This article discusses gastro-oesophageal refluxBackflow of a bodily fluid in the wrong direction disease in children and outlines the different treatment options that are available. This article will be of help to any parents or carers whose child appears to have problems with normal gastro-oesophageal reflux.
Gastro-oesophageal reflux (GOR) occurs when contents from the stomachthe organ or the body where food is stored and broken down travel back into the gullet (oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach.). GOR is a very common and harmless thing to see in newborn babies and infants but as the child grows and matures it improves. Many parents will have experienced frequent “positing” in the early life of their baby that then resolves as they grow. Sometimes the stomach content comes out of the mouth and be seen as vomitingExpusion of the contents of the stomach through the mouth. but not all vomiting is abnormal or the result of GOR. Reflux is a naturally occurring event in all people but when it leads to complications it is called gastro-oesophageal reflux disease (GORD).
The stomach produces acid to help digest food. The stomach is used to having acid within it but the gullet is not. Exposure of the lining of the gullet to acid can lead to irritation, bleeding and in prolonged cases scarring and narrowing of the gullet leading to difficulty with swallowing. Adults and older children can experience the discomfort of acid in the gullet and this is referred to as indigestionDiscomfort after eating. or heart burn. Children may not be able to express this but a symptom of GORD in infants may be distress or in discomfort especially after meal times.
GORD can also cause problems with the lungs in children. This can cause or worsen rare forms of asthmaA respiratory disease featuring attacks of breathlessness and wheezing due to inflammation and narrowing of the upper airways. There is often an allergic component. or lead to repeated lung infections especially if the child’s swallowing mechanism does not work normally. GORD can rarely be so severe that the child can’t keep enough of its meal in its tummy and thus fail to grow normally. Inability to keep medicines in the tummy may also make it difficult to effectively treat medical conditions such as epilepsyA tendency to have recurrent seizures.. Acid reflux into the mouth can lead to bad breath and attack the enamel of the back teeth leading to premature tooth decay.
There is natural resistanceThe ability of a microbe, such as a type of bacteria, to resist the effects of antibiotics or other drugs. in the bottom of the gullet to prevent GOR occurring. In babies this resistance is low but matures with time. In some children reflux can occur because of certain forms of cerebral palsyA disorder of posture and movement resulting from damage to a child's developing brain before, during or immediately after birth. that affect the natural mechanism and working of the gullet and stomach. Children who have allergies that affect the intestineThe section of gut, or gastrointestinal tract, from the stomach to the anus. can also have GORD as a symptom. Some children have medical conditions that are known to have a high rate of GORD (e.g. cystic fibrosisA hereditary disease associated with the obstruction of various glands and organs, including the intestinal glands, the pancreas and the airways (bronchi).). Some children with no other medical condition have weakness in the muscleTissue made up of cells that can contract to bring about movement. at the end of the gullet that does not mature with time. Often no cause for this can be found.
If you are concerned about any of the above symptoms you should see your health visitor or family doctor. They will discuss the symptoms with you. They may suggest some simple treatment with you or they may decide that it would be sensible to refer you to a paediatrician for further assessment.
Special investigations are usually not needed and your doctor or paediatrician will be happy with the diagnosisThe process of determining which condition a patient may have. and suggest treatment based on your child’s symptoms.
However, further investigations may be needed if:
Symptoms are severe.
There are chest symptoms which are difficult to treat and GORD may be a possible cause.
There is no improvement with medication and surgery may be being considered.
The investigations that are used to diagnose GORD include:
The radiology doctor will ask your child to drink (or have through a tube if they are unable to drink) a harmless liquid which, when x-rays are taken, shows the inside of the gullet and stomach. If GOR occurs the doctors can see the contrast travelling back into the gullet.
This involves inserting a tube into the child’s gullet that remains in place for 24 hours. This measures acid travelling back into the gullet and will establish how much reflux is occurring. A newer technique called impedance can now measure any liquid that travels back from the stomach regardless of whether it is acid or not.
The doctor may need to see the lining of the gullet to check for damage and irritation. This is done with a flexible camera. Your child will need to come to hospital and have this procedure performed under anaestheticA medication that reduces sensation. or deep sedation.
Some simple manoeuvres can often make a significant difference in terms of making GOR better. These are as follows:
Ensuring you have winded your baby as effectively as you can.
Avoiding excessive movement of your baby after feeds.
Slight elevation of the head end of the cot when you baby is asleep.
Using some special formulas that are designed for GOR in babies.
Some simple medicines can chemically neutralise acid in the stomach and thicken the stomach content slightly, which helps to prevent GOR.
Some medicines try and make the stomach empty its contents into the intestine faster so lessening the liquid in the stomach that can reflux (e.g. Domperidone).
Some medicines act on cells in the lining of the stomach to make them produce less acid (e.g. Ranitidine, Omeprazole).
Your paediatrician may suggest other forms of drug treatment if a specific cause of the GORD has been found.
Fortunately surgery is required in only a very small number of children. Your paediatrician may consider referring your child to a paediatric surgeon to consider surgery if:
Your child’s symptoms show no signs of improvement and they are on the highest doses of the medications.
Your child is experiencing severe chest problems that in rare cases can be life threatening.
Your child’s symptoms of GORD may be potentially life long in which case surgery can be considered as an alternative to taking drugs for years to come.
The most common operation that is performed for GORD in children is called a Nissen Fundoplication. This involves wrapping the top part of the stomach around the lower part of the gullet to form a type of one-way valveA structure that allows fluid to flow in one direction only, preventing backflow.. Children, if they are able, can still swallow normally but when things have reached the stomach they cannot reflux back into the gullet (Figure 1). It is now almost exclusively performed in infants and children with key-hole surgery. Figure 2 shows where the tiny scars are normally situated on the tummy. Recovery is quick and reliable and most children can be discharged within 3 to 4 days after the operation. Check with your surgeon to ensure that he has experience with key-hole surgery for this operation.
Ask your surgeon to go through the risks and benefits of the surgery with you. They should mention the following things:
Children will not be able to be sick after the surgery and usually can’t burp very well. They should avoid fizzy drinks.
Children may have some early difficulty in swallowing that settles after surgery. If it is prolonged further treatment may be required.
Children have slightly smaller stomachs after the surgery and may prefer to have smaller, more regular meals.
It is known that the valve mechanism can weaken with time and a small number of children may need to have the operation performed again to regain control of the GORD.
You should ask your surgeon to discuss alternative procedures that, in a very small number of children, may be possible.