Judy J. Davis, M.D, F.A.A.P.
7405 N. Fresno Street
Fresno, CA 93720
(559) 438-8400 Fax (559) 438-1174
Gastroesophageal Reflux in Children
Gastroesophageal reflux: (which causes recurrent vomiting or regurgitation) is a
common problem and is related to transient relaxations of the lower esophageal
sphincter. The lower esophageal sphincter is found between the bottom part of the
esophagus and the upper part of the stomach and acts to prevent stomach contents
including acid from washing up into the esophagus. When this sphincter does not work
properly or when food does not empty out of the stomach normally, vomiting,
regurgitation or reflux can occur. In most children the recurrent vomiting is not
detrimental to normal growth and development. However, some children develop
complications of reflux and they can include irritability, abdominal and chest pain due to
irritation of the esophagus from the stomach acid (esophagitis). Poor growth can also
develop from reflux due to food being lost through vomiting, or from poor appetite due to
pain experienced with reflux (which is usually worse after eating). Reflux may result in
anemia due to blood loss from esophagitis. Other complications or reflux include apnea,
recurrent pneumonia, bronchitis and asthma from stomach contents washing up into the
esophagus and aspirated into the airway (trachea and bronchi), recurrent ear infections,
recurrent sinusitis, recurrent sore throat, cavities and hoarseness.
A variety of tests can be used in order to diagnose gastroesophageal reflux. These
include an x-ray study called a barium swallow or upper GI, which allows the physician
to evaluate the anatomy of the esophagus, stomach, and upper intestine to rule out
other causes of recurrent vomiting besides reflux. A more sensitive method to rule out
reflux is the pH probe which measures the amount of time the esophagus is exposed to
an acid environment over a 24 hour period. The pH probe study is sometimes preceded
by esophageal manometry which helps locate the lower esophageal sphincter, located
between the esophagus and stomach, and also gives some information on how well the
esophagus and sphincter perform. Occasionally, a gastric emptying time study is done in
order to assess whether the stomach empties more slowly than normal, as well as
whether stomach contents are refluxed into the esophagus or if aspiration of stomach
contents into the lungs occurs. In most cases, these tests can be done on an outpatient
basis. If any of the above studies identify that gastroesophageal reflux is present,
endoscopy may be done to rule out esophagitis. Endoscopy allows the physician to look
directly at the esophageal tissue and obtain tissue samples for evaluation of esophageal
inflammation under the microscope.
After gastroesophageal reflux has been diagnosed, medical therapy may be instituted.
This could include metoclopramide (Reglan) or urecholine Bethanechol), which tightens
the lower esophageal sphincter and improves gastric emptying. Metoclopramide can
cause side effects of sleepiness and irritability. Rarely, it causes stiffening of the tongue,
back and neck muscles. If stiffening occurs, stop the metoclopramide and take
diphenhydramine (Benadryl)____ every six hours for 24 hours. Metoclopramide can also
cause movement disorders which may be permanent. These medications should be
given 20-30 minutes before feedings to be most effective. Bethanechol should not be
given to children with asthma, as it can worsen asthma symptoms. Reglan should
not be given to children with seizures, as it can worsen seizure activity. These
medications are not as effective in reducing reflux symptoms as the medications
that decrease stomach acid production.
Agents that stop stomach acid production may be necessary. These include cimetidine
(Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), omeprazole
(Prilosec, Zegerid), rabeprazole (Aciphex), esomeprazole (Nexium), lansoprazole
(Prevacid), pantoprazole (Protonix) and dexlansoprazole (Kapidex). Less often, antacids
such as Maalox and Mylanta are used. These medicines are used because they
increase the healing rate of esophagitis by decreasing the acidity of the stomach
contents and prevent the pain that stomach acid causes when it goes up into the
esophagus.
There are a very small number of children with gastroesophageal reflux who do not
respond to medical management. These children may need surgery to tighten the
sphincter between the stomach and esophagus to prevent reflux and its complications.
The surgery is called a fundoplication. Unfortunately, the surgery doesn’t last forever and
reflux will recur in most people.
In summary, gastroesophageal reflux is a very common problem in children and 95% of
those children are successfully managed with conservative measures and various
medications and only a small fraction, approximately, 5% require surgery. If your child
does require medical management for his/her gastroesophageal reflux, he/she will be
seen in the clinic on a regular basis and monitored for appropriate weight gain and
development, evidence of irritability and sleeplessness, pain, anemia and pulmonary
problems including apnea, asthma and recurrent pneumonia. Repeating pH probe
studies and endoscopy may be necessary to ascertain the effectiveness of medical
therapy.
If this handout has not answered all of your questions, please call our office at (559)4388400.
Judy Davis, MD, FAAP
Fellow American Academy of Pediatrics
Fellow Sub-Board American Academy of Pediatric Gastroenterology
American Board of Nutrition
Clinical Professor, Department of Pediatrics, University of California, San Francisco
revised 11/09