Apple juice and gastroesophageal reflux disease
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Apple Juice and Gastroesophageal Reflux Disease (GERD) in Children
Apple Juice Feeding and GERD Frequency
Research shows that apple juice can increase the frequency and duration of gastroesophageal reflux (GER) episodes in children, especially within the first two hours after feeding. Both asymptomatic and symptomatic children experience frequent GER after apple juice, but symptomatic children tend to have longer-lasting episodes. In comparison, milk-formula feedings result in less esophageal acidity during this period. This suggests that clear liquids like apple juice are more likely to provoke GER episodes shortly after consumption, and this effect is considered physiologic in children, particularly within the first two hours post-feeding .
Mechanisms of Reflux After Apple Juice
The main mechanism behind GER after apple juice feeding in children is transient lower esophageal sphincter relaxation (TLESR). This is true for both children with and without esophagitis, although those with more severe disease may also experience reflux due to gradual drifts in lower esophageal sphincter pressure. After apple juice feeding, the rate of TLESR and the percentage of these relaxations associated with reflux increase significantly, leading to greater esophageal acid exposure compared to the fasting state 36.
Patterns of Reflux and Gastric Emptying
Infants show different patterns of GER after drinking apple juice. Some have continuous reflux and may have large hiatal hernias, while others have discontinuous reflux linked to delayed gastric emptying and motility disorders. A mixed pattern with features of both is also observed. However, measured gastric emptying of apple juice is generally similar in children with and without GER, and many children with GER actually show increased effective gastric emptying when postcibal reflux is accounted for 45.
Thickened Apple Juice and GERD Management
Thickening apple juice with rice cereal does not consistently reduce GER episodes in infants. In fact, in some positions, such as the 30-degree prone position, thickened feedings can increase reflux time. The effect of thickened feedings on GER is unpredictable, and a significant portion of infants may experience increased reflux after thickened apple juice .
Post-Surgical Considerations
In children with neurological impairment who have undergone antireflux surgery (Nissen fundoplication), recurrent GER is still most commonly caused by transient LES relaxation after apple juice feeding. This highlights the persistent role of TLESR in GER, even after surgical intervention .
Conclusion
Apple juice feeding is associated with increased frequency and duration of gastroesophageal reflux episodes in children, especially within the first two hours post-feeding. The main mechanism is transient lower esophageal sphincter relaxation, and thickening apple juice does not reliably reduce reflux. These findings suggest that clear liquids like apple juice can provoke physiologic GER in children, and management strategies should consider the type of feeding and underlying mechanisms of reflux.
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