Gastroesophageal Reflux in Children and Adolescents - National ...

Gastroesophageal Reflux (GER) andGastroesophageal Reflux Disease(GERD) in Children and AdolescentsNational Digestive Diseases Information ClearinghouseWhat is GER?Gastroesophageal reflux (GER) occurswhen stomach contents flow back up into theesophagus—the muscular tube that carriesfood and liquids from the mouth to thestomach.GER is also called acid reflux or acidregurgitation because the stomach’s digestivejuices contain acid. Sometimes people withGER can taste food or acidic fluid in theback of the mouth. Refluxed stomach acidthat touches the lining of the esophaguscan cause heartburn. Also called acidindigestion, heartburn is an uncomfortable,burning feeling in the midchest, behindthe breastbone, or in the upper part of theabdomen—the area between the chest andthe hips.Occasional GER commonly occurs inchildren and adolescents––ages 2 to 19––anddoes not always mean they have GERD.Children and adolescents may be able tocontrol GER by• avoiding foods and beverages thatcontribute to heartburn, such aschocolate, coffee, peppermint, greasyor spicy foods, tomato products, andalcoholic beverages• avoiding overeating• quitting smoking• losing weight if they are overweight• not eating 2 to 3 hours before sleep• taking over-the-counter medicationsRead more about over-the-countermedications in the section “How is GERDtreated in children and adolescents?”What is GERD?Gastroesophageal reflux disease (GERD) isa more serious, chronic––or long lasting––form of GER. GER that occurs morethan twice a week for a few weeks could beGERD, which over time can lead to moreserious health problems. If caregiverssuspect their child or adolescent has GERD,they should take their child or adolescent tosee a pediatrician—a doctor who specializesin treating children and adolescents.What causes GERD inchildren and adolescents?Gastroesophageal reflux disease results whenthe lower esophageal sphincter—the musclethat acts as a valve between the esophagusand stomach—becomes weak or relaxeswhen it should not, causing stomach contentsto rise up into the esophagus.

Other factors that can contribute to GERDinclude• obesity• certain medications, such as asthmamedications and many antihistamines,pain killers, sedatives, andantidepressants• smoking, which is more likely withadolescents than younger children, orinhaling secondhand smokeChildren who have a history of esophagealsurgery and children with severedevelopmental delays are more likely todevelop GERD. Pregnant adolescent girlsmay also develop GERD symptoms. Anychild or adolescent can develop GERD,some for unknown reasons.What is the gastrointestinal(GI) tract?The GI tract is a series of hollow organsjoined in a long, twisting tube from themouth to the anus. The movement ofmuscles in the GI tract, along with therelease of hormones and enzymes, startsthe digestion of food. The upper GI tractincludes the mouth, esophagus, stomach,small intestine, and duodenum, which is thefirst part of the small intestine.MouthEsophagusStomachEsophagusLoweresophagealsphincterLoweresophagealsphincterSmallintestineAcidStomachSmallintestineAnusGERD results when the lower esophageal sphincter—the muscle that acts as a valve between the esophagus andstomach—becomes weak or relaxes when it should not, causing stomach contents to rise up into the esophagus.2 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Children and Adolescents

A completely accurate test for diagnosingGERD does not exist. However, severaltests can help with diagnosis:Upper GI series. While a pediatricgastroenterologist does not use an upper GIseries to diagnose acid reflux or GERD, thetest can provide a look at the shape of theupper GI tract. An x-ray technician performsthis test at a hospital or an outpatient center,and a radiologist—a doctor who specializesin medical imaging—interprets the images.This test does not require anesthesia. Ifpossible, a child or an adolescent shouldnot eat or drink before the procedure, asdirected by the health care staff. Caretakersshould check with the child’s or adolescent’spediatric gastroenterologist about what to doto prepare for an upper GI series.During the procedure, the child or adolescentwill stand or sit in front of an x-ray machineand drink barium, a chalky liquid. Bariumcoats the esophagus, stomach, and smallintestine, so the radiologist and pediatricgastroenterologist can see these organs’shapes more clearly on x rays. A pediatricgastroenterologist cannot use this test todetect mild irritation; however, this test candetect esophageal strictures—narrowing ofthe esophagus that can result from GERD.Children and adolescents may experiencebloating and nausea for a short time afterthe test. For several days afterward, bariumliquid in the GI tract causes white or lightcoloredstools. A health care provider willprovide specific instructions about eating anddrinking after the test.Upper endoscopy. A pediatricgastroenterologist may use anupper endoscopy, also known as anesophagogastroduodenoscopy, if a childor an adolescent continues to have GERDsymptoms despite lifestyle changes andtreatment with medications. An upperendoscopy is a common test used to evaluatethe severity of GERD. This procedureinvolves using an endoscope—a small, flexibletube with a light—to see the upper GI tract.A pediatric gastroenterologist performs thistest at a hospital or an outpatient center.Children and adolescents may receive aliquid anesthetic that is gargled or sprayedon the back of the throat. If sedation isused, a health care provider will place anintravenous (IV) needle in the child’s oradolescent’s vein.4 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Children and Adolescents

After the child or adolescent receivessedation, the pediatric gastroenterologistcarefully feeds an endoscope through themouth and down the esophagus, then intothe stomach and duodenum. A small cameramounted on the endoscope transmits avideo image to a monitor, allowing closeexamination of the intestinal lining. Thepediatric gastroenterologist uses theendoscope to take a biopsy, a procedure thatinvolves taking a small piece of esophagealtissue. A pathologist—a doctor whospecializes in diagnosing diseases—willexamine the tissue with a microscope anddetermine the extent of inflammation.A pediatric gastroenterologist diagnosesGERD when the test shows injury tothe esophagus in children or adolescentswho have had moderate to severe GERDsymptoms.Esophageal pH monitoring. The mostaccurate test to detect acid reflux, esophagealpH monitoring measures the amount ofliquid or acid in the esophagus as the childor adolescent goes about normal activities,including eating and sleeping. A pediatricgastroenterologist performs this test at ahospital or an outpatient center as a part ofan upper endoscopy. The child or adolescentcan remain awake during the test.A pediatric gastroenterologist passes a thintube, called a nasogastric probe, through thechild’s or adolescent’s nose or mouth to thestomach. The pediatric gastroenterologistwill then pull the tube back into theesophagus, where it will be taped to thechild’s or adolescent’s cheek and remain inplace for 24 hours. The end of the tube inthe esophagus has a small probe to measurewhen and how much liquid or acid comes upinto the esophagus. The other end of thetube, attached to a monitor outside the body,shows the measurements taken.This test is most useful when combined witha carefully kept diary of when, what, and howmuch food the child or adolescent eats andGERD symptoms that result. The pediatricgastroenterologist can see correlationsbetween symptoms and certain foods ortimes of day. The procedure can also helpshow whether reflux triggers respiratorysymptoms.How is GERD treated inchildren and adolescents?Treatment for GERD for children andadolescents may involve one or more ofthe following, depending on the severity ofsymptoms: lifestyle changes, medications, orsurgery.Lifestyle ChangesSome children and adolescents can reduceGERD symptoms by• losing weight, if needed• wearing loose-fitting clothes aroundthe stomach area, as tight clothing canconstrict the area and increase reflux5 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Children and Adolescents

• remaining upright for 3 hours after meals • raising the head of the bed 6 to 8 inchesby securing wood blocks under thebedposts––just using extra pillows willnot help• avoiding smoking and being around others who are smoking MedicationsCaregivers can purchase many GERDmedications without a prescription.However, caregivers should not give childrenand adolescents any medications unlesstold to do so by their child’s or adolescent’spediatrician.Antacids, which include over-the-countermedications such as Alka-Seltzer, Maalox,Mylanta, Rolaids, and Riopan, are a first-lineapproach most health care providers usuallyrecommend to relieve heartburn and othermild GERD symptoms. Antacids, however,can have side effects, including diarrhea andconstipation.H2 blockers, such as cimetidine (TagametHB), famotidine (Pepcid AC), nizatidine(Axid AR), and ranitidine (Zantac 75),decrease acid production. These medicationsare available in both over-the-counter andprescription strengths. H2 blockers provideshort-term or on-demand relief and areeffective for many children and adolescentswith GERD symptoms. They also can helpheal the esophagus, although not as well asproton pump inhibitors (PPIs).PPIs include omeprazole (Prilosec, Zegerid),lansoprazole (Prevacid), pantoprazole(Protonix), rabeprazole (Aciphex), andesomeprazole (Nexium), which areavailable by prescription. Omeprazole andlansoprazole also come in over-the-counterstrengths. PPIs are more effective thanH2 blockers and can relieve symptoms andheal the esophageal lining in most childrenand adolescents with GERD. Health careproviders most commonly prescribe PPIs forlong-term management of GERD. However,studies show they are more likely to causehip, wrist, and spinal fractures when takenlong term or in high doses. Children andadolescents should take these medications onan empty stomach in order for stomach acidto activate them.Prokinetics, which include bethanechol(Urecholine) and metoclopramide(Reglan), help make the stomach emptyfaster. However, both bethanechol andmetoclopramide have side effects that oftenlimit their use, including nausea, diarrhea,tiredness, depression, anxiety, and problemswith physical movement. Prokinetics caninteract with other medications, so caregiversshould tell the health care provider about allmedications the child or adolescent takes.6 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Children and Adolescents

Eating, Diet, and NutritionChildren and adolescents with GERD canoften reduce reflux by avoiding foods anddrinks that worsen symptoms. Other dietarychanges that can help reduce symptomsinclude decreasing fat intake and eatingsmall, frequent meals instead of three largemeals. Children and adolescents who areoverweight can talk with a pediatricianabout dietary changes that can help themlose weight, which may decrease GERDsymptoms.Points to Remember• Gastroesophageal reflux (GER)occurs when stomach contents flowback up into the esophagus.• GER is also called acid reflux or acidregurgitation because the stomach’sdigestive juices contain acid.• Gastroesophageal reflux disease(GERD) is a more serious, chronicform of GER.• GERD results when the loweresophageal sphincter becomes weakor relaxes when it should not, causingstomach contents to rise up into theesophagus.• In older children and adolescents, themain symptom of GERD is frequentheartburn. Most children with GERDwho are younger than 12 do not haveheartburn.• Other common GERD symptomsinclude a chronic cough, asthmaor recurrent pneumonia, nausea,difficulty swallowing or painfulswallowing, and pain in the chest.• A pediatrician may refer children andadolescents with suspected GERDto a pediatric gastroenterologist fordiagnosis and treatment.• Treatment for GERD for children andadolescents may involve one or moreof the following, depending on theseverity of symptoms: lifestyle changes,medications, or surgery.• A pediatrician should monitorchildren and adolescents withGERD to prevent or treat long-termcomplications.9 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Children and Adolescents

Hope through ResearchThe Division of Digestive Diseases andNutrition at the National Institute ofDiabetes and Digestive and Kidney Diseases(NIDDK) supports basic and clinicalresearch into GI diseases, including GERand GERD.Clinical trials are research studies involvingpeople. Clinical trials look at safe andeffective new ways to prevent, detect, ortreat disease. Researchers also use clinicaltrials to look at other aspects of care, suchas improving the quality of life for peoplewith chronic illnesses. To learn more aboutclinical trials, why they matter, and how toparticipate, visit the NIH Clinical ResearchTrials and You website at www.nih.gov/health/clinicaltrials. For information about currentstudies, visit www.ClinicalTrials.gov.For More InformationNorth American Society for PediatricGastroenterology, Hepatology and Nutrition(NASPGHAN)P.O. Box 6Flourtown, PA 19031Phone: 215–233–0808Fax: 215–233–3918Email: naspghan@naspghan.orgInternet: www.naspghan.orgPediatric/Adolescent GastroesophagealReflux AssociationP.O. Box 7728Silver Spring, MD 20907Phone: 301–601–9541Email: gergroup@aol.comInternet: www.reflux.org10 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Children and Adolescents

You may also find additional information about thistopic by visiting MedlinePlus at www.medlineplus.gov.This publication may contain information aboutmedications and, when taken as prescribed,the conditions they treat. When prepared, thispublication included the most current informationavailable. For updates or for questions aboutany medications, contact the U.S. Food and DrugAdministration toll-free at 1–888–INFO–FDA(1–888–463–6332) or visit www.fda.gov. Consult yourhealth care provider for more information.The U.S. Government does not endorse or favor anyspecific commercial product or company. Trade,proprietary, or company names appearing in thisdocument are used only because they are considerednecessary in the context of the information provided.If a product is not mentioned, the omission does notmean or imply that the product is unsatisfactory.National Digestive DiseasesInformation Clearinghouse2 Information WayBethesda, MD 20892–3570Phone: 1–800–891–5389TTY: 1–866–569–1162Fax: 703–738–4929Email: nddic@info.niddk.nih.govInternet: www.digestive.niddk.nih.govThe National Digestive Diseases InformationClearinghouse (NDDIC) is a service of theNational Institute of Diabetes and Digestiveand Kidney Diseases (NIDDK). TheNIDDK is part of the National Institutes ofHealth of the U.S. Department of Healthand Human Services. Established in 1980,the Clearinghouse provides informationabout digestive diseases to people withdigestive disorders and to their families,health care professionals, and the public.The NDDIC answers inquiries, develops anddistributes publications, and works closelywith professional and patient organizationsand Government agencies to coordinateresources about digestive diseases.This publication is not copyrighted. The Clearinghouseencourages users of this publication to duplicate anddistribute as many copies as desired.This publication is available atwww.digestive.niddk.nih.gov.NIH Publication No. 13–5418September 2013The NIDDK prints on recycled paper with bio-based ink.