Gastroesophageal reflux is the return of the stomach contents back into the esophagus, the tube that runs between the mouth and stomach. Parents should be aware that this may occur in very healthy infants and is not necessarily a sign of illness or abnormality. Many children grow and develop normally despite spitting up their food from time to time. In very young children gastroesophageal reflux is often due to chalasia, a malfunction of the lower esophageal sphincter, which normally functions to prevent food from returning to the esophagus. This malfunction is considered by some to be simply an indication of immaturity of the sphincter, which in a few weeks or months begins to function as it does in adulthood. Most children who demonstrate gastroesophageal reflux before they reach the age of three months may be expected to be symptom free by the time they reach two years of age. Symptoms persist in some children until four years of age. By the time the child reaches 12 months of age he is spending most of his time in the upright position and even those whose sphincters are slower in development may expect improvement in symptoms with the change in position.
Gastroesophageal reflux can also be caused by hiatal hernia, but this is more common in older children than in the young age group most likely to suffer chalasia.
Symptoms include vomiting, failure to gain weight, irritability, refusal to eat, blood in the stools, and anemia. Vomiting is the main symptom in about two-thirds of all infants with gastroesophageal reflux. Onset may be at the time of birth or six weeks later. The vomiting may be mild, a sort of spitting up, or may be projectile, shooting out of the child’s mouth. Children may be hungry immediately after vomiting and wish to eat again.
The repeated return of food and hydrochloric acid into the esophagus may cause irritation or even esophagitis, making it painful for the child to eat. If the irritation becomes severe the esophagus may bleed, and blood may pass through the digestive system and be eliminated with or in the stool, or the child may vomit fresh blood. The continued blood loss may lead to anemia.
About one-third of these children fail to grow properly because of inadequate nutrition, but once successful treatment is begun they grow normally. Some children have episodes of cessation of breathing. There may be associated respiratory problems, such as cough or asthma, because of inhalation of the refluxed material. Cow’s milk placed in the trachea of some very young laboratory animals causes cessation of breathing. For this reason it may be well to avoid giving cow’s milk to children with gastroesophageal reflux. Older children who suffer gastroesophageal reflux, for whatever reason, may have heartburn.
Most of these children will rapidly outgrow gastroesophageal reflux. The treatment is controversial, but we will discuss both sides, and if one method does not work the other is worth a trial. Both sides claim high success rates.
For decades gastroesophageal reflux has been treated by keeping the child upright at about a 60 degree angle in an infant seat to enable gravity to assist in keeping the food in the stomach. However, some observers point out that children slump in the infant seat, increasing pressure on the abdomen, which encourages the food to reflux upward. These people claim that the proper position for the child is lying face down on a board slanted upward at a 30 degree angle. This may be done by the use of a board with a brace, or a harness attached to the head of the bed. This position is felt to encourage stomach emptying. The child should be kept in this position constantly during the treatment program, which should last at least six weeks. After this period of time the child may be taken off the board for short periods of time, gradually increasing the time if symptoms do not recur. During the treatment time the child should be removed from the slant board for bathing and diaper changes before feedings and held up to the shoulder or placed back on the board immediately after feedings. He should never be placed flat after a feeding.
Older children who have gastroesophageal reflux should have the head of their bed raised, and should not go to bed for several hours after eating. Foods high in fat and chocolate should be eliminated from the diet as these are known to decrease the lower esophageal sphincter pressure.
Some children develop a stiff neck while on the slant board. The parents should turn the head from one side to the other frequently to prevent this. Sometimes the position causes the child’s legs to swell from fluid accumulation. Simply lifting the legs up for a few minutes will often be effective in resolving this.
Until at least six months of age infants should receive only breast milk. For the older infant, feedings should be thick, as thick material is less likely to reflux. Whole grain rice cereal boiled gently for three hours or blended with expressed breast milk or fruit juice may be spoon-fed in small amounts every four hours, or at regular feeding times; or the child may be fed rice cereal prior to nursing. If the child is receiving formula it may be necessary to enlarge the nipple hole to allow the food to flow freely. Symptoms may worsen if the child swallows air in an attempt to get his food. He should be burped frequently. Many children on thickened feedings show improvement within about two weeks, but the feeding schedule demands cooperation on the part of all family members.
For esophageal reflux, we have found people have good benefit by sitting and standing in very good posture, and by yawning. If you are aware that you are having reflux, if you can induce a good yawn, sometimes that will help amazingly to relieve the sensation. If you take pills of any kind, the time to swallow them is when you have in your mouth already thoroughly chewed food ready to swallow. Introduce the pill, and swallow it all together. by Dr. Trash.
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