Gastroesophageal Reflux
Gastroesophageal reflux is the backward movement of food and acid from the stomach into the esophagus and sometimes into the mouth (see Section 9, Chapter 121).
Nearly all infants have episodes of gastroesophageal reflux; "burping up" that babies do after feeding is considered normal. Gastroesophageal reflux becomes a concern when it interferes with feeding and nutrition, causes poor weight gain, damages the esophagus, leads to breathing difficulties, or continues beyond infancy into childhood.
Causes
Healthy infants have reflux for many reasons. The circular band of muscle that normally keeps stomach contents from entering the esophagus (lower esophageal sphincter) is not fully developed in infants, allowing stomach contents to move backward into the esophagus. Being held flat during a feeding (instead of more upright) or lying down after a feeding promotes reflux. Overfeeding predisposes to reflux, as does exposure to cigarette smoke or caffeine in breast milk, both of which relax the lower esophageal sphincter and can cause the child to become irritable and eat poorly. Less commonly, children may have an anatomic abnormality, such as narrowing of the esophagus or abnormal position of the intestines (malrotation), which makes reflux even more likely. Immaturity of the nerves that control stomach emptying can also lead to gastroesophageal reflux. Milk allergy is a rare cause.
Symptoms
The most obvious symptoms of gastroesophageal reflux in infants are vomiting and excessive spitting up. Less obviously, the infant may be irritable, may not eat well, or may have "spells" of twisting and posturing that may be confused with seizures.
Reflux usually improves gradually until the age of 1 or 2 years, when the child starts eating solid foods and is able to eat on his own in an upright position. However, reflux occasionally leads to complications. Some infants lose weight. Some develop a low red blood cell count (anemia) because of bleeding from the esophagus, and some inhale (aspirate) stomach acid and food into their lungs. Aspiration of stomach contents can cause pneumonia, asthma, periods when breathing stops (apnea), a slow heart rate, and, extremely rarely, infant death.
Older children are usually able to describe chest pain or heartburn when they have gastroesophageal reflux. Chronic cough, hoarseness, hiccups, ear pain, and high-pitched breathing (stridor) may also be subtle signs of reflux in older children. In some children, reflux may be a cause of chronic ear infection (serous otitis media (see Section 23, Chapter 276)).
Diagnosis and Treatment
Diagnosis of gastroesophageal reflux can be difficult when the symptoms are not obvious. Some doctors recommend simple measures to see if an infant's symptoms improve before ordering more extensive tests. For example, a doctor may recommend thicker, smaller, and more frequent feedings with more frequent burpings. Eliminating a child's exposure to cigarette smoke and caffeine also helps. Laying the child to sleep on the stomach or on an angle with the head elevated also reduces reflux. This is one of the few exceptions to the general recommendation that infants be put to sleep on their back and should be done only when a doctor specifically recommends it. Occasionally, doctors recommend a change of formula to determine if cow's milk or a formula ingredient is contributing to the infant's problem.
Some doctors recommend that infants whose symptoms do not improve with these measures and most older children try drug treatment for a short time before undergoing diagnostic testing. Drugs for reflux are generally safe and effective. Antacids neutralize stomach acid, and histamine-2 blockers and proton pump inhibitors suppress acid production by the stomach and improve reflux symptoms, at least temporarily. Promotility drugs, such as metoclopramide, stimulate the stomach to move its contents forward rather than backward and may tighten the lower esophageal sphincter.
Various tests can be used to diagnose reflux. X-rays taken after swallowing barium help doctors determine if the anatomy of the esophagus and stomach is normal. In addition, a diary can be kept to record the child's symptoms. Information from this diary, combined with monitoring of the level of acid in the esophagus through a small flexible tube that has been passed through the nose, helps doctors determine if reflux episodes are the cause of the symptoms. A form of radionuclide imaging called a gastric emptying study can reveal to what degree stomach contents move forward appropriately or reflux backward. Examination of the esophagus using a flexible viewing tube (endoscopy) allows doctors to see if the esophagus is inflamed or bleeding. Examination of the voice box (larynx) and airways through a flexible viewing tube (bronchoscopy (see Section 4, Chapter 39)) gives information that helps doctors decide if reflux is a likely cause of lung or breathing problems.
|
