Pediatric Gastroesophageal Reflux Disease (GERD)

GERD (gastroesophageal reflux disease) is a long-term (chronic) digestive disorder. It happens when stomach contents flow back up (reflux) into the food pipe (esophagus) and cause symptoms or problems.

GERD is a more serious and long-lasting form of gastroesophageal reflux (GER).

GER is common in babies under 2 years old. Most babies spit up a few times a day during their first 3 months. GER does not cause any problems in babies. In most cases, babies outgrow this by the time they are 12 to 14 months old.

It's also common for children and teens ages 2 to 19 to have GER from time to time. This doesn’t always mean they have GERD.

When GER becomes GERD

Your baby, child or teen may have GERD if:

• Your baby’s symptoms prevent him or her from feeding. These symptoms may include vomiting, gagging, coughing and trouble breathing.
• Your baby has GER for more than 12 to 14 months
• Your child or teen has GER more than two times a week, for a few months 

GERD is often caused by something that affects the lower esophageal sphincter (LES). The LES is a muscle at the bottom of the food pipe (esophagus). It opens to let food into the stomach. It closes to keep food in the stomach. When the LES relaxes too often or for too long, stomach acid flows back into the esophagus. This causes vomiting or heartburn.

Everyone has reflux from time to time. If you have ever burped and had an acid taste in your mouth, you have had reflux. Sometimes the LES relaxes at the wrong times. Often your child will just have a bad taste in their mouth. Or your child may have a short, mild feeling of heartburn.

Babies are more likely to have a weak LES. This makes the LES relax when it should stay shut. As food or milk is digesting, the LES opens. It lets the stomach contents go back up to the esophagus. Sometimes the stomach contents go all the way up the esophagus. Then the baby or child vomits. In other cases, the stomach contents only go part of the way up the esophagus. This causes heartburn or breathing problems. In some cases, there are no symptoms at all.

Some foods seem to affect the muscle tone of the LES. They let the LES stay open longer than normal. These foods include:

• Chocolate
• Peppermint
• High-fat foods

Other foods can bring on symptoms because they are acidic. These foods include:

• Citrus foods
• Tomatoes and tomato sauces

Other things that may lead to GERD include:

• Being obese
• Medicines, including some antihistamines, antidepressants and pain medicines
• Being around secondhand smoke

GER is very common during a baby’s first year of life. It often goes away on its own. Your child is more at risk for GERD if they have:

• Down syndrome
• Neuromuscular disorders such as muscular dystrophy and cerebral palsy

Heartburn, or acid indigestion, is the most common symptom of GERD. Heartburn is described as a burning chest pain. It begins behind the breastbone and moves up to the neck and throat. It can last as long as two hours or even longer. It's often worse after eating. Lying down or bending over after a meal can also lead to heartburn.

Children younger than age 12 will often have different GERD symptoms. They will have a dry cough, asthma symptoms or trouble swallowing. They won’t have classic heartburn.

Each child may have different symptoms. Common symptoms of GERD include:

• Burping or belching
• Not eating
• Having stomach pain or chest pain
• Being fussy around mealtimes
• Vomiting often
• Having hiccups
• Gagging
• Choking
• Coughing often
• Having coughing fits at night

Other symptoms may include:

• Wheezing
• Getting colds often
• Getting ear infections often
• Having a rattling in the chest
• Having a sore throat in the morning
• Having a sour taste in the mouth
• Having bad breath
• Loss or decay of tooth enamel

GERD symptoms may seem like other health problems. Make sure your child sees his or her healthcare provider for a diagnosis.

Your child's healthcare provider will do a physical exam and take a health history. Other tests may include:

• Chest X-ray. An X-ray can check for signs that stomach contents have moved into the lungs. This is called aspiration.
• Upper GI series or barium swallow. This test looks at the organs of the top part of your child’s digestive system. It checks the food pipe (esophagus), the stomach and the first part of the small intestine (duodenum). Your child will swallow a metallic fluid called barium. Barium coats the organs so that they can be seen on an X-ray. Then X-rays are taken to check for signs of sores (ulcers) or abnormal blockages.
• Endoscopy. This test checks the inside of part of the digestive tract. It uses a small, flexible tube called an endoscope. It has a light and a camera lens at the end. Tissue samples from inside the digestive tract may also be taken for testing.
• Esophageal manometry. This test checks the strength of the esophagus muscles. It can see if your child has any problems with reflux or swallowing. A small tube is put into your child’s nostril, then down the throat and into the esophagus. Then it measures the pressure that the esophageal muscles make at rest.
• pH monitoring. This test checks the pH or acid level in the esophagus. A thin, plastic tube is placed into your child’s nostril, down the throat, and into the esophagus. The tube has a sensor that measures pH level. The other end of the tube outside your child’s body is attached to a small monitor. This records your child’s pH levels for 24 to 48 hours. During this time your child can go home and do their normal activities. You will need to keep a diary of any symptoms your child feels that may be linked to reflux. These include gagging or coughing. You should also keep a record of the time, type of food, and amount of food they eat. Your child’s pH readings are checked. They are compared to their activity for that time period.
• Gastric emptying study. This test is done to see if your child’s stomach sends its contents into the small intestine correctly. Delayed gastric emptying can cause reflux into the esophagus.

Treatment will depend on your child’s symptoms, age and general health. It will also depend on how severe the condition is.

Diet and Lifestyle Changes

In many cases, diet and lifestyle changes can help to ease GERD. Talk with your child’s healthcare provider about changes you can make. Here are some tips to better manage GERD symptoms.

For babies:

• After feedings, hold your baby in an upright position for 30 minutes.
• If bottle-feeding, keep the nipple filled with milk. This way your baby won’t swallow too much air while eating. Try different nipples. Find one that lets your baby's mouth make a good seal with the nipple during feeding.
• Adding rice cereal to feeding may be helpful for some babies.
• Burp your baby a few times during bottle-feeding or breastfeeding. Your child may reflux more often when burping with a full stomach.

For children:

• Watch your child's food intake. Limit fried and fatty foods, peppermint, chocolate, drinks with caffeine such as sodas and tea, citrus fruit and juices and tomato products.
• Offer your child smaller portions at mealtimes. Add small snacks between meals if they are hungry. Don’t let your child overeat. Let your them tell you when they are hungry or full.
• If your child is overweight, contact their provider to set weight-loss goals.
• Serve the evening meal early, at least three hours before bedtime.

Other things to try:

• Ask your child's provider to review your child’s medicines. Some may irritate the lining of the stomach or esophagus.
• Don’t let your child lie down or go to bed right after a meal.
• Always check with your baby’s provider before raising the head of the crib if they have been diagnosed with gastroesophageal reflux. Place all babies, including babies with GERD, on their backs for all sleeping until they are 1 year old. This is for safety reasons and to reduce the risk for SIDS and other sleep-related infant deaths.

Medicines and Other Treatments

Your child’s healthcare provider may also recommend other options.

Medicines

Your child's provider may prescribe medicines to help with reflux. There are medicines that help reduce the amount of acid the stomach makes. This reduces the heartburn linked to reflux. These medicines may include:

• H2-blockers. These reduce the amount of acid the stomach makes by blocking the hormone histamine. Histamine helps to make acid.
• Proton pump inhibitors. These help keep the stomach from making acid. They do this by stopping the stomach's acid pump from working.

The provider may prescribe another type of medicine that helps the stomach empty faster if it's clear that your child has a stomach-emptying delay. If food doesn’t stay in the stomach as long as normal, reflux may be less likely to occur.

Calorie Supplements

Some babies with reflux can’t gain weight because they vomit often. If this is the case, your child's healthcare provider may suggest:

• Adding rice cereal to baby formula
• Giving your baby more calories by adding a prescribed supplement
• Changing formula to milk- or soy-free formula if your baby may have an allergy

Tube Feedings

Surgery

In severe cases of reflux, surgery called fundoplication may be done. Your baby’s provider may recommend this option if your child is not gaining weight because of vomiting, has frequent breathing problems, or has severe irritation in the esophagus. This is often done as a laparoscopic surgery. This method has less pain and a faster recovery time. Small cuts or incisions are made in your child’s belly. A small tube with a camera on the end is placed into one of the incisions to look inside. The surgical tools are put through the other incisions. The surgeon looks at a video screen to see the stomach and other organs. The top part of the stomach is wrapped around the esophagus. This creates a tight band. This strengthens the LES and greatly decreases reflux.

Some babies and children who have GERD may not vomit. But their stomach contents may still move up the food pipe (esophagus) and spill over into the windpipe (trachea). This can cause asthma or pneumonia.

The vomiting that affects many babies and children with GERD can cause problems with weight gain and poor nutrition. Over time, when stomach acid backs up into the esophagus, it can also lead to:

• Inflammation of the esophagus, called esophagitis
• Sores or ulcers in the esophagus, which can be painful and may bleed
• A lack of red blood cells, from bleeding sores (anemia)

Many babies who vomit outgrow it by the time they are about 1 year old. This happens as the LES gets stronger. For other children, taking medicines and making lifestyle and diet changes can reduce reflux, vomiting and heartburn.

Call you child's healthcare provider if your baby or child:

• Has reflux and is not gaining weight
• Has signs of asthma or pneumonia. These include coughing, wheezing or trouble breathing.
• Has vomiting that continues or is vomiting blood