Acid Reflux | Symptoms | Treatment - By Dr. Arun Aggarwal

What is acid reflux?

When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure. The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis. Acid reflux (also called "gastroesophageal reflux" or just "reflux") is when the acid that is normally in the stomach backs up into the esophagus. Gastroesophageal reflux (GER) is the medical term for spitting up.

A small amount of acid reflux is normal. Healthy babies often have reflux, and spit up milk or formula after eating. This does not usually hurt them, and most babies grow out of it without treatment. But if the reflux happens frequently, it can cause problems such as esophagitis, nutritional compromise, or respiratory complications. Reflux that has become more serious is called "gastroesophageal reflux disease," or GERD.

Reflux is a normal process that occurs in healthy infants, children, and adults. As the infant grows and the angle of the stomach and esophagus changes, reflux naturally becomes less frequent. Spitting up disappears in over half of infants by 10 months of age, 80 percent by 18 months, and 98 percent by two years of age. Uncomplicated reflux does not usually bother the infant, has a low risk of long-term complications, and does not usually require treatment.

Children with certain health issues have a higher risk of getting reflux. These include children with autism spectrum, Down syndrome, cerebral palsy, or other problems with the brain or spinal cord. Children who are overweight also are more likely to have reflux.

Although most infants with GER disease improve as they grow, some children have symptoms later in childhood. Infants who have colic or who are unusually irritable should have a basic evaluation by a health care provider, but in most cases, they do not have GERD.

Uncomplicated GER

Infants who spit up frequently but who feed well, gain weight normally, and are not unusually irritable are usually considered to have "uncomplicated" reflux. These infants are sometimes referred to as "happy spitters." In this group, spitting up is a natural consequence of the baby's anatomy, because the short esophagus and small stomach allow liquid to escape from the stomach easily. Burping frequently during feeding and limiting activity after feeding may reduce the frequency and amount of spitting up.

GERD

Reflux becomes GERD when acid in the reflux causes a problem such as a chronic cough, failure to grow, or irritation/injury to the esophagus. This only occurs in a small percentage of infants who spit up frequently. The amount of reflux required to cause injury varies. In general, damage to the esophagus is more likely to occur when acid refluxes frequently, there is a large amount of reflux, or the esophagus is unable to clear away the acid quickly.

Some of the signs or symptoms that may indicate GERD include refusing to eat, frequently crying or arching the neck and back as if in pain, choking while spitting up, forceful or projectile vomiting, spitting up blood, frequent coughing, or not gaining weight. These behaviors are not normal and further testing is recommended to determine if GERD (or another condition) is the cause.

It is often difficult to know if an infant is in pain. In general, an infant who is crying for "normal" reasons can be consoled by comforting, distraction, or seeing to the child's needs (hunger, sleep, or a diaper change). Parents who are concerned about their infant's crying should see a pediatric gastroenterologist to discuss their concerns and possible management strategies.

What are the symptoms of acid reflux?

Preschool children with acid reflux might:

• Vomit
• Taste stomach acid in the mouth, or feel it in the throat
• Not want to eat
• Lose weight

Older children or adolescents with acid reflux might:

• Taste stomach acid in the mouth, or feel it in the throat
• Have an upset stomach
• Feel burning in the chest (known as "heartburn")
• Have trouble swallowing

If your baby has GERD, the symptoms might include:

• Refusing to eat
• Crying and arching the back, as if in pain
• Choking on spit-up
• Vomiting forcefully
• Not gaining weight normally

Should my child see a doctor?

 Yes. If you think your child might have acid reflux, talk to his or her doctor before you try any treatments. He or she can suggest ways to help relieve symptoms. He or she might also do tests to figure out if your child's symptoms are caused by reflux or something else. It’s best to see a Pediatric Gastroenterologist for these conditions.
Take your child to see a Pediatric Gastroenterologist right away if he or she:

• Has trouble swallowing, or feels as though food gets "stuck" on the way down
• Loses weight
• Has chest pain
• Chokes when he or she eats
• Vomits blood

Reflux Diagnosis

If a child is suspected of having GERD, the first step in the evaluation is a complete medical history and physical examination. The need for further testing depends upon what is found, and may include one or more of the following:

• Laboratory testing (blood and/orurine tests)
• An x-ray study to evaluate how well the infant swallows and to evaluate the anatomy of the stomach (modified barium swallow)
• A procedure, called upper endoscopy, to view the lining of the esophagus

Is there anything a parent can do to help the child feel better?

zes. There are some things that might help with acid reflux, depending on your child's age and symptoms. Your child's Pediatric Gastroenterologist might suggest that you:

• Avoid giving your child foods that make symptoms worse (examples include chocolate, peppermint, and fatty foods)
• Raise the head of your child's bed by 6 to 8 inches (for example, by putting blocks of wood or rubber under 2 legs of the bed or a Styrofoam wedge under the mattress). Do notraise the head of an infant's crib or bed.
• Help your child to lose weight, if he or she is overweight (ask your child's doctor for advice on how to do this)
• Keep your child away from cigarette smoke
• Have your child avoid lying down for a few hours after a meal

How is reflux treated?

1. Keeping the baby upright after eating – Your baby might spit up less often if you calmly hold him or her up on your shoulder for 20 to 30 minutes after a feeding, instead of putting him or her in a sitting or lying position. Putting the baby in an infant seat (such as a car seat) right after feeding does not help with reflux, and can actually make it worse. Also, don't try to get your baby to eat when he or she doesn't want to. Always put your baby to sleep on his or her back (not the side or stomach), whether or not he or she has acid reflux.
2. Quit smoking – If you smoke, or if anyone in your house smokes, this can make your baby's reflux worse and can cause other health problems for babies and children.
3. Thickened feeds –Thickening formula or expressed breast milk may help to reduce the frequency of acid reflux. For babies under three months of age, or those with allergies, a consultation with the child's healthcare provider before thickening feeds or changing formulas is advised. Infant cereal is usually used as the thickening agent (rice starch, carob flour, or locust bean gum may be used). Oat infant cereal is a good choice for most babies. Be sure to check the ingredients in the infant cereal as some brands contain soy protein to which the infant may be intolerant. To thicken the feed, one ounce (30 mL) of formula or expressed breast milk is usually combined with up to one tablespoon of infant cereal. The nipple of the bottle may need to be made larger by cross-cutting it, to allow the thickened liquid to pass. Use caution when the hole in the nipple is larger because the child can choke if the formula comes out too fast. Nipples that allow for adjusted flow are also available. For formula-fed infants, premixed "antireflux" formulas also are available, which contain rice starch to thicken the formula. Women who breastfeed are encouraged to continue doing so; an infant should not be switched to formula for the purpose of thickening the feeds. Breastfeeding may reduce the risk of reflux in infants.
4. A milk-free and soy-free diet – Some babies have trouble digesting cow's milk or products made with soy. Your baby's doctor might suggest that you try removing milk and soy from the baby's diet. If you breastfeed your baby, you can try removing all milk and soy from your diet, too. Then see if your baby's acid reflux improves after a few weeks. If your baby drinks formula, there are special brands available that do not contain cow's milk or soy. Most babies who have trouble with milk or soy outgrow the problem by the time they are 1 year old.
5. Most times, acid reflux symptoms can be treated with medicines. There are 3 main types of medicines that can help:
   1. Antacids can relieve mild symptoms, but they work only for a short time.
   2. Histamine blockers are stronger and last longer than antacids.
   3. Proton pump inhibitors are the most effective medicines in treating GERD.

All of these medicines, even antacids, can cause side effects and are not recommended for infants unless you talk to your child's doctor first.

6. Few children need surgery to treat their GERD. This is more likely in children who have a problem with the brain or spinal cord (such as cerebral palsy), and if the GERD is causing problems like pneumonia.

OUTCOMES FOR CHILDREN WITH REFLUX

For most babies with acid reflux, symptoms go away by one year of age and do not recur later in life. Infants with symptoms that last for more than three months are more likely to have heartburn later in childhood.