Pediatric Reflux Disease
Gastroesophageal reflux—or when acidic stomach juices, or food and fluids move back up to the esophagus—is common and normal among infants. In fact, it is so common that parents mostly know it by a different name: spitting up. “When babies spit up and then smile afterwards, we call them ‘happy spitters,’” says Yale Medicine's Anthony Porto, MD, MPH. “We’re more worried about it than they are.”
But when repeated regurgitation begins to cause an infant pain with feeding, then doctors and parents should think about treating this condition. At Yale Medicine, our unique Pediatric Aerodigestive Disorders Program includes not pediatric gastroenterologists, but also other pediatric specialists, including ear-nose-and-throat surgeons, pulmonologists, and nutritionists. We work as a team to evaluate, treat and coordinate treatment plans.
What is pediatric gastroesophageal reflux?
Pediatric gastroesophageal reflux refers to the backward movement of stomach acid into the esophagus. In infants, having gastroesophageal reflux is normal, a result of of their physiology. The muscle in their lower esophageal sphincter opens and closes at random times; its length is shorter in infants and does not reach adult length until they are 2 years old. Because the baby is eating frequently, there’s a high chance of some spit up. Still, the reflux usually improves by the time a child is 9 months to a year old.
“Most happy spitters will not require any treatment other than reassurance and waiting,” Dr. Porto says. “And a lot of laundry.”
On the other hand, pediatric gastroesophageal reflux becomes a disease when that regurgitation irritates the esophagus so much that the child experiences pain or a burning sensation.
What are risks and related conditions for pediatric gastroesophageal reflux?
For infants, reflux can simply be a normal physiologic condition and should gradually improve with age. Reflux symptoms in children that are born prematurely may improve even later.
Children with asthma or who are overweight are at greater risk for reflux since increased abdominal pressure can cause food that they’ve eaten to move back up into the esophagus. Having a hiatal hernia—when part of the stomach rises above a weakened diaphragm—can also be a risk factor for symptoms.
For older children, the condition can have its origins in the child’s diet.
“The body naturally makes acid,” says Dr. Porto. “And it makes more once we are eating and chewing. If you’re eating a high acid diet, you’re introducing more acid in addition to that.”
Culprits could include tomatoes (including ketchup), citrus fruits, and spicy foods. Anything that’s carbonated or caffeinated can also cause the esophageal sphincter to remain open.
What are the symptoms of pediatric gastroesophageal reflux?
For babies, pediatric reflux disease presents as spitting up or vomiting and may lead to feeding problems and slow weight gain. In older children, it could be upper belly or chest pain, especially after they eat. Unlike adults, children don’t typically describe heartburn or throat pain, but they may describe a feeling of food coming back up into their throat after eating.
How is pediatric gastroesophageal reflux diagnosed?
For younger infants, doctors note the frequency of symptoms and ask parents whether the reflux is affecting the child’s feeding or weight gain. “It’s difficult,” Dr. Porto says. As long as babies are feeding and gaining weight, doctors will often simply monitor their health.
Older children can report their symptoms, which helps doctors to make their diagnoses.
How is gastroesophageal reflux disease treated?
For babies who aren’t gaining weight or feeding well, doctors may start by recommending some simple lifestyle changes. “We ask parents to burp the babies in pauses during feeds,” says Dr. Porto. Other tips include keeping the baby upright for 20 minutes after feeding. For older children, doctors suggest sleeping on their left sides or their stomachs, and altering diets or aiming to control weight or asthma.
If none of those lifestyle changes improve the regurgitation, there are some medications to try. These fall into three group:
- Antacids, which neutralize stomach acid in mild cases
- Histamine H2 blockers, which block where acid is produced in more severe cases
- Proton pump inhibitors, which prevent all the acid from forming and are used in the most severe cases
“It can take a few days to weeks for the medicine to take effect,” Dr. Porto says, adding that he will keep a child on the medication for at least two to four weeks and, if there is an improvement, continue it for three months. “That’s how long it takes for healing in the esophagus to occur,” he says.
Once inflammation has gone down, doctors may then have children step down the drugs. “Hopefully by then, the esophagus is healed and the inflammation that caused symptoms is gone,” Dr. Porto says. Sometimes, doctors can then take a child off of medication completely, or do a trial with them at a lower level.
Occasionally, an upper endoscopy may be needed if symptoms do not improve or if they recur after a child stops the medication.
In the case of children who need long-term therapy, doctors may perform a pH impedance study. This can determine how high the reflux is coming up and highlight what is affecting the movement of food in a patient’s esophagus. Occasionally, a surgical procedure called fundoplication can be performed; this repositions the stomach vis-à-vis the esophagus in order to strengthen the valve between them.
“This procedure is done in special circumstances and with the goal of reducing reflux symptoms and decreasing the need for long-term medications,” says Dr. Porto.
What makes Yale Medicine’s approach to pediatric gastroesophageal reflux unique?
First, the accessibility of Yale Medicine means that doctors can see patients living with gastroesophageal reflux disease throughout Connecticut. Second, we offer the unique, multidisciplinary Pediatric Aerodigestive Disorders Program, which has doctors in a variety of specialties in addition to pediatric gastroenterology, such as pediatric ear-nose-and-throat surgeons, pediatric surgeons, pulmonologists, and nutritionists. Together, we perform a thorough evaluation, develop treatment plans and coordinate procedures that approach the whole child.