Reflux and Childhood Feeding Disorders

Reflux—The silent enemy

“My child will eat smooth yogurt and loves goldfish crackers, but spits out any texture in between!”

“Susie acts like she is hungry, but when I go to put her in the chair she starts crying… before I even show her any food”

“Ben is so fussy during meals; it is such a struggle to feed him”

What is reflux?

The Pediatric/Adolescent Gastroesophageal Reflux Association (PAGER) defines gastroesophageal reflux as a condition in which stomach contents – food and gastric acid – frequently flow back up out of the stomach and “regurgitate” into the esophagus. How does this fit into feeding complications such as food refusal and picky eating? Simply put, the discomfort caused by painful contents flowing back up into the esophagus before, after, or during eating leads to very negative meal time associations. The reflux doesn’t necessarily have to occur each time your child eats, it just has to create some kind of discomfort at some point and in most cases the discomfort is associated with eating. The complaints quoted above are commonly heard from parents who are referred for feeding evaluations and treatment.

What are the symptoms?

PAGER has put together a list of pediatric reflux symptoms to help parents recognize patterns as early as possible. These symptoms, along with other reported symptoms, are as follows:

• pain, irritability, constant or sudden crying, “colic”
• frequent spitting-up or vomiting
• vomiting or spitting-up more than one hour after eating
• not outgrowing the spitting-up stage
• poor sleep habits, frequent waking
• “wet burp” or “wet hiccup” sounds
• bad breath
• constant eating and drinking (to soothe a sore throat)
• intolerance of certain foods
• poor weight gain; weight loss
• swallowing problems, gagging, choking
• hoarse voice
• frequent red, sore throat
• respiratory problems; pneumonia, bronchitis, wheezing, asthma, nighttime cough, apnea, aspiration, noisy or labored breathing
• ear infections
• constantly running nose; sinus infections
• tooth enamel erosion
• excessive salvation, drooling
• repeated swallowing not associated with eating

Feeding behaviors

Perhaps your child does not exhibit some of the more overt symptoms such as vomiting, coughing, choking, or respiratory symptoms but is becoming more and more challenging at meal time. The following feeding behaviors are commonly seen in children with reflux:

• crying or fussing during meals
• arching back during bottle feedings, often taking only a few ounces at a time
• very picky eater
• often does not tolerate textures on hands or is very fussy when having the face cleaned
• refusing food or accepting only a few bites
• shows signs of being hungry, but does not enjoy eating
• often wants to feed self and raises hand in refusal of spoon

What causes reflux?

The Lower Esophageal Sphincter, or LES, is a sphincter muscle that connects the esophagus to the stomach. When the LES relaxes or opens, stomach contents can flow upward into the esophagus. There are several different reasons for relaxation or opening of the LES including increased pressure on the stomach caused by bending over, wearing tight clothes, straining, overeating.

In many cases increased pressure has no relation at all to the reflux. Many children have food allergies or intolerances that have not been identified. The foods not tolerated well may cause the LES to open. Other triggers may be spicy foods, caffeine, and cigarette smoke. The LES strengthens over time and reflux in infants may be due to the simple fact that it has not matured. Many children with cerebral palsy experience reflux secondary to muscle functioning or lack there of. It is important to consult a specialist if you recognize any reflux symptoms because the same treatment is not designed for all children.

Where can I find more information and what are the treatment options?

If you feel that your child may be suffering from gastroesophageal reflux—whether he is vomiting or is showing the symptoms of ‘silent’ non-regurgitant reflux, contact your pediatrician. Please visit www.reflux.org for a description of the tests designed to study reflux. Your pediatrician will decide whether or not a specific test is needed or if a trial of anti-reflux medication can be prescribed right away. Since reflux does not always occur at the same time and may not be ruled out on an x-ray, many pediatricians support the medication trial and monitor the symptoms.

Should I wait for my child to ‘grow out’ of his reflux?

No. As a speech-language pathologist specializing in pediatric dysphagia, I have seen the feeding complications associated with reflux that has not been treated. You may feel strongly against using medication or you may think that the condition will disappear, but the feeding complications that often arise from reflux are serious and dangerous if not treated. I say dangerous because your child’s picky eating may become so ‘picky’ that his diet only consists of crackers and milk and forcing him to eat will only lead to further refusal and distrust. It may be that your child has a milk intolerance or allergy and a simple formula change or dietary elimination trial is the answer. Treatment is available, please seek help.

Gastroesophageal Reflux and Childhood Feeding Disorders, by: Kristina Starnes, MS, CCC-SLP
Published: August 2006 © Carolina Pediatric Therapy