Gastroesophageal Reflux Disease (GERD) / Heartburn

This is a chronic digestive disorder that is caused by the abnormal flow of gastric acid from the stomach into the esophagus. GER is very common in infants, it can occur at any age. it is the most common cause of vomiting during infancy.

What causes GERD? 

GERD 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 into the stomach 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

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

Why is GERD a concern?

Some infants and children who have GER may not vomit, but may still have stomach contents move up the esophagus and spill over into the windpipe, which can cause asthma and/or pneumonia. Infants and children with GERD who vomit frequently may not gain weight and grow normally. These can be painful and also may bleed, leading to anemia. Esophageal narrowing and Barrett's esophagus are long-term complications from inflammation that are seen in adults.

What are the symptoms of GERD?

  • belching
  • refusal to eat
  • stomachaches 
  • fussiness around mealtimes
  • frequent vomiting 
  • hiccups
  • gagging
  • chocking
  • frequent cough
  • coughing fits at night
  • wheezing 
  • frequent upper respiratory infections
  • frequent ear infections
  • rattling in the chest
  • frequent sore throats in the morning
  • sour taste in the mouth

How is GERD diagnosed?

  • chest x-ray - A diagnostic test to look for evidence aspiration -- the movement of stomach contents into the lungs.
  • Upper GI (gastrointestinal) series - A diagnostic test that examines the organs of the upper part of the digestive system, the esophagus, stomach, and duodenum. A fluid called barium is swallowed. X-rays are then taken to evaluate the digestive organs for evidence of ulceration or abnormal blockages.
  • Endoscopy - A test that uses a small, flexible tube with a light and a camera lens at the end to examine the inside of part of the digestive tract.
  • Esophageal manometric study - A test that helps determine the strength of the muscles in the esophagus.
  • pH monitoring - To measure the acidity inside of the esophagus. It is helpful in evaluating the extent of GERD.
  • Gastric emptying study - A test designed to determine if the stomach releases its contents into the small intestine properly. Delayed gastric emptying can contribute to reflux into the esophagus.

Treatment for GERD

  • your child's age, overall health, and medical history
  • extent of the disease
  • the expectations for the course of the disease
  • your opinion or preference
In many cases, GERD can be relieved through diet and lifestyle changes. Some ways to better manage GERD symptoms include the following

  • ask your child's doctor to profile any of the medications he or she is taking--some may irritate the lining of the stomach or esophagus.
  • 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.
  • if your child is overweight, consult his or her doctor 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, hold your infant in an upright position for 30 minutes.
  • if bottle-feeding, keep the nipple filled with milk so your infant does not swallow too much air while eating.
  • adding rice cereal to feeding may be beneficial for some infants.
  • burp your baby several times during bottle-feeding or breastfeeding. Your child may reflux more often when burping with a full stomach.

Treatment may include:

  • Medications. If needed, your child's doctor may prescribe medications to help with reflux. There are medications that 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 doctor 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.

  • Calorie supplements. Some infants with reflux will not be able to gain weight due to frequent vomiting. Your child's doctor 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- or soy-free formula if allergy is 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 eat or 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 doctor may recommend this operation if your child is not gaining weight due to vomiting, has frequent respiratory problems, or has severe irritation in the esophagus. This procedure is usually done laparoscopically, which means that pain in 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 reinforces the lower esophageal sphincter and greatly decreases reflux.

What is the long-term outlook for a child with GERD?

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.

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