Gastrointestinal Conditions. Reflux
What is GERD?
Gastroesophageal reflux disease (GERD) is a digestive disorder that is caused by gastric acid flowing 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.

GER is very common in infants, though it can occur 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 in 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 gastroesophageal reflux from time to time. If you have ever burped and had an acid taste in your mouth,
you have 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 have the lower esophageal sphincter (LES) relax when it should remain shut. 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 problems 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, the following:

high-fat foods

Other foods increase acid production in the stomach, including:

citrus foods
tomatoes and tomato sauces
Why is gastroesophageal reflux (GERD) a concern?
Some infants and children who have gastroesophageal reflux may not vomit, but may still have stomach contents move
up the esophagus and spill over into the windpipe. This can cause asthma, pneumonia, and possibly even SIDS (sudden
infant death syndrome).

Infants and children with GERD who vomit frequently may not gain weight and grow normally. Inflammation (esophagitis)
or ulcers (sores) can form in the esophagus due to contact with stomach acid. These can be painful and also may bleed,
leading to anemia (too few red blood cells in the bloodstream). Esophageal narrowing (stricture) and Barrett's esophagus
(abnormal cells in the esophageal lining) are long-term complications from inflammation.

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 can also result in heartburn. The following are other common
symptoms of GERD. However, each child may experience symptoms differently. Symptoms may include:

refusal to eat
fussiness around mealtimes
frequent vomiting
frequent cough
coughing fits at night
frequent upper respiratory infections (colds)
rattling in the chest
frequent sore throats in the morning
sour taste in the mouth
The symptoms of GERD may resemble other conditions or medical problems. Consult your child's physician for a

How is GERD diagnosed?
Your child's physician will perform a physical examination and obtain a medical history. Diagnostic procedures that may
be done to help evaluate GERD include:

chest x-ray - a diagnostic test to look for evidence of aspiration.
upper GI (gastrointestinal) series - a diagnostic test that examines the organs of the upper part of the digestive system:
the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium (a metallic,
chemical, chalky, liquid used to coat the inside of organs so that they will show up on an x-ray) is swallowed. X-rays are
then taken to evaluate the digestive organs.
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
esophageal manometric studies
pH testing
gastric emptying studies

Treatment for GERD:
Specific treatment will be determined by your physician based on the following:

your  age, overall health, and medical history
extent of the disease
your  tolerance for specific medications, procedures, or therapies
the expectations for the course of the disease
your opinion or preference

In many cases, GERD can be relieved through diet and lifestyle changes, under the direction of your physician. Some
ways to better manage GERD symptoms include the following:

Ask your physician to profile any of the medications he/she is taking - some may irritate the lining of the stomach or
Watch yours food intake - 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 you smaller portions at mealtimes, and include small snacks in-between meals if you are hungry. Avoid letting
yourself  overeat. Allow him/her to let you know when he/she is hungry or full.
If youare overweight, consult  physician to set weight loss goals.
Do not allow yourself to lie down or go to bed right after a meal. Serve the evening meal early - at least two hours before

For a child
After feedings, place your infant on his/her stomach with the upper body elevated at least 30° F, or hold him/her in a
sitting position in your lap for 30 minutes.
If bottle-feeding, keep the nipple filled with milk so your infant does not swallow too much air while eating. Try different
nipples to find one that allows your baby's mouth to make a good seal with the nipple during feeding.
Adding rice cereal to feeding may be beneficial for some infants.
Burp your baby several times during bottle or breast feeding. Your child may reflux more often when burping with a full

Treatment may include:

If needed, your child's physician may prescribe medications to help with reflux. There are medications which help
decrease the amount of acid the stomach makes, which, in turn, will cut down on the heartburn associated with reflux.
One group of this type of medication is called "H2-blockers".Medications in this category include cimetidine (Tagamet ®)
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 your child's physician may prescribe 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 ®). This medicine is usually taken three to four times a day, before meals or
feedings and at bedtime.

calorie supplements
Some infants with reflux will not be able to gain weight due to frequent vomiting. Your child's physician may recommend
the following:
adding rice cereal to baby formula
providing your infant with more calories by adding a prescribed supplement (such as Polycose™ or Moducal™) to
formula or breast milk to make the milk higher in calories than normal
change formula to milk/soy free formula if allergy is suspected
tube feedings
Some babies with reflux have other conditions that make them tired, such as congenital heart disease or prematurity. In
addition to having reflux, these babies may not be able to drink very much without becoming sleepy. Other babies are not
able to tolerate a normal amount of formula in the stomach without vomiting, and would 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. Nasoduodenal tubes
can also be used to bypass the stomach.
In severe cases of reflux, a surgical procedure called fundoplication may be performed. Your physician may recommend
this operation if your child is not gaining weight due to vomiting, has frequent respiratory problems, or has severe
irritation in the esophagus. This procedure is usually done laparoscopically, which means that pain in minimized and the
recovery time is faster after surgery. Small incisions are made in the abdomen, and a small tube with a camera on the
end is placed into one of the incisions to look inside. The surgical instruments are placed through the other incisions
while the surgeon looks at a video monitor to see the stomach and other organs. The top portion of the stomach is
wrapped around the esophagus, creating a tight band that greatly decreases reflux.

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.

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