INTRODUCTION

Gastroesophageal reflux, also called acid reflux, occurs when the stomach contents back up (reflux) into the esophagus 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 problems.

However, some people with acid reflux have troublesome symptoms, including heartburn, vomiting, or pain with swallowing. In this case, the problem is called gastroesophageal reflux disease (GERD). Treatments for GERD are available and can help to reduce symptoms.

This article 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 open and squeeze to move food to the stomach.

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 so that food enters the stomach. The muscle then squeezes shut to prevent food and acid from backing up into the esophagus. However, the muscle does not always stay completely closed, allowing the stomach juices and acid to back up into the esophagus occasionally. Most of these episodes go unnoticed because the acid reflux stays in the lower esophagus.

Acid reflux becomes gastroesophageal reflux disease (GERD) when the reflux causes irritation, injures the esophagus, or causes other problems, such as asthma. The amount of acid reflux required to cause injury varies. In general, the esophagus is more likely to be injured when:

• Acid backs up into the esophagus frequently
• The stomach juices are very acidic
• The esophagus cannot clear away the acid quickly

The treatments for GERD are designed to prevent one or all of these elements from occurring.

ACID REFLUX SYMPTOMS

The symptoms of gastroesophageal reflux depend upon the child's age. (See "Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents".)

• Preschool — Symptoms of acid reflux in preschool-age children can include:

• - Vomiting or feeling stomach acid or food in the throat or mouth
• - Less commonly, there can be wheezing, particularly in children with asthma
• - Lack of interest in eating (because of pain with eating)
• - Weight loss

• Older children and adolescents — The most common symptoms of GERD in older children and adolescents include many of the symptoms listed above, plus:

• - Tasting stomach acid in the throat
• - Nausea
• - Pain or burning in the upper chest (heartburn)
• - Discomfort or pain with swallowing
• - Feeling that food gets stuck while swallowing

Children who do not talk may pound their chest when they feel the heartburn. Pain usually happens after meals, may awaken the child from sleep, and may be worse with stress or when lying down. Pain can last minutes to hours.

In all age groups, constipation can cause some of the symptoms of GERD, such as upset stomach, heartburn, and nausea. Treating constipation can relieve these problems. (See "Patient information: Constipation in infants and children".)

ACID REFLUX DIAGNOSIS

If your child has reflux, vomiting, or abdominal pain, consult your child's doctor or nurse before giving any treatment. There are many possible reasons for these symptoms, and it is important to confirm the cause before starting a medicine.

In children who have reflux but no reflux-related complications, the doctor or nurse might recommend lifestyle changes or a medicine before ordering tests. (See 'Acid reflux treatment' below.)

If your child has reflux-related complications or other medical problems (eg, asthma, pneumonia, weight loss, persistent pain or vomiting, pain or difficulty with swallowing), testing is often needed. The type of testing depends upon your child's age and symptoms. The following is a brief description of some of the more common tests.

Upper endoscopy — An upper endoscopy is a test that might be recommended for children who have vomiting or pain or difficulty with swallowing.

A doctor performs the test, usually in the hospital, after the child is sedated. The doctor places a small, flexible tube through the mouth into the esophagus and stomach (figure 1). The tube has a light and a camera. The doctor can see if there is damage and, if needed, take a sample of tissue (biopsy). The test is not painful. (See "Patient information: Upper endoscopy".)

24-hour esophageal pH study — A 24-hour esophageal pH study can show how frequently reflux occurs. 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 reflux symptoms despite treatment.

The test involves placing a thin tube through the nose and into the esophagus. The tube is attached to a small device that measures how much stomach acid is reaching the esophagus. The tube is left in place for 24 hours. The tube does not hurt, although some children will try to pull it out.

While the tube is in place, you will keep a diary of your child's symptoms. A doctor will review the diary and pH results to see how frequently acid refluxes and whether there is a relationship between symptoms and reflux.

Barium swallow — A barium swallow, sometimes called an upper GI series, is a test that might be recommended for children who have difficulty or pain with swallowing. A barium swallow is not usually done to confirm whether the child has reflux, but pain or difficulty swallowing can be caused by problems other than 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 see the shape and structure of the mouth, esophagus, and stomach.

ACID REFLUX TREATMENT

Several treatment options are available for children with acid reflux. The "best" treatment depends upon your child's age, the type and severity of symptoms, and how your child responds to treatment. (See "Management of gastroesophageal reflux disease in children and adolescents".)

Lifestyle changes — Lifestyle changes, such as raising the head of the bed and losing weight, are commonly recommended for adults with GERD. These changes might be helpful for some, but not all, children with mild symptoms of acid reflux.

Lifestyle changes are not recommended as the ONLY treatment for a child with moderate or severe symptoms of GERD. Call your child's healthcare provider before beginning any treatment for acid reflux.

• Avoid certain foods — Certain foods, including caffeine, chocolate, and peppermint, can relax the muscle in the esophagus, allowing acid to reflux. Acidic foods and drinks, including colas, orange juice, and spicy foods, may also cause more symptoms. Foods that are high in fat, such as pizza and french fries, may also increase reflux by slowing stomach emptying. These foods should be avoided if they seem to cause more symptoms, and particularly if the child is overweight.
• Raise the head of the bed 6 to 8 inches — Although some people only have heartburn for the two to three hours after meals, others wake up at night with heartburn. Raising the head of the bed might help to reduce nighttime heartburn. This raises the head and shoulders higher than the stomach, allowing gravity to prevent acid from backing up into the esophagus.

You can raise the head of the bed with blocks of wood under the legs of the head of the bed or a foam wedge under the mattress. However, it is not helpful to use extra 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 might help reduce reflux. If you are worried about your child's weight, consult a doctor or nurse for advice on helping the child to lose weight.
• Stay away from tobacco smoke — Smoking or being around tobacco smoke reduces the amount of saliva in the mouth and throat, which can worsen reflux. Saliva helps to neutralize acid. Tobacco smoke also provokes coughing, causing frequent episodes of acid reflux in the esophagus.

Parents and adolescents who smoke are encouraged to quit. (See "Patient information: Quitting smoking".)

• Avoid lying down after eating — Lying down with a full stomach makes it easier for acid to reflux. By eating three or more hours before bedtime, you are less likely to have acid reflux while sleeping. Also avoid eating before exercising.
• Chew gum — Chewing gum can increase the amount of saliva you make, which can help to neutralize stomach acid that has entered the esophagus. However, gum is not recommended for children who are less than four years old.

Medicines — There are several medicines available to treat the symptoms of acid reflux. You should discuss the need for medicine with your child's doctor or nurse before beginning treatment. If your child's doctor or nurse recommends a medicine, it is usually given for a trial period (two to four weeks). After the trial period:

• Your child can continue taking the medicine if reflux symptoms have improved. Children with heartburn alone are sometimes able to stop treatment after a month or two. Those with damage to the esophagus (esophagitis) may need treatment for a longer period of time.
• Your child's doctor or nurse might recommend a different medicine or further testing if symptoms have not improved or have worsened (if testing not done previously, (see 'Acid reflux diagnosis' above).

Proton pump inhibitors — Proton pump inhibitors (PPIs) are a type of medicine that works in the stomach to block acid. PPIs are more effective than other medicines in relieving symptoms, reducing acid secretion, and healing esophagitis. The most commonly used medicines in children include:

• Omeprazole (Prilosec®, available without a prescription)
• Lansoprazole (Prevacid®, available without a prescription)
• Esomeprazole (Nexium®)
• Pantoprazole (Protonix®)
• Rabeprazole (Aciphex®)

PPIs are usually taken by mouth (in pill or liquid form) once per day and may be taken long-term, if needed. Taking the medicine on an empty stomach (30 minutes before breakfast) will help the medicine to work best. If your 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 blockers — The histamine blockers also reduce acid in the stomach. However, they are somewhat less effective than PPIs. Examples of medicines available in the United States include:

• Ranitidine (Zantac®)
• Famotidine (Pepcid®)
• Cimetidine (Tagamet®)
• Nizatidine (Axid®)

These medicines are usually taken by mouth, in pill or liquid form, once or twice per day. Cimetidine, ranitidine, and famotidine are available without a prescription.

If your child takes a histamine blocker first but does not get better, your child's doctor might recommend trying a PPI next. (See 'Proton pump inhibitors' above.) Histamine blockers are not usually recommended for long-term treatment of GERD because they do not work as well over time. If your child's symptoms come and go, he or she can take a histamine blocker when needed.

Antacids — Antacids are commonly used for short-term relief of symptoms of GER in adults. However, antacids work for a very short time after each dose, so they are not very effective. Examples of antacids include Tums®, Maalox®, and Mylanta®.

Antacids are not recommended for infants or young children. With a doctor or nurse's approval, school-age children and adolescents can use antacids, if needed. In all age groups, antacids are not recommended for long-term treatment because they do not work as well as other medicines.

Surgery — Surgery is not usually necessary in healthy children with GERD. Surgery might be an option for certain children who have serious complications of acid reflux that cannot be controlled with medicines.

WHEN TO SEEK HELP

Call your child's doctor or nurse if your child has one or more of the following:

• Repeated vomiting, especially if the vomit is bloody or the child is losing weight
• Frequent heartburn or pain in the upper chest or throat
• Pain or difficulty with swallowing (eg, a sense of food getting stuck in the throat)
• 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.

This article will be updated as needed every four months on our Web site (www.uptodate.com/patients).

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

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: Quitting smoking

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)

The following organizations also provide reliable health information:

• Children's Digestive Health and Nutrition Foundation

      (http://gerd.cdhnf.org/)

• 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 Portuguese)

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