Older children and adults with chronic reflux sometimes complain of frequent heartburn, chest pain, or indigestion. Some adults experience frequent or recurrent hiccups or complain that food “gets stuck” in their throat (dysphagia). Most of these symptoms are thought to develop when the esophageal lining becomes inflamed or irritated by chronic or repeated exposure to gastric acid and gastric digestive juices (esophagitis).
While we often assume young infants experience similar symptoms with reflux, it is very difficult to know whether a baby’s irritability, difficulty sleeping, or feeding problems are caused by reflux. Thirty-six percent of infants experience daily episodes of hiccups, 17% cry for at least an hour each day, and 10% have at least one episode of arching each day so these behaviors are by no means specific for reflux. Nevertheless, there are reports of infants with feeding failure or feeding refusal, repeated arching (opisthotonus), or other unusual forms of posturing whose symptoms improve or resolve when they are treated for reflux.
Very rarely, infants with chronic and/or severe reflux may develop erosive or bleeding esophagitis. This can result in blood being visible when the child vomits or spits up. If the esophagitis is extremely severe or it persists for a prolonged period of time, it is possible for esophageal scarring to develop. This is termed an esophageal stricture. It is very difficult to determine how many children with chronic reflux develop esophageal strictures, but this is very rare. Among adults with chronic esophagitis, only 3 in 1000 will develop esophageal strictures over many years of follow-up.
It is extremely unusual for GE reflux to impair or limit a child’s growth if adequate number of calories are being provided. In most cases, poor growth in a child with reflux occurs when a family unintentionally limits the child’s intake. To try to lessen the vomiting, they may dilute the formula with water, or limit milk/formula intake and substitute water or Pedialyte®.
A long list of respiratory symptoms may be associated with GE reflux, however, it is often difficult to know whether the reflux causes the lung problems or the other way around. Since the windpipe (trachea) and the esophagus are very close together, many people have assumed that aspiration of refluxed stomach contents leads to respiratory symptoms.
Reflux of stomach contents up into the upper esophagus occurs in some patients with recurrent respiratory symptoms, but this appears to be very uncommon and is probably extremely rare among children who are neurologically normal.
While children with neurological abnormalities may aspirate refluxed stomach contents, more often, these children aspirate while they are eating. This is called laryngeal penetration and it occurs when swallow-breathe patterns are not well coordinated. Normally, with the initiation of a swallow, there is a pause in breathing and the larynx closes to protect the airway. In children who show no swallowing difficulties, it is reasonable to assume that these protective reflexes will function during an episode of reflux.
There are reports describing children who suffer from chronic congestion and chronic hoarseness having GE reflux. It is thought that aspiration of refluxed stomach contents causes inflammation and swelling of the upper airways and results in noisy breathing (stridor) or spasms of the vocal cords (laryngospasm). If evaluation of the upper airway shows chronic inflammation, it is reasonable to consider GE reflux as a potential source of the symptoms.
The role of GE reflux in apnea (stopping breathing) and bradycardia (slowing of the heart rate) has been of great interest because of the potentially life-threatening nature of these symptoms. Although many studies have shown that infants with apnea may have reflux, there is usually little or no correlation between apneic episodes and reflux episodes. Instances in which apnea and reflux have been directly associated in a cause-and-effect manner are extremely uncommon.
Both children and adults with chronic asthma have an increased incidence of GE reflux. However, it is extremely difficult to know whether reflux causes asthma or asthma causes reflux. Chronic asthma may precipitate reflux because chronic coughing and increased respiratory efforts increase abdominal pressure which tends to force stomach contents upwards. Among children with chronic asthma, the incidence of reflux has been reported to range from 46-75%. In one study, 82% of adult asthmatics had evidence of reflux! Relatively few children with chronic asthma experience significant improvement in their asthma when they are treated for reflux, so while reflux should be considered as a possible cause of uncontrolled chronic respiratory symptoms in children, it is important to remember that many of the trigger factors for wheezing also trigger reflux.