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Gastroesophageal Reflux

What is gastroesophageal reflux?

Gastroesophageal (pronounced gas-troh-ess-ahf-uh-JEE-ul) reflux occurs when food and acid from your baby's stomach come back up into the esophagus. The esophagus is the tube that food goes down as it travels from the mouth to the stomach. A complex mechanism made of three elements normally prevents reflux.

These three parts include:

  • The muscle around the esophagus as it enters the abdomen
  • The amount of esophagus that is in the abdomen before it enters the stomach
  • The angle at which the esophagus enters the stomach

In simple terms, some people may describe these elements as a valve, but no specific valve really exists.

Acid can hurt the esophagus and cause a burning feeling or pain. This may make your baby fussy or unwilling to eat much. Reflux can also lead to other problems, like pneumonia, breathing problems and problems gaining weight.

Who gets reflux?

Reflux is common in babies. About half of them have it. Most outgrow it by the age of 6 months to 1 year of age.

What are the symptoms?

Your baby may have one or more of these symptoms:

  • Frequent spitting up or vomiting
  • Coughing, choking, gulping swallows, or trouble breathing if spit-up is in their throat
  • Fussiness or crying throughout the day, especially one to two hours after feeding
  • Restless sleep or waking often from discomfort
  • Changes in breathing patterns, or long pauses in breathing (apnea)
  • In older children, more subtle problems that can be linked to reflux, such as asthma or chronic sinus problems

Symptoms tend to be worse when the baby is lying flat and tend to improve when the baby is sitting or held upright.

Babies who vomit often may not gain weight or may even lose weight. If spit-up gets from your baby's esophagus into the windpipe, or trachea, it may go into the lungs. This is called aspirating. This can lead to pneumonia, bronchitis or wheezing. If the esophagus gets irritated over and over by acid, a scar may develop. This can cause narrowing in the esophagus (stricture) and make it hard to swallow.

How do you diagnose reflux?

The doctor will ask questions about your child's symptoms and feeding patterns. Sometimes the answers are enough to diagnose reflux. If the doctor needs more information, your baby may have a series of X-rays called an upper GI (PDF 48KB) (short for gastrointestinal) series. First your baby will swallow a liquid that shows up on the X-ray. This can show how well food travels to and stays in the stomach. An upper GI is done mostly to look for structural, or anatomic, problems that might be causing reflux. Often it doesn't show reflux even in babies who do have reflux, so in general it's not used either to prove or disprove the presence of reflux.

A common test for babies who might have reflux is a pH probe study. A thin tube with a sensor is passed through your baby's nose into the esophagus. It can measure the level of acid. This test usually lasts 24 hours and is done in the hospital. The babies need to be off of all antacid medications for a minimum of 24 hours prior to doing this study.

What is your experience with reflux at Children's?

We treat many children with reflux at Children's. Most of these children do not need surgery. In many cases we work closely with the gastroenterology or pulmonary doctors to help make the decision about whether an operation will benefit your child. Before we recommend surgery for your child, we will do a thorough check of your child's health and talk with you to decide whether other steps may help. An important part of our service is to work with children and families to get good results without surgery whenever possible.

Some children do need surgery because other treatments are not enough. Our surgeons are experienced at performing the operations these children need to correct reflux. We have performed hundreds of anti-reflux operations and usually do 50 to 75 each year. We can recommend whether a laparoscopic or open operation is the best for your child. Most of the time we do this operation laparoscopically. We tend to do less of these operations than many pediatric centers because we believe that many children can be well taken care of without surgery.

When you come to Children's, you have a team of people to care for your child before, during and after surgery. Along with your child's surgeon, you are connected with nurses, dietitians, child life specialists and others. We work together to meet all of your child's health needs and help your family through this experience.

Since 1907, Children's has been treating children only. Our team members are trained in their fields and also in meeting the unique needs of children. For example, the doctors who give your child anesthesia are board certified in pediatric anesthesiology. This means they have extra years of training in how to take care of kids. Our child life specialists know how to help children understand their illnesses and treatments in ways that make sense for their age. Our expertise in pediatrics truly makes a difference for our patients and families.

How do you treat reflux?

Most children with reflux improve with simple changes in their position and their feedings and by taking an antacid medication. Before thinking about surgery, your child's health-care team may suggest taking steps like these:

  • Keeping your baby in a straighter, more upright position at all times. This way gravity helps keep the food in the stomach.
  • Making your milk or formula thicker, such as with rice cereal.
  • Feeding your baby smaller amounts more often, and burping your baby often during feeding.
  • Giving your baby certain medicines that help food move faster from the stomach to the intestine or that cut down on stomach acid.

Surgery

If these steps don't improve your baby's symptoms, doctors may suggest surgery to create a valve at the bottom of the esophagus. This surgery is called fundoplication (pronounced fun-doe-plik-A-shun). There are several methods. Your doctor will discuss these with you. Another surgical option for some children is to put in place a gastrojejunostomy tube. This is a feeding tube that bypasses the stomach and feeds directly into the small intestine.

At the time of surgery, your child will have general anesthesia. This means we will give your child medicine to make them sleep without pain during the surgery. The surgeon will make a cut, or incision, in your child's belly (abdomen). Most times when doing this operation, surgeons make several small incisions, 3 to 5 millimeters long, where they can insert a thin, lighted tube with a camera and their surgical instruments. This is called laparoscopic or minimally invasive surgery.

Sometimes they need to make one longer incision instead (called open surgery). The surgeon pulls the top of the stomach up and wraps it around the lower esophagus. Then the surgeon sews the newly formed valve in place and closes the incision. The surgery takes about two hours, and your child will be in the recovery room for another hour.

Sometimes this operation is combined with placement of a gastrostomy tube, a feeding tube in the stomach that is placed through the abdominal wall. Your surgeon will talk with you about whether your child needs this.

After surgery

After surgery, we will give your child pain medicine to make them comfortable. They will get fluids and medicine through an IV (short for intravenous) line, a tube that goes into a vein. Your child may also need a tube that goes from the nose to the stomach (called a nasogastric tube, or NG tube) to help keep the stomach empty during recovery.

You can expect your child to stay in the hospital for about two to five days. At home, you'll need to keep the incisions clean and dry until they heal. The surgery team will teach you how to care for the incision, explain what kinds of food or medicine to give your child, and tell you if you need to limit your child's activity for a while.

About two to three weeks after surgery, your child will need to see the surgeon for a follow-up visit. The surgeon will make sure the incision is healing and your child is recovering well.

Resources

Read more about what to expect when your child visits a clinic at Children's, has surgery here or needs to stay in the hospital. You can get practical details about topics like what to do and bring the day of surgery and who will be on your child's care team. You can also take a virtual tour of our surgery rooms and other parts of the hospital.

To learn more about this condition, you may want to visit our resource list.