Gastroesophageal Reflux (GER) in Older Children
During normal swallowing, food and liquids travel past the entrance to the lungs and into the esophagus. The esophagus is the long tube that leads from the pharynx in the upper throat to the stomach. The average esophagus is about ten inches long, and its walls are made of muscle fibers which contract in waves (called peristalsis) to push the chewed food and saliva down to the stomach. The entrance to the lungs is the larynx (“voice box”) which closes to protect the lungs from food and allows us to breathe. The junction of the esophagus and the stomach is the lower esophageal sphincter (LES), which is a muscular valve that relax to allow food to enter the stomach and tightens to prevent the exit of stomach contents backward into the esophagus (reflux). Normally the stomach contents move forward out the end of the stomach (pylorus) and into the small intestine (duodenum).
Gastroesophageal reflux (GER) occurs when the stomach contents consisting of stomach acid and partially digested food or liquid come back up into the esophagus. GER occurs normally in all ages and is the most common cause of chronic vomiting in infants. GER usually resolves by age two. GER episodes are normally brief, without symptoms and without complications. The common ailment of heartburn occurs when stomach acid washes back up into the esophagus. Since the esophagus has no protective mucosal layer, as does the stomach, the acid causes pain just behind the sternum (breastbone) and seems to come from the heart, hence the term "heartburn.”
Pathologic GER
Having a number of reflux episodes is abnormal and causes health problems. GER can cause irritation to the esophagus (esophagitis) and pain known as “heartburn.” GER can also cause respiratory problems when stomach contents enter the larynx or lungs (aspiration). Mild reflux even without aspiration can set off a reflex causing the airways to tighten (bronchospasm) and can cause wheezing, respiratory distress and coughing.
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Symptoms of GER
In infants, reflux may cause symptoms such as irritability, pain with arching of the neck (Sandifer's Syndrome), stridor, wheezing, cough, abnormal cry, respiratory distress, vomiting, apnea (abnormal breathing), laryngitis, chronic bronchitis, pneumonia and severe choking.
In older children and adults, GER causes esophagitis, heartburn and chest pain. Some patients can taste acid as it comes back into their mouths. Many people can have reflux with no symptoms at all.
Because there are many symptoms of GER, which can cause many different problems, it is important to diagnose and treat reflux properly.
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Diagnosis of GER
A careful history may reveal a pattern suggestive of reflux. Additional testing, however, is needed to confirm the diagnosis and decide on the best treatment. Some of the tests we use are:
1. Chest x-ray to look for inflammation in the lungs.
2. Barium swallow, esophagram or Upper GI x-ray to evaluate swallowing, the anatomic structure of the esophagus and stomach, and how the food moves through these structures.
3. PH Probe study to assess how much acid and how often acid refluxes back into the esophagus and if these episodes are related to symptoms.
4. Endoscopy to look into the esophagus and stomach with a flexible fiber-optic “telescope” and assess inflammation and/or ulceration.
5. Bronchoscopy to look into the throat, airway and lungs to assess inflammation and the structure of the respiratory tract.
6. Pulmonary function testing is a serious of tests to evaluate breathing and how the lungs are moving air.
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Treatment of Reflux
1. Positioning
Reflux is more likely to happen when a patient is lying down because gravity does not work to keep fluid in the stomach. Elevating the head (especially after feeding) by putting infants in a 20-30 degree upright position or elevating the head of the crib on cinder blocks can improve symptoms. For the older child, elevating his or her head with a foam wedge (pillows cause bending and actually increase reflux) or raising the bed on blocks also helps.
2. Feeding
Decreasing meal size and feeding more often decreases the fullness of the stomach. For infants, burping often during and after feeding and using rice cereal (1 teaspoon per ounce of formula) to thicken the feeding can also help. Avoid large meals at bedtime when the LES is most relaxed. Formula and food changes only help if allergy is a trigger for reflux in a given child. Most often, however, it is mechanical weakness of the LES.
3. Foods to Avoid
Historically, certain foods have been known to increase reflux. Avoid large fatty meals, citrus, tomato, carbonated drinks, caffeine, chocolate and mint.
4. Medications
When basic measures fail to control symptoms, medication may be indicated. Usually two types of medication are used. Acid-blocking medications (famotidine/Pepcid, ranitidine/Zantac, cimetidine/Tagamet, omeprazole/Prilosec and lansoprazole/Prevacid) suppress stomach acid and prevent it from doing damage to the esophagus. Pro-Motility agents (bethanechol, metoclopramide/Reglan, cisapride/Propulsid) help by increasing the tone of the lower sphincter and increasing gastric emptying. For children, these medications are by prescription only.
All of these medications are safe in infants and children and have only minor side effects. If your child experiences side effects, we will adjust the dose or change medication.
5. Surgical treatment
Surgery is reserved for patients in whom medical management is not effective or when reflux is so severe it causes multiple complications. The operation is called a fundoplication and involves a portion of the stomach being wrapped around the lower esophagus to tighten the opening and decrease reflux. It can be done by open surgery or laparoscopically. In those cases where the stomach does not empty well, a surgery to loosen the outlet of the stomach (pyloroplasty) may be performed.
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Notify your doctor if your child:
• Stops breathing (apnea)
• Turns color (gray, dusky, blue)
• Has noising breathing (stridor)
• Is unable to gain weight
• Is vomiting bile
• Has side effects from the medication
• Complains of chest pain or pain behind the sternum
• Continues to taste acid in his mouth
• Has pain with swallowing
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Expected Course
In most cases, gastroesophageal reflux in infants improves by age 9 to 12 months. Even children on medication may spontaneously improve by this time. Although children referred for sub-specialty care have more significant reflux, they too can improve. If your child does not improve, it suggests that a change in therapy or more evaluation is needed. We will ask you to keep a calendar of symptoms to help us in caring for your child.
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