Gastroesophageal Reflux Disease and Heartburn

What is GERD?

Gastroesophageal refluxGastroesophageal reflux disease (GERD) is a chronic digestive disorder that is caused by the abnormal flow of gastric acid from the stomach into the esophagus. Gastroesophageal refers to the stomach and esophagus, and reflux means to flow back or return. Gastroesophageal reflux (GER) is the return of acidic stomach juices, or food and fluids, back up into the esophagus. GERD is very common in infants but can happen at any age. It is the most common cause of vomiting during infancy.

What causes GERD?

GERD is often the result of conditions that affect the lower esophageal sphincter (LES). The LES, a muscle located at the bottom of the esophagus, opens to let food into the stomach and closes to keep food in the stomach. When this muscle relaxes too often or for too long, acid refluxes back into the esophagus, causing vomiting or heartburn. Everyone has GER from time to time. Anyone who has ever burped and had an acid taste in their mouth has had reflux. The lower esophageal sphincter occasionally relaxes at inopportune times, and usually, all your child will experience is a bad taste in the mouth, or a mild, momentary feeling of heartburn.

Infants are more likely to experience weakness of the lower esophageal sphincter (LES), causing it to relax when it should remain shut. This is often due to immaturity. As food or milk is digesting, the LES opens and allows the stomach contents to go back up the esophagus. Sometimes, the stomach contents go all the way up the esophagus and the infant or child vomits. Other times, the stomach contents only go part of the way up the esophagus, causing heartburn, breathing problems or, possibly, no symptoms at all.

Some foods seem to affect the muscle tone of the lower esophageal sphincter, allowing it to stay open longer than normal. These include, but are not limited to:

  • Chocolate
  • Carbonated drinks
  • High-fat foods.

Other foods increase acid production in the stomach, including:

  • Citrus foods
  • Tomatoes and tomato sauces
  • Spicy foods.

Why is GERD a concern?

Some infants and children with GERD may not vomit, but may still have stomach contents coming up into the esophagus and causing difficulty breathing, episodes of pneumonia, chronic coughing or wheezing, or in some cases, turning blue around the mouth. Although rare, infants and children can stop breathing for brief moments.

What are the symptoms of GERD?

Heartburn, also called acid indigestion, is the most common symptom of GERD. Heartburn is described as a burning chest pain that begins behind the breastbone and moves upward to the neck and throat. It can last as long as two hours and is often worse after eating. Lying down or bending over after a meal can also contribute to heartburn. Many children who are diagnosed with GERD will experience a dry cough, wheezing or trouble swallowing, instead of classic heartburn.

Although each child may experience symptoms differently, signs of GERD in infants can include:

  • Fussiness around mealtimes
  • Hiccups
  • Refusal to eat
  • Frequent vomiting
  • Gagging.

Symptoms in children may include:

  • Belching
  • Stomachache
  • Choking
  • Frequent cough
  • Coughing fits at night
  • Wheezing
  • Frequent upper respiratory infections (colds)
  • Frequent ear infections
  • Rattling in the chest
  • Frequent sore throat in the morning
  • Sour taste in the mouth.

The symptoms of GERD often resemble those of other gastrointestinal conditions, including eosinophilic esophagitis. At CHOC, we thoroughly assess each patient to ensure proper diagnosis.

How is GERD diagnosed?

Our gastroenterology specialists perform a physical examination and obtain a medical history of each patient. Additionally, we may use the following tests to help diagnose whether the child has GERD or other gastrointestinal condition:

Endoscopy. A test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Tissue samples from inside the digestive tract may also be taken for examination and testing. Learn more about endoscopy procedures at CHOC.

pH monitoring. Used to measure the acidity inside of the esophagus, this test is helpful in evaluating the extent of GERD. A thin plastic tube is placed into a nostril, guided down the throat, and then into the esophagus. The tube stops just above the lower esophageal sphincter, which is at the connection between the esophagus and the stomach. The end of the tube inside the esophagus contains a sensor that measures pH, or acidity. The other end of the tube outside the body is connected to a monitor that records the pH levels for a 24- to 48-hour period. Normal activity is encouraged during the study, and a diary is kept of symptoms experienced, or activity that might be suspicious for reflux, such as gagging or coughing. It is also recommended to keep a record of the time, type, and amount of food eaten. The pH readings are evaluated and compared with the patient’s activity for that time period to help determine possible GERD triggers.

Bravo pH studies. In older children, the pH study can be done without an external wire. At the end of the upper endoscopy, the physician attaches a small capsule (approximately the same size as a pencil eraser) to the wall of the esophagus. The capsule sends information to a device outside the child’s body that records reflux events. This data collection device is about the size of a cell phone and can be attached to the child’s belt or waistband. The device needs to be within 3 feet of the patient during the 48 hours of recording time. Some patients say that they can feel the capsule while it is in place. This can cause mild, temporary discomfort for those patients. After the second day of collecting information about the child’s reflux, the Bravo capsule falls off the lining of the esophagus, travels through the gastrointestinal tract and is eventually passed in the patient’s stool. It does not have to be retrieved.

What is the treatment for GERD?

Specific treatment will be determined by your child’s doctor based on the following:

  • The child’s age, overall health and medical history
  • Extent of the disease
  • The child’s tolerance for specific medications, procedures or therapies
  • The expectations for the course of the disease
  • The family’s opinion or preference.

In many cases, GERD can be relieved through diet and lifestyle changes, under the direction of one of our specialists. We will evaluate:

  • Medications the child is taking that may irritate the lining of the stomach or esophagus.
  • Evidence of poor weight gain due to reflux.
  • The types of foods the child is eating.
  • Information about the child’s feeding and mealtime patterns.

Caregivers are encouraged to:

  • Watch their child’s food intake and limit fried and fatty foods, peppermint, chocolate, drinks with caffeine (such as colas, Mountain Dew and tea), citrus fruit and juices and tomato products.
  • Offer their child smaller portions at mealtimes, and include small snacks in-between meals if the child is hungry. Caregivers should avoid letting the child overeat. Allow him or her to let you know when he or she is hungry or full.
  • Do not allow the child to lie down or go to bed right after a meal. The evening meal should be served at least two hours before bedtime.
  • Infants with GERD should be held upright for 30 minutes after feedings.
  • If bottle-feeding, keep the nipple filled with milk so the baby does not swallow too much air while eating. Try different nipples to find one that allows the baby’s mouth to make a good seal with the nipple during feeding.
  • Adding rice cereal to feeding may be beneficial for some infants. We typically recommend adding 1 teaspoon of rice cereal per ounce of formula.
  • Burp the baby several times during bottle- or breast-feeding. The baby may reflux more often when burping with a full stomach.

Treatment may include:

Medications. If needed, our specialists may prescribe medications to help with reflux. There are medications which help decrease the amount of acid the stomach makes, which cuts down on the heartburn associated with reflux. One group of this type of medication is called “H2-blockers.” Medications in this category include famotidine (Pepcid) and ranitidine (Zantac). Another group of medications is called “proton-pump inhibitors.” Medications in this category include omeprazole (Prilosec) and lansoprazole (Prevacid). These medications are taken daily to prevent excess acid secretion in the stomach. Another type of medicine we may prescribe is one that helps the stomach empty faster. If food does not remain in the stomach as long as usual, there may be less chance of reflux occurring. A medicine in this category that can be prescribed is metoclopramide (Reglan) or a very low dose of the antibiotic erythromycin. This medicine is usually taken three to four times a day, before meals or feedings, and at bedtime.

Tube feedings. Some babies with reflux have other conditions, such as congenital heart disease or prematurity. In addition to having reflux, these babies may not be able to eat or drink very much without becoming sleepy. Other babies are not able to tolerate a normal amount of formula in the stomach without vomiting and do better if a small amount of milk was given continuously. In both of these cases, tube feedings may be recommended. Formula or breast milk is given through a tube that is placed in the nose, guided through the esophagus, and into the stomach (nasogastric tube). Nasogastric tube feedings can be given in addition to or instead of what a baby takes from a bottle.

Surgery. In severe cases of reflux, a surgical procedure called fundoplication may be performed. This operation may be recommend if the child is not gaining weight due to vomiting, has frequent, severe respiratory illnesses such as pneumonia or has severe irritation in the esophagus. Learn more about surgery at CHOC.

What is the long-term outlook for a child with GERD?

Many infants who vomit will “outgrow it” by the time they are about a year old, as the lower esophageal sphincter becomes stronger. For others, medications, lifestyle, and diet changes can minimize reflux, vomiting and heartburn.

Gastroesophageal Reflux Disease and Treatment Options

doctor checking boy's stomach

GER occurs in more than two-thirds of healthy infants, and half of these infants experience regurgitation or “spitting up” that spontaneously resolves without medication by approximately 1 year of age. When the reflux causes intolerable discomfort or complications, patients should be evaluated by a doctor for gastroesophageal reflux disease (GERD).

What is eosinophilic esophagitis?

Eosinophilic esophagitis also known as EoE, is a disease in which eosinophils (allergy cells) build up in the lining of the esophagus. Although the cause is not clear, research has shown a strong connection between food allergies and EoE.  Environmental allergens may also play a role in this disease but more research is needed. Many patients with EoE also experience gastroesophageal reflux disease (GERD). Learn more about the Eosinophilic Esophagitis Program at CHOC.