Childen's Hospital Boston 300 Longwood Avenue
Boston, MA 02115
(617) 355-6000
X
My Child Has:
Gastroesophageal Reflux
Programs that treat this condition
Robotic Surgery   Center for Motility and Functional Gastrointestinal Disorders  
Community Asthma Initiative   General Surgery Program  
Center for Aero-Digestive Disorders (CADD)  
Related Links:
Gastroesophageal Reflux
What is Gastroesophageal Reflux?
Gastroesophageal reflux disease 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 is the return of acidic stomach juices, or food and fluids, back up into the esophagus. Reflux is very common in infants, though it can occur at any age. It is the most common cause of vomiting during infancy.

In most babies with reflux, the problem resolves on its own over time. However, medical management may be needed. Surgery is reserved for some of the complications of reflux discussed below.

What causes Gastroesophageal Reflux?
Image
click to enlarge
Reflux 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:

  • chocolate
  • peppermint
  • high-fat foods
Other foods increase acid production in the stomach, including:
  • citrus foods
  • tomatoes and tomato sauces
What are the symptoms of gastroesophageal reflux?
Heartburn, also called acid indigestion, is the most common symptom of reflux. 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. The following are other common symptoms of reflux. However, each child may experience symptoms differently. Symptoms may include:
  • belching
  • refusal to eat
  • stomachache
  • fussiness around mealtimes
  • frequent vomiting
  • hiccups
  • gagging
  • choking
  • frequent cough
  • coughing fits at night
  • wheezing
  • frequent upper respiratory infections (colds)
  • rattling in the chest
  • frequent sore throats in morning
  • sour taste in the mouth
  • failure to grow and gain weight
Symptoms of reflux may resemble other conditions or medical problems. Consult your child's physician for a diagnosis.
What are the complications associated with gastroesophageal reflux?
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. This can cause asthma, pneumonia, and possibly even SIDS (sudden infant death syndrome). Infants and children with reflux 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.
How is Gastroesophageal Reflux diagnosed?
Your child's physician will perform a physical examination and obtain a medical history. Diagnostic procedures that may be done to help evaluate REFLUX include:
  • Chest X-ray - a diagnostic test to look for evidence of aspiration or pneumonia.
  • 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 are designed to measure the pressure of the lower esophageal sphincter
  • pH testing - requires the passage of a small tube into the esophagus which will measure the pH or acid level in the esophagus. Measurements are continued over 12-24 hours.
  • Gastric emptying studies use a nuclear medicine isotope, which is swallowed and then the area around esophagus and stomach is scanned.
Treatment for Gastroesophageal Reflux
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
  • parental opinion or preference
In many cases reflux resolves on it's own. Your doctor may decided the following treatments are appropriate for your child:
  • Medications - 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) 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.

  • 7 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 is allergy 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.

  • Surgery - 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, such as recurring pneumonia or has severe irritation in the esophagus. This procedure is done either laparoscopically or by an open incision. With minimally invasive laparoscopic surgery, pain is 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.

    The surgeons at Children's Hospital Boston have extensive experience peforming laparoscopic fundoplications, and use state-of-the-art robotic surgery equipment.

In many cases, reflux can be relieved through diet and lifestyle changes alone, under the direction of your child's physician. Some ways to better manage reflux symptoms include the following:
  • Watch your child's food intake - limit fried and fatty foods, peppermint, chocolate, drinks with caffeine (such as colas, Mountain Dew, 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.
  • After feedings, place your infant on his/her stomach with the upper body elevated at least 300 F degrees, or hold him/her in a sitting position in your lap 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.
What is the long-term outlook for a child with 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. Finally, when indicated, the role of an operation to correct reflux is an effective technique to stop a child's reflux.
X
X The information on this website should not be taken as medical advice,
which can only be given to you by your personal health care professional.
X
X Copyright © Children's Hospital Boston. All rights reserved.