Risk Factors
GERD occurs monthly in about half of American adults and weekly in about 20%. People of all ages are susceptible to GERD. Elderly people with GERD tend to have a more serious condition than younger people.
Risk Factors for Heartburn, GERD, or Both
Eating-Pattern Risk Factors. Anyone who eats a heavy meal and subsequently lies on the back or bends over from the waist is at risk for an attack of heartburn. Anyone who snacks at bedtime is at high risk for heartburn.
Pregnant Women. Pregnant women are particularly vulnerable to heartburn in their third trimester as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even antacids.
Obesity. A number of studies suggest that obesity contributes to GERD and may increase the risk for erosive esophagitis in GERD patients. Not all studies, however, support any strong link between GERD and obesity and more research is needed. A few experts believe that the increasing prevalence in obesity may play some role in the dramatic rise in esophageal cancer (although a less healthy diet in these people -- not GERD -- is likely to be the factor in any higher risk for cancer).
People with Respiratory Diseases. People with asthma are at very high risk for GERD. A study also indicated that patients with chronic obstructive pulmonary diseases (e.g., emphysema or chronic bronchitis) were more likely to have GERD.
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| Chronic obstructive pulmonary disease (COPD) refers to chronic lung disorders that result in blocked air flow in the lungs. The two main COPD disorders are emphysema and chronic bronchitits, the most common causes of respiratory failure. Emphysema occurs when the walls between the lung's air sacs become weakened and collapse. Damage from COPD is usually permanent and irreversible. |
Smokers. Evidence is increasing that smoking increases the risk for GERD. Studies have suggested that smoking may reduce LES muscle function, increase acid secretion, impair muscle reflexes in the throat, and damage protective mucus membranes. Smoking reduces salivation, which helps neutralize acid. Whether it is the smoke, nicotine, or both that triggers GERD is not clear. Some people who use nicotine patches to quit smoking, for example, experience heartburn, but it is not clear if its the nicotine or stress that produces acid back-up.
Alcohol. Alcohol has mixed effects on GERD. It relaxes the LES muscles and, in high amounts, may irritate the mucous membrane of the esophagus. All alcoholic beverages increase stomach acid levels. A combination of heavy alcohol use and smoking even increases the risk for esophageal cancer. (Small amounts of alcohol, however, may actually protect the mucosal layer.)
Risk Factors for Severe GERD
In general, overweight Caucasian males over 40 are at highest risk for complications, notably Barrett's esophagus. A 2001 study also reported that the following people with GERD are at risk for severe symptoms, inflammation, or both:
- People who use nonsteroidal anti-inflammatory drugs (NSAIDs). Studies suggest that certain NSAID users are at higher risk for GERD, including older adults, women, alcohol and tobacco users, and patients with asthma, hiatal hernia, or obesity. One study reported that NSAIDs put people at risk for ulcers but not for erosive esophagitis or strictures. Interestingly, NSAIDs are being studied for protection against Barrett's esophagus.
- People with hiatal hernia.
Gastroesophageal Reflux Disease in Children
High-Risk Children
As with adults, GERD is very common in children of all ages, but it is usually mild. Heartburn has been reported in 1.8% of three-year-olds and in 5.2% of young people between 10 and 17 years old. Children at higher risk for severe GERD are those with the following conditions:
- Neurologic impairments.
- Food allergies.
- Scoliosis.
- Cyclic vomiting.
- Cystic fibrosis.
- Problems in the lungs, ear, nose, or throat.
- Any medical condition affecting the digestive tract.
Symptoms in Children
A physician should examine any child who has the following symptoms as soon as possible, particularly if these are signs of complications such as anemia, failure to gain weight, or respiratory problems. Symptoms of severe GERD in infants and small children may include, among others:
- Chronic coughing.
- Frequent infections.
- Wheezing.
- Gasping or frequent cessation in breathing while asleep (called apneas). (It should be noted that a 2001 study found no association between GERD and apneas in premature infants.)
- Frequent vomiting in infants. It should be noted that about half of all infants up to three months regurgitate milk at least once a day. Some simply spit up; others vomit large amounts after feedings. Vomiting in infants and older children is rarely a sign of GERD. Severe vomiting -- particularly if it is bilious ("green") -- should always be checked out with a physician, since it could be a symptom of severe obstruction.
- Having to burp babies very frequently during and after feeding.
It should be noted that babies and children experience may of these symptoms without having GERD. And, an Australian study suggested that many infants who have normal irritability may be treated inappropriately for reflux disorders.
Complications in Infants and Children
Feeding Problems. Feeding problems may be more severe than is previously thought in children with GERD. In one study, children who had GERD and problems swallowing tended to refuse food and were late in eating solids. They also cried more and reacted more negatively in general than non-GERD babies. Such behaviors negatively affected the mothers as well. These findings were supported in an earlier study when it was reported that children at one year, who had GERD in infancy, were no longer spitting up, but still tended to have negative dining experiences ("too slow," "upsetting"). It should be noted that these children were at no greater risk for respiratory illnesses than other one-year olds.
Associations with Asthma and Infections in the Upper Airways. GERD has become associated with asthma and many upper airway problems, including ear infections and sinusitis. Some experts argue that the association with common childhood infections and asthma is unfounded, since GERD is normal in most children.
Dental Erosion. GERD can cause irreversible loss of tooth enamel. Based on a 2002 study, some experts suggest checking for GERD in children with dental erosions. In the study, no child without GERD experienced loss of tooth enamel.
Rare Complications in Infants. Although GERD is very common, the following complications are very rare and only occur in certain cases:
- GERD may cause failure to thrive.
- Feeding problems and severe vomiting may cause anemia.
- Acid back-up may be inhaled into the airways and cause pneumonia.
The infant's life may be in danger if acid reflux causes spasms in the larynx severe enough to block the airways. In fact, some experts believe this action may contribute to sudden infant death syndrome (SIDS). More research is needed to determine whether this association is valid.
Managing GERD in Infancy
Here are some hints on managing GERD in infants:
- During and after feeding, infants should be positioned vertically and burped frequently.
- If a baby with GERD is fed formula, a mother should ask the doctor how to thicken it in order to prevent splashing up from the stomach.
- Parents of infants with GERD should discuss baby's sleeping position with their pediatrician. Experts strongly recommend that all healthy infants sleep on their backs to help prevent sudden infant death syndrome (SIDS). For babies with GERD, however, lying on the back may obstruct the airways. In one study for example, infants with gastroesophageal reflux who spent prolonged periods of time in infant seats, including car seats, had more reflux than those who spent waking time on their stomachs. If the physician recommends that babies with GERD sleep on their stomachs, parents should be sure that their infant's mattress is very firm, possibly tilted up at the head, and that there are no pillows. The baby's head should be turned so that the mouth and nose are completely unobstructed.
- Because food allergies may trigger GERD in children, parents may want to discuss a dietary plan with their physician that starts the child on formulas using non-allergenic proteins, and then add other foods back one at a time until symptoms are triggered.
Managing GERD in Children
The same drugs used in adults may be tried in children with chronic GERD. It is very important to note that some of the drugs are available over the counter but no one should give them to children without physician supervision.
- Milder medications, such as antacids, are used first.
- H2 blockers may be tried next. They are available over the counter and include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). The FDA has issues a warning on Pepcid AC for adults with kidney problems.
- Proton-pump inhibitors, such as omeprazole (Prilosec) and lansoprazole (Prevacid), are even more powerful agents that suppress the production of stomach acid. They appear to be safe and effective even for children as young as one year old who fail the less intensive therapies. Lansoprazole is available in flavored liquid form and has been approved for children.
Until recently, surgery was the primary treatment for children with severe complications from GERD, because drug therapies previously used had severe side effects, were ineffective, or had not been designed for children. With the introduction of the proton-pump inhibitor drugs, some children may be able to avoid surgery.
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