Gastroesophageal reflux disease (GERD)    

What is gastroesophageal reflux?

Gastroesophageal reflux disease or GERD is a common disorder affecting people of all ages but may present as young as the first weeks of life.  In adults, GERD is commonly known as acid indigestion or heartburn, although this disorder has nothing to do with the heart itself.  It is estimated that up to 40% of infants less than 6 months of age will have symptoms of GERD to some extent. 

GERD occurs when stomach contents back up into the esophagus (the tube that connects the mouth to the stomach).  This occurs when the lower esophageal sphincter – a muscle at the end of the esophagus which normally prevents the stomach acid from backing up into the esophagus- fails.   Acid in the esophagus can damage the lining of the wall.  Acid in the mouth can lead to hoarseness; and acid which enters the airways can cause coughing and wheezing. 

How would I know if my child has GERD?

In young infants GERD may present with frequent spitting up, vomiting, refusal to feed, irritability and crying during feeding (“colic”), trouble sleeping, choking or gagging, coughing or wheezing, arching, or abnormal neck posturing (Sandifer’s syndrome)

A typical case is an infant in the first weeks of life that spits up some of his feeds shortly after feeding.  The infant is otherwise a happy, the so called “happy spitter”.  

Less commonly, the infant may present with apnea (child stops breathing for a number of seconds) or seizures.   

In older children and adults, the presentation may be persistent heartburn, chest pain, hoarseness, trouble swallowing, persistent cough or bad breath. 

What is the expected course of GERD?

In infants GERD usually improves with age, even without treatment.  By the time your child has been walking for 3 months most symptoms should have cleared. 

Are there any serious complications that may develop?

Although uncommon there may be serious complications to untreated GERD.  Acid in the esophagus may lead to damage to the wall and narrowing (“strictures”).  Erosions to the wall may lead to blood loss and anemia.  Children may develop swallowing problems, weight loss, chronic ear infections, dental erosions and failure to thrive.  Continued aspiration of acid into the airways may cause lung disease and difficulty in breathing. 

Does my child need any tests to determine if he has GERD or not?

Usually not.  A good history by your physician is usually all that is required to make a diagnosis of GERD.  However, in more serious or atypical cases, a number of tests and procedures may be done.  Some of these will be done by a gastroenterologist – a physician that specializes in stomach problems such as GERD.   

Diagnostic tests include an upper GI series or barium swallow (an X-ray study of the digestive tract), a pH probe study (to determine how much acid is in the esophagus), nuclear scintigraphy (to assess gastric emptying time and aspiration into the lungs), and upper endoscopy (to actually look down into the esophagus with a special instrument to determine if there has been any damage to the lining of the esophagus).  

Most likely, however, your child will not need any of these tests.    

How can I help my child that has been diagnosed with GERD?

There are a number of simple things you can do at home to help your child.  This includes:

• feeding smaller amounts

• frequent burping

• keeping your child in an upright position after feedings

• avoiding pressure on the abdomen such as the use of tight diapers

• thickening feeds (see below)

Older children should avoid spicy foods (like pizza), acidic foods (like oranges and tomatoes) and fried and fatty foods.  They should also maintain an ideal body weight, and sleep with their head raised. 

If these measures do not help your doctor may suggest a trial of a different formula (if your child is not breasting feeding) such as a hypoallergenic formula or a pre-thickened formula such as Enfamil A.R.LIPIL®.  This formula has been shown to very effective in reducing the frequency and severity of regurgitation, crying, and trouble sleeping. 

An alternative to the use of Enfamil A.R. LIPIL® is to thicken the child’s regular feeds.  This may be done with rice cereal by adding one tablespoon of dry rice cereal to two ounces of regular formula.  (Do not add rice cereal to Enfamil A.R. LIPIL®; this is already a thickened formula).   Sometimes it is necessary to enlarge the nipple to allow the thickened formula to flow easily.  Some infants may become constipated on a thickened formula. 

Remember that if you are breastfeeding you should continue to breast feed unless otherwise advised by your physician. 

Are there any medications that will help my child?

Yes, there are a number of medications your doctor may prescribe if simple home measures are not helping your child.

The first are antacid medicines such as ranitidine (Zantac®). These medications work by impeding acid production. 

Second are proton pump inhibitors (PPIs) such as lansoprazole (Prevacid®).   These medications work by decreasing the amount of acid produced by the stomach. 

Third are prokinetic agent drugs such as metoclopramide (Reglan®) or erythromycin (an antibiotic).  These medications work by accelerating the emptying of the stomach.   Reglan®, however, can have undesirable side effects that limit its usefulness.   Cisapride (Propulsid®) is no longer available because of its association with life-threatening arrhythmias (irregular heart beats)

What happens if my child has severe reflux and is not improving on the medications?

At this point your child will need to be evaluated by a gastroenterologist and a surgeon.  If, after extensive testing, it is documented that your child is having ongoing damage to the esophagus and/or lungs, and/or is failing to thrive, then consideration will be given to perform a surgical procedure called a Nissen fundoplication.  In this procedure the lower esophageal stricture is tightened by wrapping the upper part of the stomach around the sphincter.   This operation can now be performed by a minimally invasive laparoscopic technique.   

My doctor diagnosed my child with mild reflux and I am treating him at home with thickened feeds.  How would I know my child is getting worse and needs to be brought back to the doctor?

Warning signs that you need to be aware of include:

·        poor weight gain  

·        spitting up blood

·        projectile vomiting

·        vomiting green material (bile) or blood

·        refusal to eat

·        extreme irritability during eating

·        choking episodes

·        recurrent coughing or wheezing

·        failure to improve with time.