Gastroesophageal Reflux (GER)

What Is Gastroesophageal Reflux (GER)?

Gastroesophageal reflux (GER), also called reflux, is when food and acid from the stomach go back up into the esophagus. This causes an uncomfortable feeling in the chest, often called heartburn.

GER can happen in adults and kids, even babies. It’s normal and most kids who have gastroesophageal (gass-troh-eh-soff-eh-JEE-el) reflux outgrow it over time. Changes in diet can help, but some kids might need medical treatment.

Reflux that happens a lot and causes problems like poor growth, vomiting, or damage to the esophagus is called GERD (gastroesophageal reflux disease). GERD is more serious than GER and is usually treated with medicine.

What Are the Signs & Symptoms of Gastroesophageal Reflux?

Common signs of reflux include:

• heartburn (a burning sensation in the chest, neck, and throat). It can last up to 2 hours and tends to be worse after meals and when lying down
• burping
• frequent hiccups
• frequent spitting up or vomiting, especially after meals
• the feeling of stomach acid coming up into the back of the throat
• acidic or bad breath
• frequent cavities, especially in the back teeth, despite good brushing 

Signs of GER in babies and young children include:

• choking or wheezing (if the contents of the reflux get into the windpipe and lungs)
• wet burps or wet hiccups
• spitting up that continues beyond a child's first birthday (when it stops for most babies)
• irritability or inconsolable crying after eating
• refusing to eat or eating only small amounts
• failure to gain weight

Some of these symptoms may get worse if a baby lies down or is placed in a car seat after a meal.

What Causes Gastroesophageal Reflux?

A ring of muscle, called the lower esophageal sphincter, separates the esophagus from the stomach. GER symptoms happen if this ring relaxes at the wrong time or doesn't close as it should. This lets acidic fluid from the stomach flow backward into the esophagus, into the back of the throat, and sometimes out the mouth or nose.

Often, reflux is minor and no cause for concern. But in people who have GERD, reflux happens more often and causes noticeable discomfort. After many meals, they have heartburn (also called acid indigestion).

In babies with GERD, breast milk or formula regularly refluxes into the esophagus, and sometimes out of the mouth. Sometimes babies regurgitate forcefully or have "wet burps."

What Problems Can Happen?

Babies who have GER usually outgrow it by the time they’re 1 or 2 years old. But in some cases, GER symptoms last. Kids with developmental or neurological conditions, such as cerebral palsy, are more at risk for GER and can have more severe, lasting symptoms.

A steady reflux of stomach acid into the esophagus can lead to:

• breathing problems (if the fluid enters the trachea, lungs, or nose)
• redness and irritation in the esophagus, a condition called esophagitis
• bleeding in the esophagus
• scar tissue in the esophagus, which can make it hard to swallow
• pneumonia
• repeated asthma attacks

Because these complications can make eating painful, GER can interfere with proper nutrition. So if your child isn't gaining weight as expected or is losing weight, talk with your doctor.

How Is Gastroesophageal Reflux Diagnosed?

In older kids, doctors usually diagnose reflux by doing an exam and hearing about the symptoms. If your child has GER symptoms, try to keep track of the foods that seem to cause them. This can help the doctor figure out what's going on.

In younger children and babies, doctors might run these tests to diagnose GER or rule out other problems:

• Upper GI radiology study. This special X-ray can show liquid backing into the esophagus, irritation or narrowing of the esophagus, and any upper digestive tract problems. For the test, your child will swallow a small amount of a chalky liquid (barium). This liquid appears on the X-ray and shows the swallowing process.
• 24-hour impedance-ph probe study. This is the most accurate way to detect reflux and how often it’s happening. A thin, flexible tube goes through the nose into the esophagus. The tip rests just above the esophageal sphincter for 24 hours to check acid levels in the esophagus and to detect any reflux.
• Milk scans. This series of X-ray scans tracks a special liquid as a child swallows it. The scans can show whether the stomach is slow to empty liquids and whether the refluxed liquid is being inhaled into the lungs.
• Upper endoscopy. Doctors look at the esophagus, stomach, and part of the small intestines using a tiny fiber-optic camera. They also may take a small tissue sample (a biopsy) of the lining of the esophagus to rule out or find other problems.

How Is Gastroesophageal Reflux Treated?

Treatment for GER depends on the symptoms and how severe they are. 

Reflux is common in babies, and some simple feeding changes can help:

• Do not overfeed you baby. Smaller, more frequent feedings can reduce reflux. Talk to your health care provider about how much and how often your baby should feed.
• Burp your baby before and after feeding.
• Hold the baby upright while feeding and for 15–30 minutes after. Do not put your baby in an infant seat after feeding. This position can make reflux worse
• Talk to your health care provider before changing your baby’s diet or your diet, if you are breastfeeding.

Don’t let anyone smoke around your baby. Tobacco smoke can make reflux worse.

The doctor may recommend thickening formula with a little bit of oat infant cereal or using an anti-reflux formula to reduce reflux. Breastfed infants with reflux should continue to breastfeed. Talk to your doctor before thickening feedings if your infant is breastfeeding, overweight, or was born early.

Older kids often get relief by avoiding foods and drinks that trigger GER symptoms. Often, these include:

• citrus fruits
• chocolate
• food and drinks with caffeine
• fatty and fried foods
• garlic and onions
• spicy foods
• tomato-based foods and sauces
• peppermint

Doctors may recommend raising the head of an older child's bed 6 to 8 inches to help with reflux that happens at night. Infants younger than 1 year old, including infants with gastroesophageal reflux, should always sleep on their backs on a flat, firm surface.

Obesity, some medicines, smoking and alcohol can make GER worse.

If symptoms continue, doctors might prescribe medicine, such as:

• H2 blockers, which can help block the production of stomach acid
• proton pump inhibitors, which reduce the amount of acid the stomach makes
• prokinetics, which help the esophageal sphincter work better and the stomach empty faster. This can prevent reflux episodes.

Rarely, medical treatment alone doesn't help and a child fails to grow well or has other problems. Then, a surgical procedure might be an option. In this surgery, called fundoplication (fun-doh-plih-KAY-shun), the doctor creates a valve at the top of the stomach by wrapping part of the stomach around the esophagus to strengthen the sphincter and prevent reflux.

When Should I Call the Doctor?

Call the doctor if your baby has GER and:

• does not seem to be growing
• cries a lot more than usual
• won't eat, or cries and arches away from the bottle or breast during feedings
• coughs, chokes, wheezes, or has trouble breathing
• has forceful vomiting more than a few times in a 24-hour period
• has blood in the poop
• still has problems with reflux after age 1

Go to the ER right away if your baby throws up blood or bile (a green or yellow liquid).

Call your doctor if an older child with GER:

• is very bothered by the reflux
• does not seem to be growing
• coughs, chokes, wheezes, or has trouble breathing
• vomits more than a few times in a 24-hour period
• has blood in the poop

Go to the ER right away if your child has severe chest pain.

What Else Should I Know?

If your child has GER:

• Encourage them to eat smaller meals more often instead of three large meals.
• Talk to the doctor about safe weight loss if your child is overweight or obese.
• Don't let anyone smoke near your child. It can make the reflux worse.