Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)

GASTROESOPHAGEAL REFLUX OVERVIEW — Gastroesophageal reflux occurs when food or liquid in the stomach flows backward into the esophagus and/or mouth. Because the stomach naturally produces acid, it is sometimes called "acid reflux." Occasional reflux is normal and can happen in healthy babies, children, adolescents, and adults, most often after eating a meal. Most episodes are brief and do not cause bothersome symptoms or problems.

In contrast, the term gastroesophageal reflux disease (GERD) refers to bothersome symptoms or damage to the esophagus as a result of acid reflux. Symptoms of GERD can include heartburn, regurgitation, and difficulty or pain with swallowing. Asthma that is triggered by reflux is also considered a form of GERD. In rare instances, severe and longstanding GERD can result in a narrowing of the esophagus (stricture) or permanent tissue change (Barrett).

This article discusses the symptoms, causes, diagnosis, and treatment of GERD in children and adolescents. Gastroesophageal reflux disease in babies and adults is discussed separately. (See "Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)" and "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)".)

WHY DOES REFLUX HAPPEN? — When you eat, food moves from your mouth through the esophagus then into your stomach. The esophagus is a tube-like structure that is made of muscles and tissue lining that expand and contract to propel food to your stomach through a series of wave-like movements called peristalsis.

The lower end of the esophagus connects to the stomach, where there is a circular ring of muscle called the lower esophageal sphincter (LES) that acts as a valve. When you swallow, the LES relaxes to allow food to enter your stomach, where it mixes with acid that help with digestion. The LES then closes to prevent the food and acid from backing up into your esophagus.

When the LES relaxes inappropriately, liquids in the stomach may wash back into the esophagus (figure 1). This happens occasionally to everyone. Most of these episodes occur shortly after meals, are brief, and do not cause symptoms. Reflux also occurs during sleep, but, in most cases, we are not aware of these episodes and they do not cause problems.

In some people, acid reflux causes bothersome symptoms or injury to the esophagus over time; when this happens, it is considered GERD. In general, damage to the esophagus is more likely to occur when the reflux is very frequent or if the esophagus is unable to clear away the acid quickly because of a nerve or muscle problem.

GERD SYMPTOMS — The symptoms of gastroesophageal reflux disease (GERD) depend upon the child's age.

●Young children – Symptoms that might be caused by of GERD include:

•Vomiting or tasting stomach acid or food in the throat or mouth

•Lack of interest in eating, food refusal, or a preference for liquids and avoidance of solid foods (because of pain with eating)

•Poor weight gain

•Uncommonly, there can be wheezing or dry cough (at night or after eating), particularly in children with asthma

●Older children and adolescents – The most common symptoms of GERD include many of the symptoms listed above, plus:

•Tasting stomach acid

•Nausea

•Halitosis (breath that smells bad)

•Excessive burping (belching)

•Pain or burning in the mid- to upper chest (heartburn)

•Difficulty, discomfort, or pain with swallowing

•Awakening at night with nausea or abdominal pain

•Damage to teeth (dental erosions)

Children who do not have language (or have difficulty expressing or describing their feelings) may tap their chest or exhibit unexpected behaviors or movements when they feel the heartburn. Therefore, changes in a child's behaviors might be caused by GERD (or by another cause of pain). 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. (See "Autism spectrum disorder in children and adolescents: Clinical features", section on 'Restricted and repetitive behavior, interests, and activities'.)

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

GERD DIAGNOSIS — If your child has frequent symptoms that might be related to GERD, consult a health care provider 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 GERD but no related complications, the provider might recommend lifestyle changes or a medicine before ordering tests. (See 'GERD treatment' below.)

If your child has reflux-related complications or other medical problems (eg, asthma, pneumonia, poor growth, 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 gastrointestinal series — An upper gastrointestinal series is a test that might be recommended for children who have forceful vomiting or difficulty or pain with swallowing. To do this test, the child swallows a liquid called "contrast" that can be seen easily with X-ray. Barium is the main type of contrast, but other substances are sometimes used. After the liquid is swallowed, a special type of X-ray (fluoroscopy) is used to see the shape and structure of the mouth, esophagus, and stomach.

The main purpose for this test is to look for structural abnormalities such as a twist in the bowel or a blockage in the stomach (both of which are rare). This test can also be helpful in evaluating causes of vomiting as well as pain or difficulty swallowing (eg, a narrowing or problems with peristalsis [muscle movements] in the esophagus). The test can also show reflux but cannot distinguish between normal reflux and GERD.

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

A gastroenterologist performs the test, usually in the hospital, after the child is sedated. The doctor passes a narrow, flexible tube through the mouth and into the esophagus and stomach (figure 2). The tube has a light and a camera. The doctor can see if there is damage and usually takes a sample of tissue (biopsy) through a channel in the tube. The test is not painful, although some children may temporarily have a sore throat following the procedure. (See "Patient education: Upper endoscopy (Beyond the Basics)".)

24-hour esophageal pH or impedance study — The most direct way to measure the amount of gastroesophageal reflux is with a test called an esophageal pH study (which measures acid reflux) or an esophageal impedance study (which measures acid and non-acid reflux). These tests are similar and are sometimes performed at the same time. They can show how frequently reflux occurs, although this information usually is not necessary for the diagnosis of GERD. These tests are usually reserved for children whose diagnosis is unclear after endoscopy or after a trial of treatment. They may also be useful for children who continue to have reflux symptoms despite treatment.

The tests involve inserting a thin tube with a sensor through the nose and into the esophagus; this is left in place for 24 hours. The tube does not hurt but can be irritating to the back of the throat, and some young children may 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 test results to see how frequently reflux is happening, how quickly the acid is cleared, and whether there is a relationship between symptoms and acidic or non-acidic reflux.

Some children are not able to handle keeping the tube in place, especially those on the autism spectrum (in whom GERD is more common). For these children, a wireless pH monitoring sensor can be clipped to the lining of the esophagus during endoscopy while the child is sedated. This device measures and transmits the pH measurements to a receiver, and the data are downloaded to a computer after 48 hours. Data about the acid level in the esophagus can then be analyzed. The capsule falls off after 48 hours and is passed in the stool.

GERD TREATMENT — Several treatment options are available for children with GERD. The choice of treatment depends upon your child's age, the type and severity of symptoms, and how your child responds to treatment.

Lifestyle changes — Lifestyle changes are commonly recommended for adults with GERD. These might include raising the head of the bed, avoiding exposure to tobacco smoke, and losing weight. These changes might be helpful for some, but not all, children and adolescents with mild GERD symptoms. For those with moderate or severe symptoms of GERD, lifestyle changes are not recommended as the only treatment.

Call your child's health care provider before beginning any treatment. If they do recommend lifestyle changes, these may include:

●Avoid certain foods – Certain foods, including caffeine, chocolate, and peppermint, can relax the valve-like muscle at the lower end of the esophagus, allowing acid to reflux into the esophagus. Acidic foods and drinks, including colas, orange juice, and spicy foods, may also cause symptoms. Foods that are high in fat, such as pizza and French fries, may also increase reflux because they slow stomach emptying. These foods should be avoided if they seem to cause symptoms.

●Raise the head of the bed six to eight inches – Although some children only have heartburn for the two to three hours after meals, others awaken 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 by putting 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 a bend in the body that increases pressure on the stomach, which can worsen acid reflux.

●Control weight – In children who are very overweight, losing weight might help reduce reflux. If you are worried about your child's weight, ask their health care provider for advice.

●Avoid tobacco smoke – Smoking or being around tobacco smoke worsens reflux in several ways. First, it reduces the amount of saliva in the mouth and throat, which can worsen acid reflux because saliva helps to neutralize acid. Tobacco smoke also provokes coughing, which causes frequent episodes of acid reflux in the esophagus. Finally, nicotine reduces the pressure in the lower esophageal muscle valve, allowing for more acid to enter the esophagus.

For these reasons, quitting smoking or eliminating secondhand smoke in the household can reduce or eliminate symptoms of mild reflux, in addition to having many other health benefits. Parents and adolescents who smoke are encouraged to quit. (See "Patient education: Quitting smoking (Beyond the Basics)".)

●Avoid lying down after eating – Lying down with a full stomach may increase the risk of acid reflux. Planning to end meals at least two to three hours before bedtime may help reduce symptoms.

●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 younger than four years old.

Medicines — There are several medicines available to treat the symptoms of GERD. You should discuss the need for medicine with your child's health care provider before beginning treatment. If your health care provider recommends a medicine, it is usually given for a trial period (two to four weeks) to see if it helps. 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.

●The health care provider might recommend a different medicine or further testing if symptoms have not improved or have worsened (if testing not done previously) (see 'GERD 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 reducing acid secretion, relieving symptoms, and healing esophagitis. Some PPIs are available over the counter, although higher doses may require a prescription.

The most commonly used medicines in children include:

●Esomeprazole (brand name: Nexium)

●Lansoprazole (brand name: Prevacid, available without a prescription)

●Omeprazole (brand name: Prilosec, available without a prescription)

●Pantoprazole (brand name: Protonix)

●Rabeprazole (brand name: Aciphex)

PPIs are usually taken by mouth (in pill, capsule, or liquid form) once per day and may be taken long term, if needed. Some medications (such as lansoprazole) are available as a dissolvable tablet. Alternatively, some capsules can be opened and the granules mixed in applesauce. Taking the medicine on an empty stomach (30 minutes before breakfast), followed by food, will help the medicine to work best. If your child's symptoms do not improve after taking a PPI for two to four weeks, a diagnostic test may be recommended. (See 'Upper endoscopy' above.)

Histamine receptor antagonists — The histamine antagonists reduce production of acid in the stomach. They are more effective than antacids in relieving heartburn, and their effects last for longer; however, they are not usually adequate for the treatment of severe, chronic, or frequent symptoms.

Examples of histamine antagonists available in the United States include cimetidine (brand name: Tagamet), famotidine (brand name: Pepcid), and nizatidine (brand name: Axid).

If your child takes a histamine blocker first but does not get better, your child's health care provider 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 continue to work as well over time. If your child's symptoms come and go, they can take a histamine blocker when needed.

Antacids — Antacids (sample brand names Tums and Maalox) are commonly used for short-term relief of symptoms of gastroesophageal reflux in adults. However, antacids only work for a very short time after each dose, so they are not very effective for ongoing treatment.

Antacids are not recommended for infants or young children. With health care provider's approval, school-age children and adolescents can use antacids, if needed. Antacids are not recommended for long-term treatment in children of any age, because they do not work as well as other medicines.

Herbal remedies and alternative medicine — A variety of herbal remedies are sometimes used for GERD or other gastrointestinal complaints, including chamomile, slippery elm, deglycyrrhizinated licorice root (DGL), and ginger root. For most of these remedies, there is limited information about whether they are effective or safe. The National Center for Complementary and Integrative Health is a reliable source of information about specific herbs and remedies.

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

WHEN TO SEEK HELP — Call a health care provider 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 mid- to upper chest or throat

●Pain or difficulty with swallowing (eg, a sense of food getting stuck in the throat or chest)

●New breathing problems, such as wheezing, a chronic cough, or hoarseness

●Recurrent pneumonia (lung infections)

WHERE TO GET MORE INFORMATION — Your child's health care 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 on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Acid reflux and GERD in children and teens (The Basics)
Patient education: Spitting up and GERD in babies (The Basics)
Patient education: Acid reflux and GERD in adults (The Basics)
Patient education: Esophagitis (The Basics)
Patient education: Eosinophilic esophagitis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)
Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)
Patient education: Constipation in infants and children (Beyond the Basics)
Patient education: Upper endoscopy (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)
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 (EoE)

Websites — The following organizations also provide reliable health information:

●GI Kids (Children's Digestive Health Information for Kids and Parents, available in English and Spanish)

(www.gikids.org/gerd)

●National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-children)

●National Library of Medicine

(www.medlineplus.gov/healthtopics.html)

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