflux can occur as a result of abnormal anatomy, inflammation caused by stomach acid, allergy, or a problem of another body system.
GERD: a Problematic, Recurring Problem
GERD is a chronic and more serious form of GER. The reflux of food or liquid from the stomach enters the esophagus or even the mouth. GERD recurs and persists and can cause problems ranging from feeding and growth disturbances in infants to nighttime wakening, teething problems, heartburn, chest pain, and difficulty swallowing.
For infants and children with respiratory diseases, neurological problems, feeding disorders, and otherwise healthy children, GERD is a concern. In many cases, GERD causes mild symptoms but, in some children, GERD can cause significant complications like esophagitis, which can worsen symptoms, cause other outcomes like iron deficiency or anemia, and can affect teething, sleep, and possibly lead to breathing problems. If GERD is diagnosed, the optimal treatment is decided upon based on the type of GERD that your child has at the time of diagnosis.
Diagnostic Testing
Symptoms that occur after the age of 6 months, or the persistence of symptoms beyond the age of 12 months, raise the possibility of GERD. However, because its symptoms are not unique to GERD, your pediatric gastroenterologist may use additional diagnostic methods to evaluate a child for the presence of GERD or to rule out other causes of the symptoms.
It is important to note that there is no single test or gold standard used to diagnose GERD in infants and children. Testing may include laboratory tests, contrast imaging, upper GI endoscopy and/or esophageal pH / multichannel intraluminal impedance (MII) – and are conducted depending on a child’s presenting symptoms. These tests may include:
Upper GI / Barium Series
In this test, your child is given flavored, somewhat chalky-tasting material (called barium) to drink prior to X-rays to assess the flow of food through the esophagus and stomach. It is used to identify abnormal anatomy or blockages within the upper gastrointestinal tract. It is not used to diagnose or rule out GERD – and may even cause reflux to occur.
24-Hour Esophageal pH Monitoring
This test is conducted to measure the amount of reflux that enters the esophagus over the course of 12 or 24 hours. A small tube is inserted into a child’s nose and down through the esophagus, where it remains for the designated time period. It contains detection devices that can measure the acid refluxing from the stomach.
It may be conducted with or without multichannel intraluminal impedance monitoring (pH-MII). The advantage of pH-MII is its ability to accurately detect acid vs. non-acid reflux based on pH changes. The pH-MII had been shown to have a high sensitivity in the detection of reflux episodes, particularly when non-acid reflux was prevalent. It may be used for patients who are taking acid suppression medication or for infants who are frequently fed. It can help distinguish esophageal pH levels due to reflux as opposed to lowered pH due to swallowing.
Upper Endoscopy and Biopsy
An upper endoscopy is conducted while your child is sedated, typically in an outpatient setting. A small, flexible tube with a high-definition, digital camera at the end is inserted through the mouth and down into the stomach and upper part of the small intestine. Your pediatric gastroenterologist will be able to see if the lining of the upper GI tract looks irritated, has ulcers, polyps (small pieces of extra tissue), or is bleeding. A biopsy may be taken during the procedure for analysis in a lab to help determine if reflux has caused inflammation and whether there are other conditions present, such as eosinophilic esophagitis, that may be causing your child’s symptoms.
High-Resolution Esophageal Manometry (HREM)
This diagnostic procedure may be done to assess a child for motility-related disorders of the upper or lower GI tract. It measures the strength and coordination of the muscles used to move food and drink through the esophagus and into the stomach.
During the test, a pressure-sensitive tube is inserted into the nose, down the esophagus, and into the stomach. Your child remains awake during an esophageal manometry, although medication is used to numb the nose. He or she may be asked to swallow at certain times in order to measure the muscle contractions of the esophagus.
High resolution esophageal manometry (HREM) was the key technique used to identify transient lower esophageal sphincter (LES) relaxations as the predominant mechanism of GERD in infants, children, and adolescent patients. It is also helpful in identifying other mechanisms of reflux, such as hypotensive LES pressure or other risk factors for reflux such as the presence of a hiatal hernia. Another possible application for HREM is in the pre- and postoperative evaluation of children undergoing fundoplication for the treatment of GERD.
Gastric Emptying Scan
In a gastric emptying scan, a child is given a drink or meal with a small amount of dye or radio-labeled tracer in it prior to X-rays. It is performed to look for the presence of reflux, and how well or efficiently the stomach empties. Impaired gastric emptying is a risk factor for GERD. A gastric emptying scan can also help determine if stomach contents get into the lungs, which typically occurs with aspiration. Also called a gastric scintigraphy, this test may be indicated when GERD symptoms are not responding to standard therapies.
Treatment Options for Acid Reflux in Kids
The treatment for GER and GERD will depend on your child’s symptoms and age. Most infants will outgrow GER by the age of 18 months. So, as long as your child is healthy, happy, and growing, the treatment is usually limited to some of the suggestions below
It is important to note that there is no single test or gold standard used to diagnose GERD in infants and children. Testing may include laboratory tests, contrast imaging, upper GI endoscopy and/or esophageal pH / multichannel intraluminal impedance (MII) – and are conducted depending on a child’s presenting symptoms. These tests may include:
Lifestyle Modifications
The treatment for GER and GERD will depend on your child’s symptoms and age. Most infants will outgrow GER by the age of 18 months. So, as long as your child is healthy, happy, and growing, the treatment is usually limited to some of the suggestions below
Medications
Common medications used to treat GERD in children include:
- Antacids and alginates – Medications designed to neutralize acid and relieve symptoms such as heartburn or dyspepsia.
- H2 blockers – A class of medications that reduce the production of stomach acid. H2 blockers are used to treat dyspepsia, peptic ulcers, and GERD – but have been surpassed by the efficiency of proton pump inhibitors.
- Proton pump inhibitors – These medications are the most potent and prolonged inhibitors of stomach acid production. The various types of proton pump inhibitors available in the marketplace differ in how the medication is broken down by the liver as well as potential drug interactions. The effects of some PPIs may last longer and thus may need to be taken less frequently.
Transpyloric (Jejunal) Feeding Tube
This type of feeding bypasses the stomach and delivers nutrients directly into the upper area of the small intestine. It reduces the possibility of reflux in infants and young children with intractable GERD. A small, flexible feeding tube enters the body either through the child’s mouth or, more likely, one of the nostrils. The tip of the feeding tube is then pushed into place – down the esophagus, through the stomach, the pylorus, and into the jejunum. Formula is then run via a pump into the small intestine over a period of hours.
Anti-Reflux Surgery
Surgical approaches to decrease acid reflux are usually undertaken only after all other options have failed.
Fundoplication involves surgically attaching part of the stomach to the sphincter that separates the esophagus and stomach. In addition to decreasing reflux, fundoplication may also reduce a hiatal hernia if present. Laparoscopic fundoplication – a technique in which surgery is conducted via a small incision in the abdomen – is considered the gold standard when it comes to surgical treatment of severe GERD. This method is preferred for its reduced post-op pain and faster recovery period.
Fundoplication may be appropriate for infants and children with GERD if:
- Life-threatening complications like cardiorespiratory failure exist after more conventional treatment methods have failed
- GERD symptoms persist despite aggressive treatment and after appropriate evaluation to exclude other possible causes for the patient’s symptoms
- Chronic conditions exist – such as neurological impairment or cystic fibrosis – that also carry a significant risk of GERD-related complications
- Continual use of medications are required to control the signs or symptoms of GERD
More info about GERD in children
Helpful information about gastroesophageal reflux disease can also be found here:
- Facts about GER and GERD in children and teens from the National Institute of Diabetes and Digestive and Kidney Diseases
- GERD parent take-home and infant reflux checklist from GI Kids, the educational outreach arm of the North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN)
- Nutrition4kids.com, a resource for parents who want to feed their kids well, regardless of medical challenges or allergies. Subscribe for updates personalized for you and your child.