Sneaky reflux

Allison asked, “My 4 year old was just diagnosed by an ENT (via rigid scope) with reflux and needs Prevacid to control it (Prilosec didn’t help). Otherwise, his voice is quite hoarse. If not for the hoarse voice, we would never have known he had it. Why would a 4 year old have reflux and is it something we should be seeing a GI doctor for?”

Reflux is both one of the most over-diagnosed and one of the most under-diagnosed conditions in pediatrics. That’s right: the same disease that’s diagnosed far too often in some children is at other times very sneaky and easy to overlook.

Gastroesophageal reflux (often abbreviated “GER”) occurs when stomach contents, including acid, come up from the stomach into the esophagus. Everyone has this at least every once in a while. If it happens frequently or severely, the stomach contents can damage tissues in the esophagus and upwards. This is called “gastroesophageal reflux disease”, or “GERD.”

GERD is very commonly over-diagnosed, especially in babies. Many babies are fussy at times, and many babies spit up, so perhaps it’s understandable that so many of them are diagnosed with GERD and put on medication. Over-medicating for GERD is especially rampant in NICUs, where tiny preemies often have little blips on their monitors that are blamed on GERD with very little evidence that the therapy is really helping anything. Good, careful studies of babies on GERD medications have shown that most of these babies don’t have GERD at all. GERD medicines are also commonly prescribed as a first-line “let’s-try-something” medication for any child with abdominal pain.

In other circumstances, GERD can easily be overlooked. Though the common symptoms of regurgitation and heartburn are easy to appreciate, GERD can be the root cause of many, more subtle things: trouble sleeping at night, recurrent ear or sinus infections, a hoarse voice, teeth problems, flare-ups of asthma, or other breathing problems. In these children with less-obvious GERD, the diagnosis is often delayed or overlooked completely.

Why would your 4 year old have reflux? Usually, there is no specific cause. We think that the esophageal sphincter that’s supposed to keep stomach contents down might be too loose, or perhaps that the stomach isn’t emptying quickly enough. Sometimes GERD runs in families. It can be made worse by some medicines and food (especially caffeine). Rarely, GERD can be part of an anatomical problem, or can be a manifestation some other esophageal disease (such as eosinophilic esophagitis, which can seem quite similar to GERD but may require different treatment.)

The treatment of GERD includes some lifestyle changes. Kids should eat more slowly, chewing their food well and drinking water during the meal. Vigorous physical activity should be avoided after a meal, and people with GERD shouldn’t lay down immediately after eating.

Medication for GERD includes older antacids like Tums or Mylanta, which will provide relief. The next-generation of reflux medications includes Zantac, Tagamet, and Pepcid, which partially block stomach-acid secretion. The most recent medicines for GERD are also the most effective. These include Prevacid and Prilosec, which completely block the production of stomach acid. All of these medicines work by reducing stomach acid so refluxed material doesn’t damage the esophagus—but none of them actually stop the reflux of material up from the stomach. All of these medications for GERD are really quite safe, which may be one reason why so many physicians use them indiscriminately for children who probably don’t even have reflux disease.

Most GERD is easy to treat with safe medications, and if the diagnosis is straightforward and treatment is effective it isn’t necessary to see a GI specialist. But if ordinary therapy doesn’t work, or the diagnosis is in question, a GI specialist should be involved.

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