What is Gastroesophageal Reflux (GER) in Babies and Children?

What is Reflux in Children?

Reflux is a general medical term and means backflow or leakage. For example, urine coming from the kidneys to the bladder (urine bag) leaks back to the kidney, which is called Vesico-Ureteric Reflux.

Gastroesophageal reflux (GER) is the involuntary leakage of stomach contents or swallowed food into the esophagus (food pipe). In fact, it is natural for healthy children and adults to experience limited and short-term GER attacks after meals. However, when their number, duration and degree increase, it becomes pathological. GER should not be confused with the conditions we call spitting up, vomiting and regurgitation, especially in babies.

Regurgitation is common in babies during and immediately after feeding, as they consume large amounts of milk and nutrients to support their rapid growth rates.

 

Is Gastroesophageal Reflux Pathological in Children at Any Age?

No, it is not. If there is no other underlying disease in children, GER is considered physiological from birth until the age of 1.5-2. However, if it continues after the age of 2 and especially causes additional clinical complaints and developmental delay, this condition is pathological and is defined as Gastroesophageal Reflux Disease (GERD) and requires treatment. GER symptoms disappear in many babies by the age of 1. After this age, GER may continue only in around 5%.

What Causes Gastroesophageal Reflux in Babies?

In newborns and babies under the age of 2, the anatomical structure we call the lower esophageal sphincter is not fully formed and developed. In addition, intra-abdominal and chest cavity pressures are not fully formed.

The length of the esophagus in babies is not sufficiently formed and is quite short. In addition, the stomach is small and since its muscle structure is not fully mature, it does not stretch easily. In short, the mechanisms that prevent reflux are not fully mature.

It may be related to the baby's feeding method and gastroesophageal reflux. For example, using ready-made formulas prepared with the wrong density or feeding the formula too quickly may cause gastroesophageal reflux.

Due to all these reasons, non-pathological GER occurs in babies.

Are There Any Other Causes of Reflux, Especially in Older Children, Apart from the Reasons Above?

Yes, there are.

Causes such as obesity, overeating, spicy foods, caffeine, and some medications that increase the pressure under the valve can also cause GER. There is also a familial tendency. However, it is not hereditary.

Are There Any Diseases That Increase Gastroesophageal Reflux in Children?

Various congenital anomalies lead to an increase in the frequency of gastroesophageal reflux disease. Neurological Diseases (Cerebral palsy, meningomyelocele, etc.), congenital diaphragmatic hernia, esophageal atresia, omphalocele, and gastroschisis are examples of these.

What Are the Mechanisms That Prevent Gastroesophageal Reflux in Babies and Children?

The length of the esophagus in the abdomen, intra-abdominal pressure, intra-thoracic pressure, the contraction ability of the esophagus, the angle of sensation (the angle at the junction of the esophagus and stomach), the pressure zone at the lower end of the esophagus and normal emptying of the stomach are the main mechanisms that prevent reflux.

 

What is the Importance of Gastroesophageal Reflux in Infants and Children?

While the most important problem caused by GER in adults is digestive tract damage (esophagitis), GER in childhood causes more frequent growth and developmental delays, as well as lower and upper respiratory tract diseases, and anemia, which cannot be corrected in later ages if the relationship with GER is not considered early and GER treatment is not given. Therefore, it is even more important to recognize and effectively treat Gastroesophageal Reflux before permanent complications develop.

What is the Frequency of Gastroesophageal Reflux in Infants and Children? At What Ages Does It Often Start to Be Seen?

According to evaluations based on clinical symptoms, GER is seen in 1-8% of infants and young children and 7% of adults.

What are the Symptoms of Gastroesophageal Reflux in Children?

GERD signs and symptoms change with age. In infants, it usually occurs with developmental failure, vomiting and recurrent respiratory tract complaints.

Children may experience abdominal pain, chest pain, and more frequent vomiting, difficulty swallowing, and developmental delay.

Neurologically disabled children have a higher rate of GERD than neurologically normal children, and may require treatment for GERD during the placement of a feeding tube.

Occult bleeding from the damaged area of ​​the digestive tract may lead to anemia due to iron deficiency in the clinic. Tooth enamel disorders and a tendency to cavities may also develop in the mouth as the stomach content reaches high levels. Pauses in breathing, recurrent otitis media, and tonsillitis involving the upper airways in young children may be associated with GERD.

Clinical Symptoms of GER in Babies and Children;

• Frequent Vomiting
• Failure to gain weight and developmental delay
• Excessive crying
• Sleep disturbance
• Colic
• Frequent or continuous cough or wheezing
• Refusal to eat or malnutrition
• A burning sensation in the stomach, gas, abdominal pain, crying spells that develop following eating
• Returning of stomach contents to the mouth and swallowing again
• A bitter taste in the mouth, especially in the morning
• Frequent chest, ear and sinus infections
• Recurrent pneumonia
• Anemia

Are There Complications of Gastroesophageal Reflux in Children?

If reflux is not treated, it can progress with serious complications. For example, it can cause weight loss, difficulty swallowing (dysphagia), a feeling of choking, cough, hoarseness, bleeding, stenosis in the esophagus, and precancerous (pre-cancerous) changes in the mucosa in adulthood (Barrett esophagus).

The most important complications of GERD occurring in childhood are growth and developmental delay, recurrent otitis media and tonsillitis, permanent upper and lower airway damage, esophagitis, gastrointestinal bleeding and, less commonly, Barrett's esophagus.

How is GER Diagnosed in Babies and Children?

The diagnosis is made with history and physical examination and confirmed with a number of tests. The diagnostic approach in GER varies according to age groups and the presence of different symptoms, which were explained above.

The most important thing in diagnosing the disease is that the family, especially the physicians, consider the disease.

We can list the tests performed for the diagnosis of reflux as follows;

Barium esophagus stomach duodenum radiograph: This is a test in which the radiologist examines the travel of barium down the esophagus and stomach under fluoroscopy while the patient drinks barium. It also gives us information about the time of stomach emptying and anatomical details.

Gastroscopy: The endoscope is a flexible tube with a light on its tip. The esophagus can be examined while this tube is advanced from the mouth to the esophagus and stomach. This procedure is performed by sedating the patient. With esophagoscopy, a biopsy can be performed from the area showing mucosal damage in the esophagus.

Esophageal manometer and pH meter: A very thin flexible tube is sent through the nose and into the stomach through the esophagus to measure the pressures and the amount of acid rising. This gives us information about the number of refluxes and the duration of reflux.

What can be done to cope with gastroesophageal reflux disease in babies and children?

• Burp your baby in the middle and at the end of feeding.
• Keep your baby in an upright position for about 20 minutes after feeding to help digestion.
• If you are feeding ready-made formula, follow the recommendations for preparing the formula, especially your doctor's recommendations.
• Try to feed smaller amounts more frequently, but be careful not to exceed or reduce the total amount of formula given daily.
• Sometimes, parental tension can worsen gastroesophageal reflux. If you feel that this is the case, ask your doctor or nurse for support.

You can get more detailed information about feeding and gas problems from your baby's Specialist Pediatrician.

What are the Treatment Methods for Gastroesophageal Reflux Disease in Babies and Children?

GERD is treated with a stepwise approach according to the existing symptoms. It can often be treated with the growth of the baby, correction of eating habits and lifestyle, weight control in overweight children, and some drugs that regulate stomach and bowel movements after meals.

Choosing loose clothing, staying away from coffee, chocolate and fatty foods that trigger reflux attacks, and avoiding excessive food consumption at meals are beneficial.

However, if there are clinical and laboratory findings suggesting esophagitis, an acid suppressant drug, high-dose H2 receptor blocker or proton pump inhibitor should be added to the treatment regimen from the beginning.

Drinking milk with a bottle while lying down or falling asleep, which is a habit especially for infants and play children, is an important factor that facilitates the development of GERD.

Treatment recommendations for babies;

• Raising the baby's back (reflux pillows can be used for this purpose)
• Keeping the baby in an upright position for 20 minutes after feeding
• Feeding at frequent intervals and in small portions
• Feeding with thicker foods

Treatment suggestions for children;

• Raising the head of the bed
• Leaving at least two hours between eating and sleeping
• Providing feeding with small portions and at frequent intervals instead of three main meals
• Avoiding overeating
• Avoiding foods that may increase reflux, such as fatty, spicy foods and caffeine

In Which Cases Should Surgical Treatment Options Be Considered in Gastroesophageal Reflux Disease in Infants and Children?

Especially in patients with neurological diseases and difficulty swallowing, gastrostomy and antireflux surgery should be considered. In addition, surgery should be considered and performed in patients with underlying congenital diseases.

In patients without neurological or other diseases, surgery should be considered and performed in patients with frequent respiratory complaints, developmental delay and anemia, and stenosis in the esophagus despite behavioral and drug treatment.

What Are the Surgical Techniques in Gastroesophageal Reflux Disease in Infants and Children?

The aim of surgery for GERD is to prevent the escape from the stomach to the esophagus without preventing the passage of food from the esophagus to the stomach. Many surgical methods have been defined for this purpose. The method to be applied depends on the patient's condition and the surgeon's choice.

In general, the fundus of the stomach is wrapped around the esophagus, this can be complete or partial, and the length of the esophagus in the abdomen is extended.

 

Surgical options can be performed as open surgery or laparoscopic. Which method will be used depends on the patient's condition and the doctor's experience and choice.

Can Laparoscopic Treatment in Gastro Esophageal Reflux Disease Be Applied to Children? Does It Have Advantages?

Laparoscopic treatment of GERD in children is based on videoscopic technology and developments. It has become possible with the development of devices designed especially for babies and children. In fact, today, the laparoscopic method has become the gold standard for this surgery.

Its advantages may include reduced hospital stay and shorter wound healing. However, when performed by inexperienced people, the surgery may be longer and mortality and morbidity may be high.

After laparoscopic surgery, the patient stays in the hospital for 2-3 days and is fed orally the next day. There is no need for the nutritional regimens and social precautions that patients have taken beforehand after the surgery. There is a long-term success rate of over 90% after surgeries performed by experienced surgeons on the subject.

Does Laparoscopic (Closed) Surgery Have Advantages Over Open Surgery?

Yes, there are, the main advantages are listed below;

• Less pain
• Less bleeding
• Less infection
• Less surgical scars or even no scars
• Shorter hospital stay
• Faster and easier recovery
• Quicker return to daily activities

How is Laparoscopic (Closed) GERD Surgery Performed?

Carbon dioxide (CO2) gas is injected into the abdomen through the tiny holes opened in the abdomen to create a large area in the abdomen and the abdomen is inflated. New tubes are placed by making 3 0.3-1 cm wide incisions in the appropriate places on the skin, one of which is from the belly button. The planned surgery is performed by placing “long surgical instruments” through these newly added tubes.

However, it should not be forgotten that Laparoscopy can cause more serious complications when performed by inactive people.

What is Done Before GERD Surgery?

First of all, a good history should be taken and a general physical examination should be performed. Then, the family (mother and father) should be well informed about the process, that is, before the surgery, during the surgery and after. If the child is older, the child is also included in this. Some tests are performed, these tests are not general and are determined according to the patient. The patient is also seen by the anesthesiologist, the family and the child are informed about the anesthesia process that will be experienced. The patient is fasted for 4 hours before the surgery.

Are There Other Methods Used in the Treatment of Gastroesophageal Reflux Disease?

There are Stretta and Endoplication and Ezofix methods that have been used in adults in recent years, but their application in children is not yet sufficient.

Does Gastroesophageal Reflux Disease Recur?

Recurrence after surgery is less than 5% in the series of experienced surgeons.

Can Gastrostomy Be Opened Along with GERD Surgery?

Yes, it can be opened. Gastrostomy can be easily opened in both cases, whether the surgery is open or laparoscopic.

Is There a Relationship Between Gastroesophageal Reflux Disease and Esophageal Cancer?

There is no such situation in infants and children. However, if it is not treated, it can be seen in adulthood. There is a relationship between reflux disease and lower end cancers of the esophagus in adults. However, the probability of cancer development is extremely low and occurs after some preliminary findings. The acid and especially bile that constantly leaks from the stomach into the esophagus causes changes in the lining of the esophagus. In order to protect the cells of the esophagus from the damage caused by acid and bile, they try to be like the acid and bile resistant cells of the stomach and imitate them. These imitation cells are called "Barret". After the changes in the Barrett cells, pre-cancerous "dysplasia" cells emerge. Barrett's esophagus develops in 10% of reflux patients.

Dysplasia can also be seen in 3-7% of these patients. Patients with Barrett's esophagus need to be followed up with a biopsy annually or at least every 3 years. Continuous medication use does not prevent cancer development 100% in cases with Barrett's Esophagus. The most important reason for this is that although acid leakage is prevented with medication, contact with bile cannot be prevented. Surgical treatment provides a more protective treatment by preventing both acid and bile from leaking from the stomach into the esophagus.

What Kind of Problems Can Be Encountered After Surgery in Gastroesophageal Reflux?

When performed by experienced people, the results are generally very good. However, some problems may be encountered, especially in patients with neurological problems. These may include; failure of the surgery and recurrence of reflux, narrowing and difficulty swallowing at the surgical site, paraesophageal hernia, wound infection, bleeding, intestinal adhesions and a condition called Gas Blotting due to the patient not being able to burp.

*** The information provided here, the content of the website, is designed to inform visitors, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. The patient should definitely be examined by a pediatric surgeon on the subject, and a decision should be made by consulting him/her and consulting his/her personal knowledge.