Prevalence and Determinants of Gastroesophageal Reflux Symptoms in Adolescents

Jiann-Hwa Chen; Hsin-Yi Wang; Hans Hsienhong Lin; Chia-Chi Wang; Li-Yu Wang


J Gastroenterol Hepatol. 2014;29(2):269-275. 

In This Article


In the present population-based study, we found that GERD symptoms were common in adolescents. We also found that asthmatic and food-related allergic symptoms were both independently correlated with GERD symptoms. To our knowledge, there were a few population-based adolescent GERD studies, and none of them had explored the relationships among GERD, asthma, and food-allergy simultaneously. This study also provided evidences about the etiology of GERD.

In our study, the cumulative and 3-month prevalence rates of adolescent GERD symptoms were 20.5% and 8.9%, respectively. The first published population-based adolescent GERD studies, which enrolled students from six Seattle middle schools, reported an overall prevalence of GERD symptoms of 6%.[29] In another study conducted by Gunasekaran and coworkers, which enrolled 1286 adolescents aged 14–18 years, the prevalence rate of at least one esophageal symptoms were as high as 40%.[12] In Gunasekaran's subsequent study, 18% of the adolescents had at least one esophageal symptoms occurred at least once per week.[30] Although the definitions, instruments, and measurements of GERD symptoms were varied, all these former studies demonstrated that GERD symptoms were frequent in adolescents, and its impact needs further and prompt exploration.

An increased prevalence of GERD symptoms in subjects who had food-related allergic symptoms was observed in the present study. When we restricted allergic symptoms related to animal milks and dairy products, the multivariate-adjusted OR of cumulative or 3-month prevalence rates of GERD symptoms were both significantly elevated (adjusted OR, 2.12 [1.23–3.67] and 2.41 [1.15–5.05], respectively). Our findings were consistent with previous studies in infants and toddlers.[31–33]

Adolescents who had asthmatic attacks were at elevated odds of having GERD than healthy adolescents, which were consistent with previous researches.[29,34] In Thakkar's review on GERD in children, the average prevalence rates were 22.0% in asthmatics and 4.8% in controls (pooled OR: 5.6; 95% CI: 4.3–6.9).[15] In the present study, we found the multivariate-adjusted OR of 3-month prevalence of GERD symptoms for subjects who had asthma attacks at least 1 year before the survey was significantly elevated (OR: 2.26; 95% CI: 1.28–3.93). These results imply that asthma is more likely to be the risk determinant of GERD. Despite all of the advances in our understanding of the correlation between asthma and GERD, it still has not been established whether the treatment of asthma influences the clinical and functional evolution of GERD.

The significant associations between smoking and GERD were well documented in adult studies.[4,8,10,35] A significantly higher prevalence of GERD in smokers than nonsmokers had been reported by a population-based adolescent study.[12] In the present study, we found that adolescents who had ever smoked cigarette had 1.5–1.6-fold higher odds of cumulative prevalence of GERD symptoms. A stronger association with the 3-month prevalence of GERD symptoms was observed. These figures indicated that cigarette smoking was more likely to be a risk determinant rather than a risk marker of GERD symptoms.

Adolescents lived in bi-ethnic family were found to have significantly elevated likelihoods of GERD symptoms than those who lived in uni-ethnic family. The cultures, dietary patterns, lifestyles, family processes, and parenting are different between Han Chinese and aborigines.[36] Several studies have documented significant variations in morbidity of internalizing disorders and stress exposure among different ethnic groups.[37,38] Significant relationships between psychosocial factors and the development of a broad array of gastrointestinal disorders had been reported.[39,40] A recent animal study demonstrated that acute stress can increase esophageal permeability, which shed light on the patho-physiological mechanism of GERD.[41] However, further research is needed to identify specific ethnic-related factors that contribute to the development of GERD.

There were several strengths of the present study. First of all, this was a large population-based study, leading to the results more likely reflect the general adolescent population. Our study also was the first population-based association study in this age group in Asia and the third worldwide. Secondly, to our knowledge, the present study was the first one that explored the relationships among GERD, asthma, and food allergy simultaneously. Lastly, the use of the validated ISAAC video questionnaire,[25] which had long been in large scale surveys in Taiwan,[26,27] to assess the presence of asthmatic symptoms.

However, there was a limitation of the present study. As with other studies using self-reported data, report error and bias may be present. To reduce their influences, we made several efforts. Firstly, we performed two pretests to make sure that the questionnaire items were appropriate for students with grade 7 level of literacy. For example, the medical terms of atopy, including atopic dermatitis, allergic rhinitis, allergic conjunctivitis, and urticaria, were replaced by more common terms in the final version of questionnaire. Secondly, to promote the understanding of GERD questionnaire, we offered a picture of upper part of the body, and the locations of gastroesophageal junction, sternum, and throat were highlighted. Lastly, detail descriptions about each questionnaire item were made by one of the coauthor (HY Wang) before students started to fill. The 2-week test-retest reliability was not very high but acceptable. More importantly, because of the study subjects were unknown about the study hypotheses, it was likely that the information bias was nondifferential, and the true figures of association between GERD symptoms and either asthma or food allergy should be larger than the observed estimates.

In conclusion, we found that GERD symptoms were common in adolescents, and its presence was significantly correlated with asthma and food-related allergic symptoms. It cannot be overemphasized that health-care providers of adolescents should recognize that GERD symptoms are common and adolescents should be questioned about these symptoms as a part of their preventative health-care visits. This may help early detection and diagnosis of GERD, minimizing or even preventing its long-term complications and improving quality of life of the adolescents.