Reflux occurs when stomach (gastric) contents back up from the stomach into the esophagus, the tube that connects the mouth to the stomach. More than half of all infants experience episodes of reflux during the first three months of life, according to the National Institutes of Health. In addition, up to 7 million U.S. children and teenagers in the United States experience occasional problems with reflux.

Reflux occurs when the lower esophageal sphincter (LES), which separates the esophagus and stomach, does not close properly and/or is weak. This allows gastric contents to flow into the esophagus, causing a burning sensation in the chest or throat called heartburn. In other cases, gastric contents may be refluxed all the way up into the mouth before they are swallowed again. When stomach acid can be tasted in the back of the mouth, it is called acid indigestion.

Almost everybody experiences occasional reflux, even if they are not aware of it. However, in some cases reflux may indicate a more serious problem. Parents are urged to consult a physician if their child experiences vomiting; especially with heavy volume or projectile vomiting. Breathing problems, poor growth and weight loss due to an inability to retain food are among the other symptoms that indicate a medical problem. 

Certain factors may be more likely to trigger reflux in infants. Overfeeding babies or holding them flat instead of upright during feedings can trigger reflux. In rare cases, a child’s reflux problem may stem from a narrowing of the esophagus or a problem with the position of the intestines, a condition known as malrotation. An allergy or intolerance to milk is also a cause of reflux in some children.

Children are less likely to tolerate investigative studies that are usually performed on adults with reflux (e.g., esophageal pH monitoring). As a result, a diagnosis typically involves a physician’s judgment based on a physical examination and the child’s medical history. To rule out anatomical abnormalities, a physician may order an x-ray of the esophagus and the stomach. Children who are diagnosed with a reflux disorder may be referred to a pediatric gastroenterologist or other specialist who has expertise in treating reflux disorders.

Reflux occurs when the contents of the stomach back up into the esophagus, the tube that connects the mouth to the stomach. In some cases, this food and stomach acid also backs up into the mouth. Most infants experience episodes of reflux during the first three months of life. This is evident when babies “burp up.”

Many children also experience occasional bouts of reflux. In rare cases, older children may experience more persistent reflux. Up to 7 million children and teenagers in the United States – one out of every 10 – experience occasional problems with reflux, according to the Pediatric Adolescent Gastroesophageal Reflux Association (PAGER).

The esophagus carries food from the mouth to the stomach. The lower esophageal sphincter (LES) is a group of muscles that serves as a valve between the esophagus and stomach. When food reaches the LES, the LES relaxes and allows the food to enter the stomach. After food enters the stomach, the LES contracts to prevent food and other stomach contents from backing up into the esophagus. The sphincter also opens to release gas during burping after meals.

Reflux occurs when the LES, which separates the esophagus and stomach, does not close properly and/or is weak. The majority of reflux episodes are associated with transient lower esophageal relaxation (tLESR), in which the LES relaxes momentarily, allowing gas in the stomach to vent. This occurs in most people from time to time, particularly when the stomach is distended. Unexpected burping is an example of tLESR.

Hiatal hernia is also a well-known cause for acid reflux. However, reflux in infants often occurs because the LES is not yet fully developed, or the gastrointestinal tract is not yet fully coordinated. When the LES is weakened or remains relaxed for too long, contents of the stomach can reflux into the esophagus. The tissue lining the esophagus differs from the stomach lining and is more susceptible to acid. This causes a burning sensation in the chest or throat called heartburn.

In other cases, stomach contents may be refluxed all the way up into the mouth before they are swallowed again. When gastric acid can be tasted in the back of the mouth, it is called acid indigestion. In some people, reflux affects the vocal cords or causes stomach contents to flow into the lungs (aspiration).

Almost everybody experiences occasional reflux, even if they are not aware of it. This is normal, and episodes usually clear up on their own. Reflux may occur immediately after eating or may not appear for several hours afterward. Infants are particularly likely to experience repeated episodes of reflux, which usually fade after a child turns 1 or 2 years old. However, in some cases reflux may indicate a more serious problem.

Left untreated, reflux problems can have a significant impact on a child’s physical and emotional health. Some babies with reflux may withdraw from the world and develop unhealthy attitudes about eating, including a fear of foods. Persistent reflux can damage the lining of the esophagus. This is known as gastroesophageal reflux disease (GERD).

Some children may develop other significant health problems, feeding and nutrition problems (including poor weight gain) or breathing difficulties. Persistent reflux that continues after infancy and into childhood may also indicate a health problem.

Reflux occurs when the lower esophageal sphincter (LES), which separates the esophagus and stomach, does not close properly and/or is weak. Certain factors may be more likely to trigger reflux in infants. Overfeeding babies or holding them flat instead of upright during feedings can trigger reflux. Babies who lie down after feedings are also more susceptible to reflux. Exposure to cigarette smoke or caffeine in a mother’s breast milk can cause the LES to relax, resulting in reflux. Coughing, crying and straining can all cause reflux.

Children who experience reflux are likely to have symptoms of chest pain or heartburn if the reflux remains in the esophagus. If stomach contents travel into the mouth, hoarseness and chronic coughing may result. Irritability and sleep problems may also occur. Infants are too young to report these feelings, but other symptoms can alert parents to the possibility of reflux.

For example, infants who experience reflux typically vomit or spit up excessively after a meal because the lower esophageal sphincter opens and stomach contents travel up the esophagus and out of the mouth. Infants may cry a lot, especially after feedings, and may experience episodes in which they twist oddly, as if undergoing a seizure. Bloody stools are also common. None of these symptoms necessarily indicate a medical problem, although steps should be taken to reduce the infant’s reflux.

By the time a child is 1 or 2 years old, reflux usually subsides. Occasional bouts of reflux thereafter are not unusual, but some children may experience more significant symptoms related to reflux.

Parents are urged to consult a physician if their child experiences vomiting with heavy volume or projectile vomiting. Vomit that is green or yellow in color or that has the appearance of blood or coffee grounds also indicates a need for medical attention. Other symptoms requiring medical attention include:

• Breathing problems after vomiting or spitting up
  
  
• Irritability or refusal to feed as a result of pain
  
  
• Painful swallowing
  
  
• Poor growth and weight loss (failure to thrive) as a result of an inability to hold down food

Some children may also inhale stomach acid or food into their lungs. This is known as aspiration, and it can result in asthma, temporary cessation of breathing (apnea), slow heart rate (bradycardia) and in rare cases even death.

Acid contained in reflux that enters the mouth can damage a child’s teeth, resulting in bad breath, cavities and erosion of the tooth enamel. The inner surface of teeth closest to the tongue is most vulnerable to this erosion.

As children grow older, they may experience additional symptoms associated with reflux. These may include chronic coughing, ear pain or infection, hiccups, hoarseness, and high-pitched breathing known as stridor. Older children with reflux may also experience the following symptoms:

• Bad breath
  
  
• Behavioral issues (e.g., chronic pain causing a low tolerance for frustration)
  
  
• Coughing
  
  
• Excessive burping
  
  
• Pickiness when eating
  
  
• Restless sleep

There are no objective standards for diagnosing problems with reflux. As a result, a diagnosis typically relies on the physician’s judgment. In some cases, physicians can diagnose reflux very easily. For example, babies who regularly spit up large portions of food after meals and who fail to gain weight normally are usually diagnosed with reflux. On the other hand, reflux is sometimes trickier to diagnose, particularly in older children. Many of the symptoms associated with reflux – such as upset stomach or persistent vomiting – can be the result of an unrelated disorder.

A physician will perform a complete physical examination and compile a thorough medical history. To rule out anatomical abnormalities, a physician may order an x-ray of the esophagus and the stomach. The child may be asked to swallow barium, a chalky substance that highlights structures inside the body on x-rays and helps reveal any abnormalities.

Other tests may include:

• Endoscopy.  One of the most common tests used to evaluate the esophagus. A small tube with a light and camera (endoscope) is inserted into the esophagus, stomach and into a portion of the small intestine. This allows a physician to determine whether there is tissue damage. Samples of tissues may be taken (biopsy) to determine the extent of the damage.
  
  
• Esophageal pH monitoring. This is the most sensitive test for diagnosing reflux problems. It involves passing a thin tube through the nose and into the esophagus. The tube is attached to a small monitoring device and is worn for 24 hours. The device records how much stomach acid reaches the esophagus. There is a newer method that allows pH recording without the need for a tube through the nose (Bravo capsule device). The patient records symptoms experienced during the 24-hour period and the physician compares acid levels with symptoms. This is typically performed when an endoscopy is inconclusive or a patient continues to experience symptoms after receiving treatment.
  
  
• Esophageal manometry. Involves a device similar to the pH monitor that measures muscle contractions to determine whether the lower esophageal sphincter (LES) is functioning properly. This is typically performed when the diagnosis is unclear and surgery is being considered.

In addition, parents may be asked to keep a diary to record the child’s symptoms and any relevant details associated with them.

Gastroesophageal reflux disease (GERD) is generally diagnosed in children who have reflux that causes some measurable physical damage to the esophagus or other area of the body. A diagnosis of GERD may also be associated with significant medical problems, such as asthma, sinus or ear infections, apnea, significantly low weight gain, or inflammation of the esophagus (esophagitis).

GERD is also sometimes diagnosed solely on the basis of extreme misery that a child experiences as a result of reflux. For example, some children may experience significant pain or other discomfort from an occasional bout of reflux.

Treatment of reflux problems typically begins with making modifications to a child’s diet and lifestyle routines. Initially, a physician may suggest changes to the infant’s diet, such as smaller or more frequent feedings, or more frequent burpings (after every 1 to 2 ounces of formula, or after feeding from each breast). Parents may be urged to hold their child upright for 30 minutes following feedings. The pediatrician may also recommend thickening a baby’s meal – such as adding a tablespoon of rice cereal to 2 ounces of infant milk – to help reduce reflux.

Certain foods and beverages are known to be triggers of reflux in many children. Types of food and beverages that trigger reflux vary from child to child, but may include:

• Caffeine
• Carbonated beverages
• Citrus foods
• Chocolate
• Fried, greasy and fatty foods
• Garlic
• Onions
• Peppers
• Peppermint
• Spices
• Tomato

If food allergies or intolerances are suspected, changes to a baby’s formula may be suggested. Cow’s milk is also sometimes recommended by a physician. Mothers who are breastfeeding children with food allergies may have to avoid dairy, wheat or egg products while nursing, as well as other foods that may be triggering reflux in their child.

Breastfeeding is typically a good choice for helping a child to avoid reflux. Babies are usually able to digest mother’s milk much more easily than formula, thus reducing the risk of reflux. Breastfeeding mothers may also be urged to quit smoking or drinking caffeinated beverages to prevent these substances from affecting the infant.

Other steps can be taken to reduce a child’s risk of experiencing reflux. Parents are urged to avoid clothing their children in tight pants or diapers that put pressure on the child’s stomach. In some cases, a physician may suggest having a baby sleep on their stomach. Some babies who sleep on their backs are at risk of experiencing reflux, and choking on the stomach contents that are refluxed. However, physicians usually strongly advise against placing infants on their stomachs during sleep, as this can increase the risk of sudden infant death syndrome (SIDS), a condition in which a child under age 1 dies for no obvious reason. Therefore, parents should never place babies to sleep on their stomachs unless recommended by a physician.

Older children may be urged to eat smaller meals and to avoid eating two to three hours before bedtime. It may also help to avoid many of the foods mentioned previously, especially carbonated drinks, chocolate, caffeine and foods that are spicy, high in fat or extremely acidic. Elevating the head of the bed by 30 degrees can also help reduce reflux. Children who are obese or overweight may benefit from losing weight to lessen the pressure on the abdomen.

If these steps fail to relieve symptoms, medications may be prescribed for infants and children. These include the following:

• Antacids. Neutralize stomach acid.
  
  
• Histamine-2 blockers and proton pump inhibitors. Suppress acid production.
  
  
• Promotility drugs. Stimulate the stomach to move contents forward instead of backward. They also may tighten the lower esophageal sphincter (LES).

When dietary changes and medications fail to resolve symptoms, the child may need a surgical procedure to tighten the LES. The standard surgical procedure performed on patients with gastroesophageal reflux disease (GERD) is called Nissen fundoplication, and it is the only anti-reflux surgery performed on children, according to the Pediatric Adolescent Gastroesophageal Reflux Association (PAGER). This surgery involves wrapping the upper part of the stomach around the LES to strengthen it and prevent acid reflux. The procedure can be performed laparoscopically. A few tiny incisions are made in the abdomen and a laparoscope is inserted. A laparoscope is a thin tube with a video camera and it can be fitted with surgical instruments.

In other cases, children who fail to gain weight may require feeding of formula through a tube at night. In some cases, a port may be installed through the child’s abdominal wall to provide a constant drip of formula over a long-term basis.

Preparing questions in advance can help parents and patients to have more meaningful discussions with physicians regarding their or their child’s conditions. Parents and patients may wish to ask the doctor the following questions related to reflux and children:

1. How many children with reflux have you treated?
   
   
2. What signs might indicate that my infant has a problem with reflux?
   
   
3. How will I know whether my child’s reflux requires treatment?
   
   
4. How will you diagnose the nature of my child’s reflux problem?
   
   
5. Should I allow my infant to sleep on his/her back?
   
   
6. What treatment options are available for my child?
   
   
7. Should I change my child’s diet? If so, in what ways?
   
   
8. What are the side effects of medications when used by a child?
   
   
9. What is the best way for me to prevent or lessen my child’s reflux symptoms?
   
   
10. Will my child ever be cured of problem reflux?