Gastrooesophageal Reflux in Children and Adolescents

Gastrooesophageal reflux (GER) occurs when stomach contents back up into the oesophagus (the tube that connects the mouth to the stomach) during or after a meal. A ring of muscle at the bottom of the oesophagus opens and closes to allow food to enter the stomach. This ring is called the lower oesophageal sphincter (LES). Reflux can occur when the LES opens, allowing stomach contents and acid to come back up into the oesophagus.

GER often begins in infancy, but only a small number of infants continue to have GER as older children. Evaluation by a physician is advised for anyone with persistent symptoms of GER.

Symptoms

Almost all children and adults have a little bit of reflux, without being aware of it. When refluxed material rapidly returns to the stomach, it causes no damage to the oesophagus. In some children, the stomach contents remain in the oesophagus and cause damage to the oesophagus lining. In other children, the stomach contents go up to the mouth (regurgitation) and are swallowed again. When the refluxed material passes into the back of the mouth or enters the airways, the child may become hoarse or have a raspy voice or a chronic cough. Other symptoms include recurrent pneumonia, wheezing, and difficult or painful swallowing.

Diagnosis

The doctor or nurse can talk with you about your child's symptoms, examine your child, and recommend tests to determine if reflux is the cause of the symptoms. These tests check the oesophagus, stomach, and small intestine to see if there are any problems. However, treatment is sometimes started without tests.

The most common tests used to diagnose GER are

  • Upper GI series x ray: Barium (a chalky drink) is swallowed so x rays will show the shape of the oesophagus and stomach. This test can find a hiatal hernia, blockage, and other problems.

  • Endoscopy: After a sedative medication is given so the patient will fall asleep, a small flexible tube with a very tiny camera is inserted through the mouth and down into the oesophagus and stomach. The lining of the oesophagus, stomach, and part of the small intestine is examined and biopsies (small pieces of the lining) can be painlessly obtained. The biopsies are later examined with a microscope for signs of inflammation and other problems.

  • Ooesophageal pH probe: A thin light wire with an acid sensor at its tip is inserted through the nose into the lower part of the oesophagus. The probe detects and records the amount of stomach acid coming back up into the oesophagus, and can tell if acid is in the oesophagus when the child has symptoms such as crying, arching the back, or coughing.
Speak with your child's health care provider if any of the following occur:
  • increased amounts of vomiting or persistent projectile (forceful) vomiting

  • vomiting of fluid that is green or yellow in colour or looks like coffee grounds or blood

  • difficulty breathing after vomiting or spitting up

  • pain related to eating, or food refusal causing weight loss or poor weight gain

  • difficult or painful swallowing

Treatment

The treatment of reflux depends on the child's symptoms and age. When a child or teenager is uncomfortable, has difficulty sleeping or eating, or fails to grow, the doctor or nurse may first suggest a trial of medication to decrease the amount of acid made in the stomach. One class of medications called H2-blockers includes cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid). Another class is proton-pump inhibitors such as esomeprazole (Nexium), omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).

    • The authors of this fact sheet do not specifically endorse the use of drugs for children that have not been tested in children ("off label" use). Such a determination can only be made under the recommendation of the treating health care provider.

    If the child continues to have symptoms despite the initial treatment, tests may be ordered to help find better treatments. It is rare for children to require surgery for GER. However, surgery may be the best option for children who have severe symptoms that do not respond to any treatment.

    Your child's doctor or nurse can discuss the treatment options with you and help your child feel well again.

    Additional suggestions are

    • Have your child or teenager eat smaller meals more often.

    • Avoid eating 2 to 3 hours before bed.

    • Elevate the head of the bed 30 degrees.

    • Avoid carbonated drinks, chocolate, caffeine, and foods that are high in fat or contain a lot of acid (citrus fruits) or spices.

    Points to Remember

    • GER occurs when stomach contents back up into the oesophagus.

    • GER is common in infants but most children grow out of it.

    • GER may cause vomiting, coughing, hoarseness, or painful swallowing.

    • Treatment depends on the child's symptoms and age, and may include changes in eating habits and medications. Surgery may be an option.

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