Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) are common conditions. GER is a condition where the contents of the stomach come back up into the esophagus (food pipe). This occurs when the circular muscle at the top of the stomach, known as the lower esophageal sphincter (LES), relaxes and creates an opening. The LES is located at the junction of the esophagus and the stomach; its job is to relax when we eat to allow food in and when we need to belch to let air out. In people with reflux, the LES relaxes at other times as well. Most of us have some GER. When GER becomes excessive, resulting in complications, it is called GERD.
In infants, common symptoms of this condition include vomiting, regurgitation, coughing and irritability. It is important to remember, however, that it is generally not worrisome for infants to have episodes of spitting up as long as they are not suffering from complications such as poor weight gain, excessive irritability or discomfort or breathing problems (such as choking/aspirating food into the airway, cyanosis [turning blue] or wheezing). Most infants grow out of GER by the age of 12 to 18 months; improvement may be noted when the infant starts to sit, stand or walk.
It is not normal for toddlers, older children or adolescents to vomit. In these age groups, children with GER/GERD may refuse to feed, vomit, and experience abdominal pain, chest pain, heartburn or the sensation of food getting stuck in the food pipe. Older patients also may describe a sour taste or acidic sensation in the back of their throat. Presence of these symptoms warrants additional evaluation.
Exams and Tests
In addition to a complete history from you and your child and a thorough physical examination of your child, the pediatric gastroenterologist may perform tests. Tests may be needed to evaluate for GER and GERD, to assess the severity of the problem and to establish associated complications.
Upper Gastrointestinal Barium X-Ray (Upper GI)
This test will show the size and shape (known as the anatomy) of the upper GI tract through x-ray images. It will allow the pediatric GI specialist to see if any obstruction or structural problems may be the cause of these symptoms. Before the test, the child will not be able to have anything to eat or drink for up to eight hours before the test is scheduled, depending on the age of the child. When the child arrives for the test in the X-ray area (known as Radiology) of the hospital, he/she will be given white liquid, called barium, to drink. This liquid will coat the GI tract and outline the esophagus, stomach and small intestine. If the child is not able to, or refuses to, drink the barium, a tube may be placed through the nose into the esophagus, and the barium will be given through the tube.
Gastric Emptying Study
This test helps evaluate for emptying of the stomach and also may provide information on the presence of reflux from the stomach to the esophagus. This test is done in the nuclear medicine area of Radiology and is an outpatient test (that is, the child does not need to be admitted to the hospital for the test). The child is fed a tasteless dye mixed with milk/formula/food. It is important for the child not to have anything to eat or drink for up to eight hours before the test to ensure that the stomach will be empty at the time the test is started.
For the liquid-meal version of this test, the child will drink the mixture and lie flat on a table. A special scanner will take pictures of the stomach every minute for approximately 60 minutes. The results will provide information about whether GER is present and the rate of stomach emptying.
For the solid-meal version of the test, the child will eat a meal of egg and toast mixed with the test-dye. The child will have a special x-ray taken right after the meal, two hours later, and if needed, another two hours later. The results provide information on rate of stomach emptying.
Upper GI Endoscopy (EGD)
This test allows the pediatric GI specialist to examine the lining of the esophagus, stomach and duodenum (first part of small bowel) using a camera in a flexible tube called an endoscope to look for mucosal damage from GER or other causes leading to similar symptoms.
The procedure is done in the operating room under general anesthesia so that the child will not feel any pain. The doctor will pass the endoscope through the child's mouth and examine the esophagus, stomach and the duodenum. After examining the upper GI tract, the doctor will collect biopsies (very small pieces of the tissue lining), which will be sent to a pathologist to examine under a microscope for inflammation and other signs of disease.
The pediatric gastroenterologist will talk with you and your child before the procedure and answer your questions. Some children may get a medication to help them relax before being taken to the operating room area. After the procedure, your child will be taken to the recovery room, allowed to fully awaken, and then be brought out to you. The doctor will discuss the preliminary findings of the procedure and show pictures taken during the procedure. Your child will be allowed to go home in a couple of hours after the procedure but must be fully awake and able to drink liquids before being discharged home. The total time spent at the hospital will depend on the testing and the time for your child to wake up. It is best to expect to spend 4-5 hours at the hospital.
Esophageal pH Probe
For this test, a small plastic tube will be passed through the nose and into the esophagus. At the end of this tube sensors that detect acid reflux are positioned at specific spots along the esophagus. Placing the tube only takes a few minutes and can be done in clinic without sedation. Some children may have the pH probe placed in the operating room under general anesthesia if the test is done in coordination with Upper GI Endoscopy (see above).
Once the tube is positioned, it is securely taped to the child's face. This probe will remain in place for 24-26 hours and record the occurrence of acid reflux on a small recorder worn by the child. For young children, soft arm restraints may be placed to avoid having the child pull the probe out of his/her nose. The child is sent home with the probe and is allowed to eat and drink with the tube in place. During the study, it is important for the child to have a normal activity and schedule as much as possible so as to get an accurate reading. There will be some additional instructions for the recording device that will be explained at the time of the procedure; you also will need to maintain a diary which will be explained to you. The child will return to the hospital the next day to have the probe pulled out.
This test is used to detect both acid and non-acid reflux. A small plastic tube will be passed through the nose and into the esophagus. At the end of the tube sensors will be positioned at specific spots along the esophagus. Placing the tube only takes a few minutes and can be done in clinic without sedation, though some children may have the pH probe placed in the endoscopy suite while under general anesthesia for endoscopic exam such as an upper GI endoscopy (see above).
Once the tube is positioned, it is securely taped to the child's face. This probe will remain in place for 24-26 hours and record the occurrence of acid reflux on a small recorder worn by the child. For young children, soft arm restraints may be placed to avoid having the child pull the probe out of his/her nose. The child is sent home with the probe and is allowed to eat and drink with the tube in place. During the study, it is important for the child to have normal activity in order to get an accurate reading. There will be some additional instructions for the recording device that will be explained at the time of the procedure; you also will need to maintain a diary which will be explained to you. Your child will return to the hospital the next day to have the probe pulled out.
Bravo pH Study
This test is similar to the esophageal pH probe except it uses a small capsule rather than a long tube and is done only in the operating room in conjunction with an Upper GI Endoscopy. The capsule is attached to the lining of the esophageal wall and sends data on acid reflux, by wireless technique, to a small recorder that the child will wear. The recording lasts for 48 hours and you will need to bring back the recorder to our office. The capsule will fall off of the esophagus after a few days and pass out in stool. You should not try to retrieve the capsule from the stool. If you have not seen the capsule pass after two weeks, the physician may use a chest x-ray to ensure that the capsule has detached from the esophagus.
The advantages of the Bravo test over the esophageal pH probe are that there is no tube sticking out of the nose and that the child does not know there is a capsule inside. The Bravo test is generally not done under the age of four years as there is a risk that the capsule may get stuck in the bowels.
Treatment of GER and GERD depends on age of the child and severity of condition. Uncomplicated GER in infants often resolves on its own or with simple behavioral changes, and does not need medications. Some of the changes the pediatric gastroenterologist may discuss include avoiding over-feeding the infant (both at individual feedings and over the entire day) and keeping the baby upright for 30 minutes after each feed. For older children and adolescents, your doctor may advise to avoid foods that worsen GERD (for example spicy or greasy foods) and to avoid laying down right after a meal.
The most common things suspected to make reflux worse are:
- Overfilling of the stomach
- Certain foods – fatty, spicy, tomato-based foods, chocolate, peppermint, caffeine and colas
- Tobacco smoke
Children with GERD may require medicines to treat their symptoms. The most commonly prescribed medicines for GERD are acid blockers that help decrease acid production in the stomach. The most commonly used acid blockers are ranitidine (Zantac®), nizatidine (Axid®), omeprazole (Prilosec®), lansoprazole (Prevacid®) esomeprazole (Nexium®) and pantoprazole (Protonix®).
Prokinetic medications, like metoclopramide (Reglan®), bethanechol (Urecholine®) and erythromycin help promote movement (peristalsis) in the GI tract and assist emptying of the stomach. Prokinetic medications are given 3-4 times a day, 15 to 30 minutes before meals and at bedtime. The dose is dependant upon the child's weight and may need to be adjusted as the child grows.
The medications generally are used for a defined period of time as will be discussed by your child's pediatric gastroenterologist. The medications help healing to occur so that the child can start feeling better. Rarely, the medications are not adequate and surgery for GERD may be discussed by your doctor.
Pediatric Gastroenterology/Hepatology/Nutrition has a strong interest in advancing the understanding of esophageal diseases, including GERD. You and your child may be offered participation in our research studies. These studies may help improve our care of children with similar problems. We encourage you to ask plenty of questions in order to make an informed decision.
Points to Remember
- GER generally resolves on its own in infants.
- Children over two who routinely spit up or vomit need further evaluation.
- Medications let healing occur so the child can start feeling better.
For More Information
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition - NASPGHAN.org
Children's Digestive Health & Nutrition Foundation - cdhnf.org
Parent Checklist for Infants with Reflux and GERD - cdhnf.org/user-assets/documents/pdf/GERD_Checklist.pdf