Spitting-up or vomiting after 12 to 24 months of age is not normal.  Persistent gastroesophageal reflux (GER) may cause damage to the esophagus, teeth and/or lungs and should be evaluated by a professional. 

 

My child is less than 12 months old...

See gastroesophageal reflux (GER) in the first year of life.

 

What causes GER? 

The lower esophageal sphincter (LES) is a normal muscular narrowing at the junction of the esophagus and the stomach where swallowed food is ideally prevented from exiting the stomach in the wrong direction.  All children, and adults for that matter, have reflux of some of the stomach contents into the esophagus after eating.  This so-called “physiologic reflux” is quickly returned to the stomach by contraction of the esophagus.  Children with abnormal GER will have reflux that results in stomach contents that leave the mouth or that stays in the esophagus for an extended period of time (more than about 3-6 minutes total per hour).  GER can be caused by: 

• abnormal relaxation of the LES
• delayed emptying of the stomach
• compression of the stomach
• excessive stomach gas
• poor infant positioning after meals
• overfilling the stomach
• illness

What are the symptoms of GER?

The stomach contains hydrochloric acid.  It is no surprise that one of the major symptoms of GER is pain or discomfort (see Esophagitis).  For children with vomiting, the diagnosis is obvious.  Other symptoms include:

• Heartburn or chest pain
• Regurgitation of sour brash (stomach contents that come back to the mouth from the stomach that is reswallowed or spit out)
• Bad breath
• Dental decay
• Painful swallowing

For severe GER, infants may develop pneumonias, poor weight gain (see failure to thrive) or breathing problems. 

Red Flags

• Severe or persistent symptoms
• Yellow or green discoloration of the vomited material
• Blood in the vomited material
• Breathing problems
• Turning blue with episodes
• Poor weight gain
• Taking 10 seconds or longer to recover
• Food getting stuck in the throat after swallowing 

 

Are there tests for GER? 

Yes.  While many cases of GER do not require testing for diagnosis, some tests are available for complex cases.

• pH probe – this is likely the best test for evaluating GER.  A wire is inserted through the nose into the lower part of the esophagus and left in place for 8-24 hours.  The wire measures the acid level in the esophagus over time.
• Nuclear medicine reflux scan – this test is good but is limited due to the limited time of the study.  An infant is fed a radioactive meal (the amount of radioactivity is very minimal and safe) and then she is placed under a scanner for 1-2 hours.
• Upper GI fluoroscopy – this test helps determine if there is a blockage in the esophagus, stomach or first part of the small intestines.  The infant is fed a contrast material and a “live-action” x-ray is used to watch the meal move through the gastrointestinal tract.
• Upper gastrointestinal endoscopy – this procedure requires sedation or anesthesia and is usually performed by a Pediatric Gastroenterologist.  The effects of GER may be seen, such as Esophagitis.  A lighted, flexible tube camera is inserted through the mouth and advanced to the first part of the small intestines.  The endoscopist can look at the surface of the gastrointestinal tract and also can take small biopsy samples for evaluation by a pathologist.

Treatment 

See diet changes below.Medicines are sometimes used:

• Prevacid® or similar proton pump inhibitor – these medicines reduce the production of stomach acid.  This does not directly inhibit GER but GER that is less irritating to the esophagus may indirectly cause a decrease in GER frequency or severity.  This medicine can be given as a liquid or the dissolvable tablets can be dissolved in a small amount of milk or water.

 

• Zantac® or similar acid blocker – like Prevacid® these medicines reduce acid production.  Unfortunately Zantac® does not taste good to many infants and children who take the liquid form.

 

• Reglan® (a.k.a. metoclopramide) – this medicine increases GI motility.  It is used less frequently due to the potential for side effects.

 

• Erythromycin – this is an antibiotic that may be used in very small doses to help improve emptying of the stomach.  It is usually reserved for older infants and children with know delayed emptying of the stomach.

Surgery is rarely necessary and is reserved for severe or complex cases.  The most commonly-performed procedure is a fundoplication. 

Prevention 

• Avoid spicy and fatty foods
• Avoid concentrated sweets (such as candy)
• Avoid chocolate (contains caffeine and sugar)
• Avoid caffeine (example – sodas, tea, chocolate)
• If you drink sodas, fizz-out the carbonation prior to drinking
• Avoid chewing gum and drinking from straws (this may cause worsening swallowing of air)
• Avoid excessive lactose (especially if you have known lactose intolerance)
• Avoid alcohol and tobacco smoke