Thanksgiving is only a couple of days away: turkey, casseroles, mashed potatoes and more! It’s also GERD Awareness Week to raise awareness of the complications of gastroesophageal reflex and to know the symptoms to look out for as you gather around the table. LaQuatre Rhodes, D.O, Gastroenterologist at Cook Children's Specialty Clinics in Prosper, breaks down what parents need to know or look out for when it comes to this common disorder.

What is GERD?

Gastroesophageal reflux is the passage of gastric/food contents into the esophagus with or without regurgitation or vomiting. It is defined as gastroesophageal reflux disease when reflux leads to troublesome symptoms or complications. A muscular valve is at the end of the esophagus to help prevent backflow of food/gastric contents, but when it doesn’t close well, it results in irritation of the esophagus and reflux symptoms. Symptoms of reflux vary by age.

What are the symptoms?

Infant/Toddler reflux symptoms:

•  Crying
• Fussiness
• Back arching
• Regurgitation
• Vomiting
• Dry cough
• Feeding difficulties
• Poor weight gain
• Breathing difficulties (wheezing, pneumonia, stridor, apnea)
• Recurrent ear infections

Older children reflux symptoms:

• Heartburn
• Abdominal pain
• Regurgitation
• Vomiting
• Acidic or sour taste
• Sore throat
•  Hoarseness
• Dry cough
• Difficulty swallowing
• Choking

Gastroesophageal reflux may be seen more in children with certain medical conditions including neurologic impairments, prematurity, and pulmonary problems (ex. cystic fibrosis, asthma, laryngomalacia).

What are the “red flag” symptoms?

Other conditions which can mimic reflux require further evaluation especially in the setting of red flag symptoms. Some of those conditions include infections, pyloric stenosis, brain tumor, meningitis, hydrocephalus, increased intracranial pressure, metabolic disorders, inflammatory bowel disease, obstruction, anatomical abnormalities, and decreased gut motility.

Red Flag Symptoms suggesting a disorder other than gastroesophageal reflux:

• Weight loss
• Lethargy
• Fever
• Irritable, severe crying, or inconsolable
• Seizures
• Bulging fontanelles in infants
• Increased head circumference in infants
• Small head circumference in infants
• Recurrent forceful or projectile vomiting
• Vomiting blood
• Vomiting bile
• Vomiting overnight
• Rectal bleeding
• Bloody stools
• Abdominal distention
• Breathing problems (difficulty breathing, stops breathing, turns blue, wheezing, frequent choking, recurrent pneumonia episodes)

How do you treat GERD?

Reflux can be concerning as a parent, but in the absence of “red flag symptoms” and if the child is gaining weight well, there's no need to worry. Symptoms should improve with time, lifestyle modifications, diet modifications, and/or acid suppression. If at any point your child develops worrisome or alarming symptoms please have evaluated by primary care physician, gastroenterologist if established care, or local emergency department.

If there are no red flag symptoms present, initial management of GERD is conservative:

Lifestyle modifications

• Staying upright at least 30 minutes after meals
• Burping infants during feeds
• Avoid tobacco smoke exposure
• Avoid tight diapers or elastic waistbands
• Weight loss if child overweight or obese
• Elevate head of bed 30 degrees

Diet modifications

• Thickening feeds with cereal or thickeners
• Formula change to hydrolyzed or amino acid based formula
• Avoid overfeeding
• More frequent smaller meals
• Avoid eating at least 2-3 hours before bedtime in older children
• Avoid large meals before exercise or increased activity
• Avoid acidic foods (ex. pickles, red sauces, citrus) spicy foods, carbonated drinks (ex. sodas, seltzer beverages), high fat foods, chocolate, and caffeine

Trial acid suppression for 4-8 weeks which may be extended longer based on clinical response and/or physician assessment.

• Proton Pump Inhibitors (ex. omeprazole, pantoprazole, lansoprazole, esomeprazole)
• Anti-histamine (ex. Famotadine, Cimetidine, Ranitidine, Nizatidine)

If alarming or worsening symptoms despite initial management, physician may proceed to gastroenterology referral and/or further evaluation including:

• Esophagogastroduodenoscopy (EGD)
• pH probe
• Abdominal ultrasound
• Barium studies (ex.  Upper GI series, esophagram, swallow study)
• Motility studies
• Severe reflux resulting in complications must consider surgery referral for Nissen fundoplication if not responding to medications and no other disorder cause of severe vomiting.

But when the fussiness symptoms are severe and consistent with reflux or the baby is not gaining weight well, treatment with an acid reduction medication is considered.

One common medication is a group of acid reducers known as H2-blockers, with the most common example containing ranitidine.

Ranitidine is in the news right now because the FDA recently reported that they had found small amount of a potentially cancer causing chemical in brand name and generic Zantac (ranitidine) products.

CVS Pharmacy has stopped selling products which contain ranitidine (Zantac as well as its generic version of the heartburn medication) until further notice.

According to the FDA, Zantac has potential cancer-causing chemicals. But those are found in anything else we eat, breathe, sleep, live on.

For now, here’s what we do know:

1. There are likely many babies who have been placed on ranitidine unnecessarily for what is normal fussiness or normal spit up.
2. There are also likely many babies and children who have been started on Zantac but no longer need the medication and have been passively continued on it.

We don’t know the long-term effects, but this is your baby we are talking about. So, even if the risk is minimal it would be reasonable to consider your baby's case and have a conversation with your doctor about whether coming off the medication might be the right thing to do anyway.