Gastroesophageal Reflux Disease (GERD) By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in November, 2005 In bygone days, heartburn or indigestion was what you got from eating too much heavy or greasy food. You took an antacid for it (like Tums) or another stomach remedy like Pepto-Bismol. In those days, no one had ever heard of GERD, and certainly didn’t imagine that babies could have “heartburn” or that it might be linked to chronic ear infections, asthma, and even learning disabilities. Well, I am here to tell you that times they are a changin’ (in the words of the immortal Bob Dylan). GERD has arrived, but hopefully, with proper diagnosis and treatment, it won’t be here to stay. What is GERD? The term GERD describes the symptom – backwards flow (reflux) from the stomach (gastro) into the esophagus – rather than the cause of this disorder. The reflux occurs because of overwhelming or dysfunction of the muscle (sphincter) separating the stomach and esophagus. The esophagus is not designed to withstand stomach acids and over time can be damaged by this reflux. What causes GERD? While it is true that the stomach has a volume limit that a large plate of nachos with a six-pack chaser may exceed, it is now known that overeating or eating the wrong foods is not the primary cause of GERD. Some individuals are probably born with a weak muscle that closes the stomach off from the esophagus. The muscle may be weak in a baby born prematurely, or it may have an intrinsic defect in its shape or structure. In some babies, the muscle strengthens and the GERD is outgrown. Outgrowing mild to moderate GERD can also come about because the baby has developed enough strength to sit up after eating and compensates with gravity for the weakened muscle. Food allergies can lead to chronic indigestion and cause or worsen GERD. In adults, chronic overeating, bulimia, or cyclic hormonal changes in women can initiate GERD. An infant who grew out of GERD may have a recurrence with age-related decrease in overall muscle mass and tone. Exposure to stomach acids weakens the muscle, so GERD often gets progressively worse. Other conditions can induce GERD, such weakening of the muscles of the esophagus used for swallowing, or a type of hernia in which the stomach migrates upwards through a small hole in the diaphragm (hiatal hernia). Infection with the bacteria Helicobacter pylori, now recognized to be the cause of many ulcers, may also contribute to GERD. How is GERD diagnosed? Mild GERD may be suspected by a description of symptoms of burning in the chest that seems to rise upward occurring primarily after meals or upon lying down. A primary care doctor should be consulted to rule out any other condition. In infants, crying after meals with or without vomiting, chronic ear infections, enlarged tonsils or adenoids, and attentional and sensory disorders may be symptoms of GERD. In moderate or severe cases of GERD, in infants, or when there are other symptoms such as pain or difficulty with swallowing, a diagnostic procedure called endoscopy should be considered. A small flexible tube with a tiny fiber-optic camera is lowered into the throat to view and possibly sample the tissues of the esophagus. Why treat GERD? In adults, GERD is usually treated in order to reduce discomfort. In some cases, if the muscle deteriorates completely or the underlying esophageal defect progresses, the stomach can no longer retain its contents, leading to chronic vomiting. Or, a hiatal hernia may be present. Severe or prolonged GERD can lead to pre-cancerous changes in the esophagus, and even esophageal cancer. These cases are rare, but another good argument for proper diagnosis and treatment of GERD. In infants, reflux of stomach acids can cause irritation and inflammation not only of the lower esophagus, but also of the throat, ears, and even lungs. Thus GERD can contribute to chronic ear infections, tonsillitis, adenoiditis, laryngitis or sore throat, and asthma. Although poorly studied as yet, the chronic pain and subsequent disturbance of sleep and mood may even contribute to developmental delays, certain learning disabilities, and sensory disorders. How is GERD treated? In mild cases, antacids are still used to neutralize the stomach acid. This reduces pain and damage to the sensitive esophageal tissues. However, the reflux may still occur along with vomiting in infants and sensitive adults. These medications (Tums, Mylanta, and generic versions) can be obtained over the counter, and are taken after meals or anytime symptoms of burning or pressure are felt. Some contain calcium and can also serve as dietary supplements for women. Pediatricians should be consulted for proper use of antacids in formula or bottled breastmilk. Antacids are frequently combined with lifestyle changes, such as avoiding trigger foods for adults or uncovering food allergies in children, and keeping an infant upright after meals and elevating the head during sleep. In moderate GERD, an H-2 blocker (e.g. Pepcid) may be suggested. This type of drug blocks the type of histamine that is linked to stomach acid production. These pills are also available over the counter and unlike antacids must be taken before symptoms occur in order to prevent the burning of reflux. Again, the acid is removed but the reflux itself may still occur. These drugs can be used in combination with antacids. The most effective pharmaceutical treatments for severe GERD are proton pump inhibitors, including Nexium – “the little purple pill.” This type of drug turns off the tiny pumps that release stomach acid into your stomach. When the acid production is decreased in this way, the effects are more long lasting that those obtained with an H-2 blocker. Because of this, the esophagus can often heal. This treatment requires a doctor’s prescription and is more expensive than the other options. It is usually reserved for GERD that cannot be adequately treated with other drugs. Prilosec is the most common member of this family prescribed for children. Other drugs may be added, to increase the rate at which food is processed from the stomach into the intestine, if needed. If Helicobacter pylori infection is suspected or diagnosed, antibiotic therapy will be used. Finally, there is a surgical option to create a stronger barrier between the stomach and esophagus. This surgery creates lifelong reduction in stomach volume and can lead to its own side effects (particularly if overeating occurs). Who should I consult if I suspect that my child or I have GERD? Your primary care doctor or child’s pediatrician are the first line of treatment and intervention. For infants, no treatment, even with over the counter medication, should be attempted without consultation with the pediatrician. Even for adults, a primary care doctor may be able to refine how and when you are taking OTC remedies or suggest lifestyle changes for optimal efficacy. If you are still experiencing symptoms, or your child is experiencing symptoms that may be related to GERD, consider asking for a referral to a gastroenterologist (a specialist in stomach and intestinal concerns).