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Gastroesophageal reflux

Gastroesophageal Reflux Disease (GERD; or GORD when spelling oesophageal, the BE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. . more...

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This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter (LES), transient LES relaxation, or association with a hiatal hernia. Gastric regurgitation is an extension of this process with retrograde flow into the pharynx or mouth.


Heartburn is the symptom of acid in the esophagus, characterized by a burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) – inflammatory changes in the esophageal lining (mucosa) – strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those findings. Atypical symptoms of GERD include cough, hoarseness, changes of the voice, chronic ear ache, or sinusitis. Complicatons of GERD include stricture formation, Barrett's esophagus, esophageal ulcers and possibly even lead to esophageal cancer.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients that have heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for development of GERD.


The most prominent symptom of GERD is heartburn, the sensation of burning pain in the chest coming upward towards the mouth caused by reflux of acidic contents from the stomach to the esophagus.

Patients with GERD also tend to get the feeling of a sour or salty taste at the back of their throats due to regurgitation. This can sometimes happen even if the pain of heartburn is absent.

Less common symptoms:

  • Chest pain without any of the above
  • Dysphagia (difficulty swallowing)
  • Halitosis (bad breath)
  • Regurgitation (vomit-like taste in the mouth)
  • Repeated throat clearing
  • Water brash (the sensation of a large amount of non-acid liquid due to sudden hypersecretion of saliva)


  • Strictures or scarring of esophagus (especially young children).
  • Barrett's esophagus (sometimes referred to as Barrett's Disease)
  • Esophageal cancer

Important Warning symptoms:

  • Trouble swallowing Dysphagia requires immediate medical attention
  • Vomiting blood or partially-digested blood (looks like coffee grounds) requires immediate medical attention as does digested blood in the stools.

GERD in Children

GERD is commonly overlooked in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food and bad breath are also common. Children may have one symptom or many - no single symptom is universally present in all children with GERD.


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What is the best treatment for gastroesophageal reflux and vomiting in infants?
From Journal of Family Practice, 4/1/05 by Vanessa McPherson

* Evidence-Based Answer

The literature on pediatric reflux can be divided into studies addressing clinically apparent reflux (vomiting or regurgitation) and reflux as measured by pH probe or other methods (TABLES 1 AND 2). Sodium alginate reduces vomiting and improves parents' assessment of symptoms (strength of recommendation [SOR]: B, small randomized controlled trial [RCT]). Formula thickened with rice cereal decreases the number of postprandial emesis episodes in infants with gastroesophageal reflux disease (GERD) (SOR: B, small RCT).

There are conflicting data on the effect of carob bean gum as a formula thickener and its effect on regurgitation frequency (SOR: B, small RCTs). Metoclopramide does not affect vomiting or regurgitation, but is associated with greater weight gain in infants over 3 months with reflux (SOR: B, low-quality RCTs).

Carob bean gum used as a formula thickener decreases reflux as measured by intraluminal impedance but not as measured by pH probe (SOR: B, RCT). Omeprazole and metoclopramide each improve the reflux index as measured by esophageal pH probe (SOR: B, RCT).

Evidence is conflicting for other commonly used conservative measures (such as positional changes) or other medications for symptomatic relief of infant GERD. There is very limited evidence or expert opinion regarding breastfed infants, particularly with regard to preservation of breastfeeding during therapy.

* Evidence Summary

Regurgitation ("spitting up") and gastroesophageal reflux are common in infants. In a cross-sectional survey of 948 parents of healthy infants aged 0 to 13 months, regurgitation occurred daily in half of infants from birth to 3 months old, peaked to 67% at age 4 months, and was absent in 95% by age 12 months. (1) Gastroesophageal disease (GERD) is characterized by refractory symptoms or complications (pain, irritability, vomiting, failure to thrive, dysphagia, respiratory symptoms, or esophagitis) and occurs in the minority of infants with reflux. (2) This distinguishes the "happy spitter," whose parents may simply require reassurance, from infants who require treatment.

Unfortunately, most of the available studies do not make this distinction in their subjects. Also, available data primarily regard formula-fed infants, and are insufficient to make recommendations for breastfed infants. Esophageal pH probe monitoring is the gold standard for measuring reflux in research; however, its correlation with symptoms is questionable and it is infrequently used in clinical practice. (3) Therefore, recommendations are focused primarily on treating only clinically-evident reflux (emesis and regurgitation).

Five small RCTs studied the practice of using formula thickeners (TABLES 1 AND 2). In 1 study, formula thickened with rice cereal decreased emesis episodes. (4) Two studies of carob bean gum-thickened formula vs plain formula yielded conflicting results. (5,6) In the study showing improvement with carob bean gum, the parents were not blinded to the treatment, which may have led to bias favoring the treatment. (5) An uncontrolled, comparative trial of carob bean gum vs rice cereal suggested superiority of carob bean gum as a thickener, although both treatments yielded improvement. (7) Carob bean gum is available in the UK as a powder (Instant Carobel) but is not widely available in the US.

Three trials studied the effects of other conservative therapies such as positional changes and pacifiers on reflux measured by pH probe; unfortunately, none assessed clinical outcomes such as emesis or regurgitation. (3) Reflux by pH probe was worsened in a trial studying the infant seat for positioning. In the trial studying elevating the head of the bed to 30 [degrees] in the prone position, reflux measured by pH probe was also unchanged; prone positioning is no longer recommended due to the risk of Sudden Infant Death Syndrome (SIDS). (8) The trial of pacifier use showed improvement of reflux by pH probe when used in the seated position, but worsening in the prone position. Since pH probe does not necessarily reflect clinical symptoms, the utility of the information from these studies is limited.

Only I trial of drugs used to treat infant reflux measured clinical symptoms. This large manufacturer-sponsored RCT found that sodium alginate (9) significantly reduced emesis episodes in treated infants. Sodium alginate is marketed in the UK as Gaviscon Infant. While this trial included breastfed infants, it did not report the numbers of breastfed infants in the 2 treatment groups or present data separately for breastfed infants. Small RCTs of metoclopramide (10) and omeprazole (11) show significant improvement in reflux index measured by pH probe. However, metoclopramide yielded no improvement in symptom counts, and the omeprazole study resulted in no differences in "cry-fuss time" between treatment groups.

* Recommendations from Others

The North American Society for Pediatric Gastroenterology and Nutrition recommends thickening agents or a trial of hypoallergenic formula for vomiting infants. (2) They caution against prone positioning and favor proton pump inhibitors over H2 blockers for symptomatic relief and healing of esophagitis. They found insufficient evidence to recommend surgery over medication.


(1.) Nelson SP, Chen EH., Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med 1997; 151:569-572.

(2.) Rudolph CD, Mazur LJ, Liptak GS, et al; North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001; 32 Suppl 2:S1-S31.

(3.) Carroll AE, Garrison, MM, Christakis DA. A systematic review of nonpharmacological and nonsurgical therapies for gastroesophageal reflux in infants. Arch Pediatr Adolesc Med 2002; 156:109-113.

(4.) Orenstein, SR, Magill, HL, Brooks, R Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr 1987; 110:181-186.

(5.) Wenzl TG, Schneider S, Scheele F, Silny J, Heimann G, Skopnik H. Effects of thickened feeding on gastroesophageal reflux in infants: a placebo-controlled crossover study using intraluminal impedance. Pediatrics 2003; 111(4 Pt 1): e355-359.

(6.) Vandemplas Y, Hachimi-Idrissi S, Casteels A, Mahler T, Loeb. A clinical trial with an "anti-regurgitation" formula. Eur J Pediatr 1994; 153:419-423.

(7.) Borelli O, Salvia G, Campanozzi A. Use of a new thickened formula for treatment of symptomatic gastroesophageal reflux in infants. Ital J Gastroenterol Hepatol 1997, 29:237-242.

(8.) Orenstein, SR. Prone positioning in infant gastroesophageal reflux: Is elevation of the head worth the trouble? J Pediatr 1990; 117:184-187.

(9.) Miller S. Comparison of the efficacy and safety of a new aluminum-free paediatric alginate preparation and placebo in infants with recurrent gastro-oesophageal reflux. Curr Med Res Opin 1999; 15:160-168.

(10.) olia V, Calhoun J, Kuhns L, Kauffman RE. Randomized, prospective double-blind trial of metoclopramide and placebo for gastroesophageal reflux in infants. J Pediatr 1989; 115: 141-145.

(11.) Moore, D J, Tao BS, Lines DR, Hirte C, Heddle ML, Davidson GR Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr 2003; 143:219-223.

* Clinical Commentary

Lack of age-appropriate RCTs make evidence-based treatment difficult

Gastroesophageal reflux, defined as the passage of gastric contents into the esophagus, is one of the most common gastroesophageal problems in infants. GERD is a pathological process in infants manifested by poor weight gain, signs of esophagitis, persistent respiratory symptoms or complications, and changes in neurologic behavior. Gastroesophageal reflux generally resolves within the first year of life, as the lower esophageal sphincter mechanism matures. Traditionally, these infants have been managed conservatively with feeding schedule modifications, thickened feeds, changes in positions after feeding, and formula changes. Depending on the history and clinical presentation of an infant with GERD, more detailed evaluation and treatment may be necessary.

As per the North American Society for Pediatric Gastroenterology and Nutrition, if an upper gastrointestinal series has ruled out anatomic causes of gastroesophageal reflux, and nonpharmacologic interventions have failed, an acid suppressive agent is usually the first line of therapy. The lack of age-appropriate case definitions and randomized controlled trials, however, make it difficult for those practitioners who treat infants to have a evidence-based protocol for managing GERD.

Alfreda L. Bell, MD, Kelsey-Seybold Clinic, Houston, Tex

Vanessa McPherson, MD, Carolinas Medical Center and University of North Carolina-Chapel Hill, Charlotte, NC

Sarah Towner Wright, MLS, Health Sciences Library, University of North Carolina at Chapel Hill

COPYRIGHT 2005 Dowden Health Media, Inc.
COPYRIGHT 2005 Gale Group

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