When you think about someone with heartburn or gastroesophageal reflux, chances are you picture an adult. But some researchers now believe that as many as half of the infants born today have gastroesophageal reflux or GERD.
John T. Boyle, M.D. moderated a panel discussion on pediatric gastroesophageal reflux at Digestive Disease Week in San Diego. Much has been learned during the past 30 years about GERD and children, noted Dr. Boyle. “Gastroesophageal reflux has come a long way in the last 30 years… in 1959 (research) estimated that the incidence of gastroesophageal reflux was one in 4,000 live births. By the early 1970′s, in the infancy of pediatric gastroenterology, this incidence had increased up to one in 500. Today, it’s felt that 40 to 50 percent of all babies have gastroesophageal reflux,” he explained.
In addition, scientists are proving what some doctors have thought all along – that there appears to be a relationship between reflux and asthma, and that GERD may be associated with other illnesses as well. “It was the radiologists, in the early 1970′s, who adapted protocols for performing barium esophagrams, that dramatically increased the (appreciation of the) incidence of reflux and associated reflux with a number of disorders including chronic respiratory disease,” said Dr. Boyle.
All (or at least most) babies spit up however, so when is it something to be concerned about? Reflux is when contents from the stomach back up into the esophagus, usually when the muscle at the entrance of the stomach – the lower esophageal sphincter or LES – relaxes, allowing a backwash of potentially highly acidic stomach contents into the esophagus. It can be as subtle as a “wet burp” or as forceful as vomiting, but it sometimes happens frequently enough to cause other complications, and this is when it becomes worrisome.
Common symptoms of significant reflux in infants might include vomiting or spitting up frequently, often more than one hour after eating. To some parents, it seems like a continuation of the spitting up stage, past the point where they feel their child should have outgrown it. Symptoms that may be due to discomfort caused by the reflux include fussiness, unexplained or sudden crying, “colic” and sleep disturbances.
Less common symptoms can include problems related to eating and nutritional status such as refusing to eat despite obvious hunger, refusing certain foods, swallowing problems, weight loss or poor weight gain. Refluxed stomach contents can be irritating to the throat and airway, and this irritation can cause symptoms such as hoarseness and a sore, red throat as well as bad breath and erosion of the tooth enamel.
Ear infections, chronic runny nose and sinus infections can also be related to gastroesophageal reflux disease. Reflux that results in airway irritation can cause wheezing, nighttime coughing, noisy or labored breathing and respiratory problems like pneumonia and bronchitis.
Initially, your child’s doctor may suspect reflux based on your child’s symptoms. If a diagnosis of reflux seems pretty clear-cut, the doctor may recommend medication without running many tests; if the medications relieve your child’s symptoms, your doctor may conclude that the diagnosis was accurate and continue from there.
If the physician thinks another condition might be involved, additional tests may be ordered. Your doctor might want to get a good look at your child’s upper gastrointestinal tract – the esophagus, stomach and maybe even the upper part of the small intestine – to make sure there are no deformities or obstructions, but also to determine how much, if any, tissue inflammation or damage has occurred in the esophagus. Two tests that could help provide this information are the barium swallow x-ray and endoscopy. Endoscopy enables the physician to collect small samples of tissue for examination in the laboratory, and the doctor may even be able to observe the appearance of the area of the esophageal sphincter and its apparent function.
A ‘milk scan’ allows your child’s doctor to actually watch foods or liquids as they travel through your child’s stomach. After consuming food or fluids mixed with a special powder, a special machine shows how quickly it empties from the stomach. This test is usually used when the physician thinks the stomach might be emptying too slowly, but it can also be useful for tracking reflux and sometimes may help to identify when these secretions have been inhaled into the lung or aspirated.
The most accurate way of evaluating reflux is by actually monitoring the pH of the esophagus and its contents. During episodes of reflux the esophageal pH may become very acidic. By continuously measuring this pH, it’s possible to identify when and how often during a given period (for instance, during a typical night) episodes of reflux occurred and how long it took for the gastric contents to empty from the esophagus. When acid levels are high much of the time, it can mean that the reflux is more severe, but it can also mean that the likelihood for tissue injury is higher because of this prolonged exposure to acidic material.
Dr. Boyle explained, “It was our friend the pH probe in the late 70′s and 80′s that introduced the concept of silent reflux and the fact that silent reflux caused disease, that made this a big player in both general pediatrics as well as pediatric gastroenterology. Reflux is now considered a major part of the differential of the irritable infant, feeding disturbance, sleep disturbance… and a wide spectrum of upper and lower respiratory disease.”
Many children will outgrow reflux sometime during the first year but some will benefit from medications, and in some cases, a surgical procedure known as a fundoplication is performed in order to tighten the LES and control the reflux. Your child’s doctor will give you specific instructions on medications, feeding and positioning based on your child’s condition.
Editorial Commentary: There has been growing knowledge in the area of pediatric gastroesophageal reflux, and the loss of ready availability of cisapride (Propulsid) has been a big problem for pediatricians and pediatric gastroenterologists. Cisapride was used quite often to treat certain reflux-related problems in children. However, children do get reflux much more commonly than formerly appreciated, and this problem can be serious. Many possible medical and surgical treatments exist, and parents should certainly discuss these problems with their children’s physicians. The other important message here is applicable to both children and to adults – and that is that reflux may lead to ‘extraesophageal’ problems such as feeding problems, asthma, cough, chest pain, and even nasal or dental disorders.
Jennifer is a clinical pharmacologist. She helps doctors of all medical specialties choose medications. Jennifer consults about drug dosage, interactions, and side effects.