Reflux

Reflux

Many children with feeding issues also have reflux. The following page is a summary of what reflux is and how it is diagnosed and treated.

What is Reflux?

digestive-system

Digestive system

Reflux, or gastroesophageal reflux (GER), occurs when the contents of the stomach pass back up through the lower esophageal sphincter (LES) into the esophagus.

This refluxed liquid contains food, stomach acid, and enzymes, which help digest protein and which may contain bile. The most harmful component of the refluxed liquid is the stomach acid, which can damage the esophagus. Up to one-third of babies have reflux at some time, but almost all outgrow it within one year.

What is Gastroesophageal Reflux Disease?

larinx-and-nasal-cavity

Aspiration occurs when food travels down the larynx rather than the esophagus.

Gastroesophageal reflux disease (GERD) is a more serious form of reflux. With GERD, the refluxed liquids can come completely up the esophagus and out of the mouth (vomiting or spitting up), into the sinuses, or even into the lungs (aspiration).

With GERD, reflux occurs more frequently and can be much more painful than with GER. Repeated exposure to stomach acid can cause the esophagus to become red and irritated (esophagitis), and in severe cases, can cause bleeding and scarring of the esophagus, which can make swallowing painful and difficult. Repeated vomiting can also damage teeth enamel. In children, the pain of reflux often leads to food refusal, lack of proper nutrition, no weight gain, weight loss, or failure to thrive, resulting in severe cases needing gastrostomy feeding tube (G-tube) or nasogastric feeding tube (NG-tube) feeding.

Another very serious implication of reflux is if refluxed liquid enters the lungs, potentially causing breathing problems or pneumonia. If the refluxed liquid enters the sinuses, it can cause sinus infections and swollen adenoids. In babies with reflux, choking or apnea may occur.

Symptoms of Reflux in Children

When refluxed liquids enter the esophagus, the acid begins to damage the esophagus, causing pain when swallowing and inconsolable crying. Repeated scarring of the esophagus may result in a narrowing and hardening of the esophagus, or strictures, which may cause food to become stuck in the esophagus.

When the acid comes up to the throat, the throat can become hoarse and laryngitis may occur. Babies may spit up frequently, spit up long after meals, and continue to spit up even as they grow older.

Because eating can be painful, children may refuse food or accept only a few bites of food during a meal. Other children may vomit frequently, even at every meal. Because they may not eat enough, children with reflux might not have adequate nutrition and may lose or stop gaining weight. In some cases, the child may stop growing for a long period of time or may lose so much weight that they fall below the average range of growth for their age, in which case they may be labeled Failure to Thrive by their pediatrician.

Reflux occurs more often when lying down, so the child may have trouble sleeping, may wake up frequently, or may cry when placed on a flat surface such as in a crib after a meal. Sleep apnea may occur if refluxed liquids block the air passage during sleep.

In some cases, refluxed liquids may travel up through the esophagus and into the lungs, called aspiration. If aspiration occurs, the refluxed liquids in the lungs may cause infections, coughing, wheezing, recurrent pneumonia, sinus infections, and asthma.

Causes of Reflux

The main cause of reflux is a malfunction of the lower esophageal sphincter (LES). Normally, the LES opens during swallowing and then closes to keep the stomach contents in the stomach. With reflux, however, the LES opens at times not related to swallowing, or stays open when swallowing is complete, allowing the stomach contents to travel up into the esophagus. In other cases, the contractions of the esophagus, which normally travel from the mouth to the stomach, occur erratically, stop before the food reaches the stomach, or don’t occur with swallowing.

Reflux can also occur if the LES is weak and does not close completely. In other cases, reflux may occur because the stomach is emptying slowly, causing more pressure to be exerted against the LES, which may make the contractions of the esophagus stronger.

Diagnosis of Reflux

Lower esophageal sphincter and stomach.

Lower esophageal sphincter and stomach.

Barium Swallow Study (Upper GI)

In a barium swallow study, also known as a video fluoroscopy / upper GI, the child drinks a chalky liquid with barium, which shows up on an x-ray. The x-ray can show places in which damage to the esophagus becomes scar tissue, making a narrow passage for food to pass. The x-ray can also show deformities of the upper digestive tract, swelling in the esophagus, stomach, and duodenum. The video fluoroscopy shows the child drinking liquids with barium and may show aspiration of food and liquids into the lungs. The child can then be fed liquids of different thicknesses to find a safe level of thickness to reduce or eliminate aspiration during meals.

24-hour pH Probe

This is a reliable test for reflux. A thin tube is fed through the nose and placed in the esophagus where the stomach and esophagus meet. The tube measures acid levels over the course of 24 hours. If acid levels are consistently high, reflux is occurring. Also, this test can show if high acid levels occur when the child cries, coughs, or shows other symptoms of reflux.

Endoscopy

A small, flexible tube with a camera is fed through the mouth into the esophagus and stomach, so the doctor can see the lining of the esophagus and look for damage that may be caused by reflux. Biopsies of the esophagus, stomach, and upper small intestines can also be taken through the scope and may be used to determine food allergies or other issues. The child will likely need to be anesthetized during this procedure.

Gastric Emptying Study (Milk Scan)

A gastric emptying study, such as a milk scan or gastroesophageal scintigraphy, measures how quickly the stomach empties. The child swallows milk or another food or drink mixed with a radium-labeled powder, which can be followed through the digestive tract. The test focuses on the esophagus (to test for reflux), lungs (to check for aspiration), and stomach (to check for slow gastric emptying).

The test may be more accurate in detecting reflux than a pH probe, because it more closely resembles normal feeding, and follows digestion through the entire digestive tract. It is less effective in detecting structural abnormality than an endoscopy or barium swallow study.

Breastfeeding and Reflux

Breastfeeding seems to provide some relief from reflux in infants. This could be because it can be soothing to be breastfed. Also, breast milk is more quickly and easily digested than formula. In particular, formulas made from cow’s milk can be hard to digest. And for babies with slow-emptying stomachs, quick digestion can decrease reflux episodes. Additionally, breast milk may have some antacid qualities, reducing acidity in the esophagus or at least washing stomach acid back into the stomach, thereby decreasing pain.

Treatment of Reflux

Lifestyle Changes

The vast majority of children eventually outgrow reflux, usually within their first year of life. For these children, lifestyle changes can be effective in increasing food intake and reducing symptoms, such as crying and pain:

Certain foods—such as spicy, fatty, or acidic foods—may increase reflux, so they can be avoided.

Burping the baby frequently and giving smaller, more frequent meals may also help.

Thickening food or formula with rice cereal or oatmeal cereal, which may be easier for a baby to digest than rice cereal, may keep the food from being regurgitated.

Gravity can also help keep the stomach contents in the stomach. Keeping the baby upright after meals by elevating the head of the bed or crib with wooden blocks or using a wedge, or having the baby sit in a bouncy seat or infant carrier, can use gravity to help keep food down.

It can also be a good idea to have the child checked for allergies, which might be making the reflux more severe.

Medications for Reflux

When these lifestyle changes are not sufficient in combating reflux, the child’s doctor may prescribe medications to help alleviate symptoms.

  1. Proton Pump Inhibitors (PPIs)
    • Decrease stomach acid production, which can protect the esophagus from damage from stomach acid
    • Should be taken one hour before a meal, so that the medication is at its highest levels during the meal
    • Examples of PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium)
  2. Antacids
    • Increase pH of the stomach, neutralizing acid
    • Although quick-acting, antacids only last 30 minutes or less, so they must be taken repeatedly throughout the day, in particular right after a meal and again two hours after a meal as stomach emptying slows
    • Calcium antacids may cause acid rebound
    • Aluminum antacids may cause constipation
    • Magnesium antacids may cause diarrhea
    • Examples of antacids include Gaviscon and Tums
  3. Histamine (H2 receptor) Antagonists
    • Reduce acid production by blocking histamine receptors, which stimulate acid production
    • Should be taken 30 minutes after a meal to allow the meal to be digested by the stomach acid
    • Do not help esophagitis (painful inflammation and redness of the esophagus)
    • Because it comes in liquid form, which is easier for a child to take, histamine antagonists may be prescribed more often for children
    • Examples include cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepsid)
  4. Prokinetic Agents
    • Make the LES close more tightly, reducing reflux
    • There is a possibility of adverse reactions to prokinetic agents
    • Examples include metoclopramide (Reglan), cisapride (Propulsid), erythromycin (Dispartab, Robimycin), and bethanechal (Duvoid, Urecholine)
  5. Pro-motility Medications
    • Stimulate the muscles of the digestive tract, including esophagus, stomach, small intestines, and colon, but may cause constipation
    • The effects of the medication on the sphincter and esophagus are small and not very effective
    • Motility medications are often paired with other reflux medications
    • The medication is taken 30 minutes before a meal and at bedtime
    • Examples include Urecholine and Regalin

Surgical Treatment for Reflux – Nissen Fundiplication

Nissen Fundoplication

If a child does not outgrow reflux, and lifestyle changes and medications are not effective, particularly when the child is not gaining weight, a doctor may consider a surgical alternative.

In a Nissen fundoplication, the top of the stomach is wrapped around the esophagus, creating an artificial sphincter. The strong stomach muscles can pinch closed the esophagus, keeping the stomach contents from coming back up into the esophagus. The operation may be completed laprascopically with a small incision in the abdomen.

The vast majority of patients have less reflux after a Nissen, but there can be complications. Food can get caught in the artificial sphincter. The food may come down on its own or it can be removed through endoscopy. In other cases, the surgery may cause oral aversion, leading to weight loss.

Links to Key Reflux Websites