Patient information: Gastroesophageal reflux disease in children and adolescents

GASTROESOPHAGEAL REFLUX OVERVIEW

Gastroesophageal reflux, also called acid reflux, occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Acid reflux is a normal process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause bothersome symptoms or complications.

In contrast, some people with acid reflux have troublesome symptoms, which may include heartburn, vomiting, or pain with swallowing. In this case, the problem is called gastroesophageal reflux disease (GERD). Less commonly, complications of GERD can develop, such as pneumonia, worsening of asthma, or damage to the esophagus (the tube that carries food from the mouth to the stomach).

This topic review discusses the symptoms, causes, diagnosis, and treatment of children and adolescents with gastroesophageal reflux disease. Gastroesophageal reflux in infants and adults is discussed separately. (See "Patient information: Gastroesophageal reflux in infants" and "Patient information: Gastroesophageal reflux disease in adults".)

WHAT IS GASTROESOPHAGEAL REFLUX?

When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure (figure 1). The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach with a series of wave-like movements called peristalsis.

At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter (LES). When food reaches the LES, it relaxes to allow food to enter the stomach and then contracts to prevent the back-up of food and acid into the esophagus. However, the ring of muscle does not always stay completely closed, allowing the liquids in the stomach to wash back into the esophagus occasionally in all individuals. Most of these episodes go unnoticed because the acid reflux stays in the lower esophagus.

Acid reflux becomes gastroesophageal reflux disease (GERD) when the acid in reflux causes irritation or injury to the esophagus. The amount of acid reflux required to cause injury varies. In general, damage to the esophagus is more likely to occur when acid refluxes frequently, the reflux is very acidic, or the esophagus is unable to clear away the acid quickly. The treatments of GERD are designed to prevent one or all of these elements from occurring.

ACID REFLUX RISK FACTORS

Between 2 and 8 percent of children between the ages of three and 17 years are estimated to have symptoms of gastroesophageal reflux. Certain medical conditions appear to increase the risk of developing GERD, including the following:

• Neuromuscular diseases, such as muscular dystrophy and cerebral palsy
• Down syndrome
• Cystic fibrosis

Reflux is very common in infants, and almost always improves with age. Infants with frequent reflux are only slightly more likely to have GERD later in childhood. (See "Patient information: Gastroesophageal reflux in infants".)

ACID REFLUX SYMPTOMS

The symptoms of gastroesophageal reflux vary according to age. (See "Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents".)

• Preschool — Preschool age children with reflux may have intermittent regurgitation (when the stomach contents reflux into the mouth or vomiting occurs). Less commonly, children can develop respiratory complications, including persistent wheezing, particularly in children with asthma. If the child's esophagus has been injured as a result of reflux (esophagitis), the only symptom may be a lack of interest in eating (caused by discomfort or pain that occurs with eating).
• Older children and adolescents — The most common symptoms of GERD in older children and adolescents include chronic heartburn and/or regurgitation. Older children may complain of nausea and/or pain in the middle of the chest. Some children pound their chest in an attempt to relieve the feeling of pain and burning.

Pain can radiate to the back, and may last minutes to hours. Pain usually occurs after meals, may awaken the child from sleep, and may be worse during times of emotional stress.

In all age groups, symptoms of an upset stomach (dyspepsia) may be a result of constipation. Constipation can cause the stomach to empty more slowly than normal, causing reflux, heartburn, and nausea. The symptoms of constipation (straining to empty, less frequent bowel movements) may be less obvious than the dyspepsia (upset stomach, heartburn). Treatment of constipation may relieve the dyspepsia, and may help to avoid the need for further testing or long-term treatment of reflux. (See "Patient information: Constipation in infants and children".)

ACID REFLUX DIAGNOSIS

Children who have symptoms of reflux, vomiting, or abdominal pain should be evaluated by a healthcare provider before any treatment is used. There are a number of possible reasons for these symptoms and it is important to confirm the diagnosis before treatment is begun.

If a child has symptoms of reflux but has no complications, a trial of treatment with lifestyle changes and in some cases, a medication, are often recommended before testing. (See 'Acid reflux treatment' below.)

If a child has underlying medical problems or potential complications of reflux (eg, asthma, pneumonia, weight loss, persistent pain or vomiting, pain or difficulty with swallowing), further testing is often needed to confirm the cause of the problem. The type of testing depends upon the child's age and specific symptoms. The following is a brief description of some of the more common tests.

Upper endoscopy — An upper endoscopy is a test that may be recommended for children who have signs or symptoms of esophagitis or gastritis (when the esophagus or stomach is damaged by acid), pain or difficulty with swallowing (dysphagia or odynophagia), or persistent vomiting.

The test is done by a physician, usually in the hospital, after the child is sedated. The physician inserts a small, flexible tube through the mouth into the esophagus and stomach. The tube has a light source and a camera that displays magnified images. Damage to the lining of these structures can be evaluated and a very small sample of tissue (biopsy) can be taken to determine the extent of tissue damage. (See "Patient information: Upper endoscopy".)

24-hour esophageal pH study — A 24-hour esophageal pH study is the most direct way to measure the frequency of reflux, although the study is not always helpful in diagnosing GERD or reflux-associated problems. It is usually reserved for children whose diagnosis is unclear after endoscopy or a trial of treatment. It may also be useful for children who continue to have symptoms despite treatment.

The test involves placing a thin tube through the nose and into the esophagus. The tube is left in the esophagus for 24 hours. During this time the parent keeps a diary of the child's symptoms. The tube is attached to a small device that measures how much stomach acid is reaching the esophagus. The data are then analyzed to determine the frequency of reflux and the relationship between symptoms and the presence of reflux. The procedure is considered to be very safe, but keeping the probe in place may be difficult in toddlers and uncooperative children.

Barium swallow — A barium swallow may be recommended for children who have difficulty or pain with swallowing. In many cases, pain or difficulty swallowing is not caused by GERD, and the barium swallow is used to look for other causes. Barium is a substance that can be seen easily with x-ray. It can be mixed into a liquid that the child swallows. After the liquid is swallowed, the barium coats the lining of the esophagus, and a special type of x-ray (fluoroscopy) is used to visualize the shape and structure of the mouth, esophagus, and stomach.

A reflux episode is often captured during the barium swallow procedure. However, this does not necessarily mean that the child has GERD because the test does not indicate how frequently the reflux episodes occur.

ACID REFLUX TREATMENT

Several treatment options are available for controlling symptoms and preventing complications of acid reflux in children. The choice among them depends upon the child's age, the type and severity of symptoms, and the child's response to treatment. (See "Management of gastroesophageal reflux disease in children and adolescents".)

Lifestyle changes — Lifestyle changes, such as elevating the head of the bed and weight loss, are commonly recommended for adults with GERD. The benefit of these changes in children has not been evaluated. Thus, these recommendations may be helpful for some, but not all, children with mild symptoms of acid reflux. Lifestyle changes are not recommended as the sole treatment for children with moderate or severe symptoms of GERD. Parents should consult their child's healthcare provider before beginning any treatment for acid reflux.

• Raise the head of the bed six to eight inches — Although some people only have heartburn for the two- to three-hour period after meals, others wake up at night with heartburn. Children with nighttime heartburn may have fewer nighttime symptoms if the head of the bed is elevated. This raises the head and shoulders higher than the stomach, allowing gravity to prevent acid from refluxing.

Raising the head of the bed can be done with blocks of wood under the legs of the bed or a foam wedge under the mattress. However, it is not helpful to use additional pillows; this can cause an unnatural bend in the body that increases pressure on the stomach, worsening acid reflux.

• Weight loss — In significantly overweight children, losing weight may help reduce reflux. Parents who are concerned about their child's weight should consult a healthcare provider for advice on helping the child to lose weight.
• Avoid acid reflux inducing foods — Some foods can cause relaxation of the lower esophageal sphincter, promoting reflux. Excessive caffeine, chocolate, alcohol, peppermint, and acidic beverages, including colas and orange juice, may cause bothersome reflux in some people.
• Minimize exposure to tobacco smoke — Exposure to tobacco smoke reduces the amount of saliva in the mouth and throat, which can worsen reflux because saliva helps to neutralize acid. Tobacco smoke also lowers the pressure in the lower esophageal sphincter and provokes coughing, causing frequent episodes of acid reflux in the esophagus.

Secondhand smoke also can cause this problem, so adults in the child's household should work hard to quit smoking, and to take other measures to reduce the child's exposure to smoke. (See "Patient information: Smoking cessation".)

• Avoid lying down after eating — Lying down with a full stomach may increase the risk of reflux. By eating three or more hours before bedtime, acid reflux may be reduced.
• Chew gum or use oral lozenges — Chewing gum or lozenges can increase saliva production, which may help to neutralize stomach acid that has entered the esophagus. However, neither gum nor lozenges are recommended for children who are less than four years old.

Medications — There are several classes of medications available to treat the symptoms of acid reflux. Parents should discuss the need for medication with their child's healthcare provider before beginning treatment. When a medication is recommended, it is usually given for a trial period (two to four weeks). After the trial period:

• If the symptoms have improved sufficiently, the medication may be continued. The length of treatment depends upon the type and severity of the acid reflux problem. Children with heartburn alone may be able to stop treatment after a month or two. Those with esophagitis may need longer treatment.
• If symptoms have not improved or have worsened, an alternate medication may be tried or a diagnostic test may be recommended (if not done previously, (see 'Acid reflux diagnosis' above.

Proton pump inhibitors — Proton pump inhibitors (PPIs) block the production of acid in the stomach. PPIs are more effective than other classes of medications in relieving symptoms, reducing acid secretion, and healing esophagitis. Omeprazole (Prilosec®) and lansoprazole (Prevacid®) are best studied in children. Other PPIs, such as esomeprazole (Nexium®), pantoprazole (Protonix®), and rabeprazole (Aciphex®), are also available. PPIs are usually taken by mouth once per day and may be taken long term, if needed.

If a child's symptoms do not improve after a two to four week trial of a PPI, a diagnostic test may be recommended. (See 'Upper endoscopy' above.)

Histamine antagonists — The histamine antagonists also reduce production of acid in the stomach. However, they are somewhat less effective than PPIs. Examples of these drugs available in the United States include ranitidine (Zantac®), famotidine (Pepcid®), cimetidine (Tagamet®), and nizatidine (Axid®). These medications are usually taken by mouth once or twice per day. Over-the-counter preparations, which contain a lower dose than the prescription strength, are available for cimetidine, ranitidine, and famotidine.

If the child is treated with a histamine antagonist first but does not improve sufficiently, most experts recommend trying a PPI next. (See 'Proton pump inhibitors' above.) Histamine antagonist are not usually recommended for long-term treatment of GERD because they often become less effective over time. Intermittent use of a histamine antagonist may be recommended if a child's symptoms come and go.

Antacids — Antacids are commonly used for short-term relief of symptoms of GER in infants and children. However, the stomach acid is only neutralized for a short time after each dose, so they are not very effective. In addition, there are some concerns about aluminum toxicity from frequent use of antacids in infants. Neither efficacy nor safety has been well studied in infants or children, and long-term use is not recommended. Examples of antacids include Tums®, Maalox®, and Mylanta®.

Surgery — Surgical treatment of reflux may be considered for children who have serious complications of acid reflux that have not improved after a trial of all other treatment options. Although surgery has been used to treat severe acid reflux for many years, the long-term efficacy, risks, and benefits of surgery in children have not been well studied. In the studies that have been done, many of the children who had surgery had severe neurological problems such as cerebral palsy, which caused the reflex to be resistant to standard treatment.

The most commonly performed surgery is called Nissen fundoplication. This procedure involves wrapping the upper part of the stomach around the lower end of the esophagus (figure 2). This may allow the lower esophageal sphincter to close more completely, minimizing acid reflux. Studies describe an improvement in symptoms in 60 to 90 percent of children after surgery [1]. However, "failure rates" (variously defined) vary widely among reports, ranging from 2 to 50 percent.

In summary, surgery may have favorable outcomes in carefully selected children whose reflux cannot be treated with medications. In each case, parents and healthcare providers must carefully weigh the potential risks and benefits.

WHEN TO SEEK HELP

Parents of a child with one or more of the following symptoms should consult the child's healthcare provider:

• Repeated vomiting, especially if the vomit is bloody or the child is losing weight
• Frequent heartburn or complaints of pain in the upper chest or throat
• If the child complains of pain or difficulty with swallowing (eg, a sense of food getting stuck in the throat)
• If the child develops new breathing problems, such as wheezing, a chronic cough, or hoarseness

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our Web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to gastroesophageal reflux disease (GERD, acid reflux, heartburn)
Patient information: Gastroesophageal reflux in infants
Patient information: Gastroesophageal reflux disease in adults
Patient information: Constipation in infants and children
Patient information: Upper endoscopy
Patient information: Smoking cessation

Professional Level Information:
Clinical manifestations and diagnosis of eosinophilic esophagitis
Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents
Gastroesophageal reflux in infants
Gastroesophageal reflux in premature infants
Management of gastroesophageal reflux disease in children and adolescents
Treatment of eosinophilic esophagitis
Patient information: A guide to gastroesophageal reflux disease (GERD, acid reflux, heartburn)

A number of Web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/gerinchildren/index.htm)

• North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

      (www.naspghan.org/wmspage.cfm?parm1=351, available in Spanish and Portugese)

• Children's Digestive Health and Nutrition Foundation

      (http://gerd.cdhnf.org/)

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