By Amana Nasir, MD
It is important to state that we all reflux! The backward movement of stomach contents into the food pipe, a.k.a. the esophagus, is termed gastro-esophageal reflux, or GER. The frequency of GER changes from infancy to adulthood, with more than 50 percent of infants refluxing during a 24-hour period and only 10 percent of adults doing the same. The reason for this is the immaturity of the sphincter that separates the stomach from the esophagus. Even when stomach contents make their way into the esophagus, there are mechanisms in place to squeeze these contents back into the stomach rapidly. When we have overwhelming amounts of stomach contents or improper clearance mechanisms, the result is gastro-esophageal reflux disease or GERD.
So what makes “good GER” turn into “GERD”? In children, the difference is simpler and the following symptoms should raise red flags:
- poor weight gain
- blood or green-colored bile in vomiting
- associated cough or choking with the reflux
- symptoms that worsen rather than improve over time.
Infants may manifest these symptoms with irritability, feeding refusal, spitting up and coughing. Older kids complain of heartburn, wet burps, tummy aches or even congestion and frequent throat clearing. These symptoms require a visit with the child’s physician.
The physician may initially recommend age-appropriate reflux precautions. For infants, these include implementing smaller feeds, burping during feeds, keeping the infant upright 30-45 minutes after feeds and/or thickening the feeds. For older children, weight control, avoiding carbonated beverages, chocolate, peppermint and high acid foods, along with loose-fitting clothes and attention to timely bathroom visits to decrease abdominal distention or bloating.
If conservative measures fail to alleviate the complaints, a more thorough investigation may be undertaken. Though the history and exam are usually enough to make the diagnosis of GERD, further testing may help quantify and assess the presence of any damage.
Diagnostic tests available include pH monitoring either with a catheter down the nose or with an innovative wireless device placed in the esophagus. In select cases, special X-ray studies using a dye to illustrate the anatomy or plumbing of the upper tract may be beneficial. We also may perform an upper endoscopy exam to visualize the tissue and, if needed, take biopsies to further define the cause and extent of disease. Biopsies are especially useful in patients with an allergic predisposition such as asthma, allergies, eczema or a family history of GERD. Recent literature has shown the presence of allergic esophagitis is the cause of some of these GERD-like symptoms. Allergic esophagitis is a condition that causes the esophagus to swell in reaction to certain allergens.
In summary, for most children, pediatric gastro-esophageal reflux is a self-limiting condition. However, attention needs to be paid to children who have poor weight gain, persistent or worsening symptoms or other associated non-gastrointestinal findings.
Amana N. Nasir, MD, is a Mercy Clinic pediatric gastroenterologist with Mercy Children’s Hospital.