Could gastro-oesophageal reflux be the cause of your child’s vomiting?

Gastro-oesophageal reflux is the passage of contents from the stomach into the oesophagus. Many of us can experience this from time to time, both in childhood and adulthood, but if the symptoms become troublesome or cause complications, treatment should be sought out. In this article, leading consultant paediatric surgeon Mr Simon Clarke expertly explains the symptoms, diagnosis and treatment of gastro-oesophageal reflux in children.

What symptoms should I look out for in my child? When should we see a doctor?

Reflux can have all sorts of symptoms, the most typical of these being vomiting. Depending on the age of your child, advice can differ. For instance, green-coloured vomit in a newborn can be a surgical emergency which needs swift, specialist advice. For babies around the age of four weeks, very forceful vomiting, can be a sign of pyloric stenosis which also requires specialist treatment. If your baby has a normal rate of feeding but is losing weight and may be malnourished, symptoms and signs of reflux need to be taken seriously. This is because poor weight gain is very common amongst babies affected by gastro-oesophageal reflux and they are unable to tell us about other symptoms, such as pain.

On the other hand, older children and teenagers are able to describe symptoms of pain, which is likely to mirror the classic symptoms adults also experience, such as burning in the chest. Although this information can be harder to illicit from younger children, wheezing or chest infections can also be a sign of gastro-oesophageal reflux.

Symptoms can also include irritability, poor feeding and a lack of weight gain, alongside chest infections in very small children. These symptoms can also be indicative of many other conditions that affect young children which can make diagnosis tricky. In any case, your child should still see a doctor to find out and treat the cause.

What factor does age play in the symptoms of gastro-oesophageal reflux?

For children from one to five years of age, the most common symptoms of gastro-oesophageal reflux include:

• regurgitation
• vomiting
• abdominal pain
• losing weight
• refusing food

Even though reflux may not necessarily interfere with growth, it can make children become aversive to food because every time they eat, it causes pain, even if they aren’t able to tell you that.

Older children and teenagers are more likely to complain of chest pain or heartburn. You may also observe a vomit smell on their breath and they may burp frequently. Coughing at night when lying flat, unexplained sore throats and chest infections as well as chronic ear, nose and throat problems can also be caused by gastro-oesophageal reflux. If you’re finding that your child is going to the dentist for erosions more often than other children of their age, it can also be a symptom of gastro-oesophageal reflux, as the acid can burn away the teeth.

How is gastro-oesophageal reflux diagnosed?

There isn’t one particular test that can diagnose gastro-oesophageal reflux, so initially it’s important to take down a full history. In the gastroenterology and surgical field, we tend to make sure there are no issues with the child’s intestinal anatomy. We can examine this by performing an upper gastrointestinal contrast series. The patient swallows a fluid which outlines the appearance of the intestinal tract so we make sure everything is as it should be.

There is a condition called malrotation which can predispose children to vomiting. This requires completely different treatment to reflux so it’s important to rule it out. The gold standard of diagnosis is to conduct a test where a small probe is inserted in the nose and is passed through into the lower part of the oesophagus. The oesophagus runs from the back of the mouth right down to where the hard part of the chest bone finishes and this is where the junction between the oesophagus and the stomach is found. This probe is connected to a small computer which stays with the child. Over a twenty-four hour period, as the child eats drinks and sleeps as normal, the computer measures the amount of acid that goes up and down. It can also give information about gas and liquids in general and it gives a really good picture of what’s going on in the lower oesophagus.

We can also do more invasive tests, such as an endoscopy where a camera is inserted through the mouth and into the lower oesophagus, showing any inflammation. We can also take biopsies which can rule out certain other causes of similar symptoms, such as a milk allergy. This involves anaesthetic, so this is at the end stage of our diagnostic work.

What are the treatment options?

There are a huge number of treatment options which vary according to the exact diagnosis and how serious the symptoms are. Initially, we can look to modify various things within the lifestyles of the infant such as a change of milk, whether it be breastfed or formula. Reducing feed volume, if the baby is being fed too much can also help.

In the early stages, it is also very common to take dairy out of the equation entirely to relieve symptoms. If the time is right, adding in solids to the baby’s diet can also help. Additionally, thickening the milk can also stop reflux. Positioning is also a key element as lying flat is a proponent in reflux, particularly in very young infants. This is why babies’ chairs are elevated. Often, raising the head of the bed is very effective in improving nocturnal symptoms.

In adolescence, tackling excessive weight can ease symptoms. In older children, the lifestyle modifications you would prescribe for an adult, such as avoiding acidic foods, can also be applied.

If these modifications don’t help to ease symptoms significantly, then we would go down the route of prescribing a medicine. Antacid formulas can help and can also act as a milk thickener. There are also some drugs that affect the production of acid or block the acid's effect within the stomach, producing a non-acid like reflux.

Proton pump inhibitors are another type of medication which can be very effective. There is, however, some controversy in its long term use due to a growing body of evidence related to recurrent chest infections and bone fractures. For patients taking proton pump inhibitors for long periods, it is important to monitor levels of electrolytes, such as calcium and magnesium, to make sure they’re within the normal limits. For those with a definitive diagnosis of gastro-oesophageal reflux who don’t want to continue taking medicine for too long, surgery is the next step in the treatment plan.

What type of surgery is needed to treat gastro-oesophageal reflux?

Surgery for gastro-oesophageal reflux usually means creating a one-way valve at the lower end of the oesophagus using muscles from the stomach itself. The procedure enables the strengthening of all of the normal mechanisms that most of us take for granted, helping to keep the pressure high in the lower part of the food pipe or oesophagus. This is classified as a major operation, so the decision to opt for surgery should not be taken lightly, but it can be performed using keyhole techniques in virtually all cases. Normally, patients are able to eat the same night after surgery or the following day.

Before considering surgery, it is essential to get the diagnosis right as if it is incorrect, the operation is very likely to fail. Therefore, every family should have proper counselling and education before any surgical procedure takes place.

If you think your child make be suffering from gastro-oesophageal reflux or you are seeking surgical treatment for your child, you can book a consultation by visiting Mr Clarke’s Top Doctors profile.