About one-third of Americans experience gastroesophageal reflux disease (GERD) — a disease traditionally associated with stressors accompanying adulthood.
But GERD is emerging as a common childhood condition, as well. GERD in children may present differently or be more difficult to diagnose, and tailored approaches may be required to manage the disease in children.
Gastroesophageal reflux (GER) is a benign, physiologic process common in infants. More than 50% of healthy infants experience a passive return of stomach contents into the esophagus during their first several months of life. GER incidence then peaks and usually resolves by the time an infant celebrates his or her first birthday.
“GERD is worrisome for parents, and we frequently get referrals from primary care offices,” says Rosemary Young, APRN, MS, CGRN, a pediatric gastroenterology nurse at the Boys Town Medical Center in Omaha, Neb. “Parents expect us to have an easy remedy.”
GERD through childrens’ eyes
Young children may not be able to verbalize or describe GERD symptoms. Infants and babies usually present with full-blown spitting up or vomiting. When the episodes are frequent, especially beyond 6 months of age, GERD is suspect.
Children also may demonstrate pain with irritability, constant or sudden crying, or back arching. If they can speak, they may describe abdominal pain above the navel, chest pain, or a burning sensation in the throat.
When children present with the following signs, clinicians may proactively treat for GER without endoscopic confirmation of esophagitis:
- Pickiness about foods or textures, gagging or choking, or poor weight gain or weight loss
- Respiratory signs such as bad breath or frequent runny nose, sore throat, sinus infection, bronchitis, wheezing, asthma, nighttime cough, or a hoarse or deep voice
- Frequent waking, frequent ear infections or congestion, tooth enamel erosion, excessive salivation or drooling, or intolerance of pressure on the stomach
GERD solutions for children are not always clear-cut. “GER requires intervention when the reflux results in esophagitis — inflammation or tissue damage to the esophagus,” says Nancy Goldberg, APRN, MSN, BC, PNP, of Children’s Hospital Boston.
Many children under age 12 have “silent” GERD; they do not visibly regurgitate or describe heartburn.
Signs to watch for include:
- Poor weight gain or failure to thrive
- Signs of esophagitis, such as heartburn that worsens upon bending, difficult or painful swallowing, or mouth sores
- Dry cough and asthma symptoms (wheezing, apnea, pneumonia, chronic sinusitis)
Pediatric GERD represents a fairly dynamic area of study with evolving management practices. Goldberg says impedance studies (computer evaluation of the contents of the esophagus through a nasogastric tube, usually for an 18- to 24-hour period) are being used to examine children with suspected GERD.
Eosinophilic esophagitis (EE), a chronic condition with persistent or relapsing symptoms, is linked to the theory that food allergens are involved in increased mucosal eosinophils. When suspected GERD is unresponsive or only partially responsive to acid-blockade therapy, or when older children say they feel as if they can’t swallow, it is standard practice to conduct endoscopy and biopsy of the esophagus to evaluate for eosinophils.
Generally, EE is diagnosed with greater than or equal to 15 eosinophils per high-powered field in the esophageal mucosa. When EE is diagnosed, clinicians usually conduct allergy tests to identify and eliminate the offending food allergen(s); however, it also is possible that environmental allergens — not food allergens — are the source of the EE.
Gastric acid reflux is thought to be the primary mediator in GERD; therefore, patients with GERD are treated primarily with acid suppression agents. With EE, food allergens are thought to be the primary mediator, and removing food allergens has been shown to treat both the symptoms and the underlying histopathology. In some cases, co-therapy with topical corticosteroids and/or acid suppression may resolve acute symptoms.
A debate is ongoing about the possible link between asthma and GERD. The two conditions are thought to feed off each other through multiple pathways. In many cases, GERD is secondary to an underlying condition such as food allergies or neurological impairment.
Help for children and parents
The initial approach to GERD treatment with children, particularly infants, is conservative, Young adds.
“We try to figure out the cause first,” she says. “Usually we suggest lifestyle alterations and assure parents this may be a normal process that will resolve naturally.”
Dietary management differs in children and in adults, according to Young. “We tell adults to avoid spicy food, fats, caffeine, and alcohol,” she says. “With children, we think in terms of hypoallergenic diets — we tell parents to try to avoid food allergens that may cause GERD.” Pediatric clinicians commonly recommend thickening infant formula with cereal to reduce regurgitation, but this practice could open the door to potential allergic response.
If symptoms persist, children may be treated with over-the-counter antacids such as Maalox or Mylanta. The next step is an H2 blocker such as ranitidine and then a proton pump-inhibitor such as lansoprazole, which has a pediatric indication. Goldberg reminds nurses that medications for children are dosed by weight and that children often metabolize drugs differently. Proton pump inhibitors, for example, are metabolized more rapidly by children, so dosages must be adjusted.
Drugs that accelerate gastric emptying such as metoclopramide rarely are used for children with pediatric GERD because of the risk of potential adverse events.
Parents require ongoing support, especially when babies are fussy.
“Nurses should talk to parents about the lower esophageal sphincter (LES), a high-pressure zone of muscles around the bottom of the esophagus where it connects to the stomach. It takes time for the LES to fully develop properly in babies,” says Young. “In older children and adults with GERD, the LES may be malfunctioning by relaxing at the wrong times, or the pressure may be consistently too low.”
Nurses should ask parents questions about how often their children regurgitate, what the volume of regurgitation is, how much their children eat at one sitting, and how frequently they eat.
“When nurses educate and assess, it can save parents and physicians a lot of agony,” Young says.