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The
Challenge of Detecting GERD in Children with “Unique” Conditions
By Lesley Bennett
When
a child is vomiting, experiencing pain, or having trouble
breathing, a parent’s natural reaction is to try and find some
way to help. The dilemma for parents, and even physicians,
caring for a child with an undiagnosed disorder (or “unique”
medical condition) is figuring out when a child’s symptoms are
caused by the child’s underlying disorder, due to a common
childhood ailment, or signs of a new or additional (secondary)
disease. This challenge is particularly difficult when a child
with a “unique” medical condition develops gastrointestinal (GI)
problems. Abdominal pain, vomiting, irritability, refusing to
eat, difficulty swallowing, or coughing can all be signs of
common childhood GI problems, or symptoms of pediatric
conditions such as neurological disorders, allergies,
mitochondrial dysfunction, metabolic disease, seizure disorders,
congenital malformations, or chronic respiratory disease. Yet,
these symptoms may also be major signs of a very serious GI
disease that is often a secondary condition in children with
“unique” or medically complex conditions called
Gastro-Esophageal Reflux Disease (GERD). The North American
Society of Pediatric Gastroenterology, Hepatology, and Nutrition
(NASPGHAN) estimates that 10% of all children develop GERD.
According to NASPGHAN, the percentage of children with “unique”
or medically complex conditions who develop GERD as a secondary
condition is probably higher since these children have many of
the factors that make them more likely to develop GERD such as:
delayed gastric emptying, severe constipation, premature birth,
malformations in the GI tract, side effects from medications,
hypotonia, developmental delays, feeding problems, neurological
conditions, asthma, or impaired muscle function. Unfortunately
GERD is often overlooked in children with “unique” medical
conditions, and this puts them at risk for developing many of
the severe or life threatening complications of GERD such as
anemia, GI bleeding, apnea, recurrent pneumonia, or malnutrition
(“failure to thrive”).
Although signs of GERD are often present in infants with
“unique” medical conditions, these early symptoms can be very
subtle and even look like typical baby or toddler problems. For
instance, Gastro-Esophageal Reflux (GER), or acid reflux as it
is often called, is a common problem in infants and young
children. It is a condition where stomach contents flow back
(reflux) up the esophagus into the throat and mouth causing an
infant to spit up (vomit) or regurgitate. GER is often caused by
a weakness or malfunction in the muscle at the lower end of the
esophagus called the lower esophageal sphincter (LES). Since the
esophagus does not have a special lining like the stomach to
protect
it from the harsh actions
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body’s digestive acids, the LES acts as a barrier or valve
that separates the stomach and esophagus. The LES opens to
let food pass from the mouth down the flexible, muscular
esophagus into the stomach (or occasionally allow gas,
burps, or sometimes vomit to pass back up the esophagus),
and then closes tightly protecting the esophagus by keeping
the food and acids in the stomach for digestion. When
children are very young, their muscles have not fully
developed and often the LES is weak or relaxes allowing the
contents of a child’s stomach to seep back up (reflux) into
the esophagus, especially when the child lies down to
sleep. Most young children outgrow GER by the time they are
12 to 18 months old and their muscles, including the LES,
become stronger. However, in some children, (especially
children with neurological or muscular conditions) the LES
may remain weak which can allow stomach acid to constantly
flow into esophagus and this constant exposure of the
esophagus to stomach acid creates a major problem. Over time
the acid can burn or damage the lining of the esophagus, and
this damage is called GERD. Since many children with
“unique” medical conditions have risk factors that can cause
the LES to malfunction, or the GI tract to stop functioning
properly, parents and pediatricians need to be aware of the
complications and symptoms of GERD.
Esophagitis is an inflammation of the esophagus that can
often be the first sign of GERD in children. Stomach acid
constantly refluxing up the esophagus often irritates the
lining of the esophagus causing some pain, swelling, and
redness (Esophagitis). Some children with Esophagitis
develop a chronic cough, hoarseness, chest pain, vomiting,
or difficulty swallowing, while other children may have no
symptoms at all. Since Esophagitis can also be caused by
other conditions such as infections or medication reactions,
a pediatrician or parent can easily miss this condition as
an early sign of GERD. If GERD goes unnoticed and
untreated, stomach acid constantly flowing into the
esophagus, and even into the throat, can cause more serious
damage. A child may start to aspirate or inhale some of the
stomach contents into the lungs causing severe chronic
respiratory problems such as asthma, apnea (stop breathing),
bronchitis, or recurrent pneumonia. Over a period of months
or years stomach acid can also slowly erode or eat away at
the lining of the esophagus causing a condition called
Erosive Esophagitis. Erosive Esophagitis is a serious
complication of GERD that is very painful and can be life
threatening for medically fragile children. The erosive
action of stomach acid can cause scarring, strictures,
ulcers, sores, or even change the make up and function of
the esophagus. Often the ulcers, or sores, caused by
erosions in the lining of esophagus can bleed when a child
tries to eat, and this is a major cause of anemia or GI
bleeding. Scarring, or scar tissue, from GERD can
build
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