Article

Acid Reflux: Causes, Symptoms, Diet, and Remedies
February 01, 201901,080

What is Acid Reflux?

The process of digestion starts even before the first spoonful of food is in your mouth. The thought of your favorite meal, the smell of dinner cooking when you’re hungry – these experiences initiate the digestive process.

Stimulated by food smells, or even by your imagination, your mouth begins to water (salivate) and your stomach increases the production of acid. This production of stomach acid is normal. Stomach acid is needed to digest certain foods, especially proteins. Stomach acid is also needed to aid the absorption of minerals.1

Once food is in your mouth, an enzyme in saliva, known as salivary amylase, starts to break food down into absorbable nutrients. The process of enzymatic breakdown is further enhanced by chewing.1

As food is swallowed, it travels down into your throat, from your throat into your esophagus, and ultimately enters your stomach through the lower esophageal sphincter. The lower esophageal sphincter, or LES, is a muscular ring that opens to allow food to pass from the esophagus into the stomach. Once food goes into the stomach, the LES closes to prevent food and fluid from traveling back up into the esophagus.1,3

Sometimes, the LES relaxes, is weakened, or for other reasons does not function properly. Malfunction of the LES may allow some stomach acid (and sometimes bile) to reflux (come back up), from the stomach into the esophagus. This is referred to as acid reflux.1-2

Acid reflux may be referred to as “heartburn” because of its hallmark symptom – a burning sensation in the chest. The burning sensation is caused by stomach acid flowing back from your stomach into your esophagus. Stomach acid is irritating to your esophagus and can cause esophagitis, or, inflammation of the esophagus.6

What are GER and GERD?

Acid regurgitation, a feeling of fluid and even small pieces of food coming up the esophagus into the throat or even into your mouth, is a symptom of gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD).3

When reflux happens from time to time, it is referred to as “acid reflux,” or “gastroesophageal reflux,” or “GER” for short. When reflux happens on a frequent, chronic basis, it is referred to as gastroesophageal reflux disease, or “GERD” for short.2

GER and GERD are experienced by people world-wide. The rates of GER and GERD have increased as obesity has become more commonplace.4 As body mass index (a measure of weight and obesity) increases, the frequency of GER/GERD symptoms increases as well.5-6 It is estimated that 60% of adults in the United States have at least one episode of acid reflux per year.6 At least 20% of the U.S. population experiences reflux symptoms once per week or more.6,7

Acid Reflux Causes

While we know that acid reflux happens because of relaxation, weakness or malfunction of the LES, it is not always clear what causes these problems with the sphincter. Some theories include3,4,8:

  • Stomach and bile acids have a lower pH (are more acidic) than what is normal in the esophagus. The tissue of the esophagus can be damaged if acidic fluid from the stomach is not readily cleared from the esophagus.
  • Disorders that affect the peristalsis (the wave-like muscle activity that propels food and fluid down) of the esophagus may predispose you to GER or GERD.
  • Poor stomach emptying, associated with conditions such as diabetes, viral infections, and neurological diseases such as Parkinson’s disease, likely contribute to GER and GERD.
  • The role of hiatal hernia (when part of the stomach bulges into the chest through part of the diaphragm) in GER and GERD is controversial. Some people with reflux have a hiatal hernia while others do not.

Acid Reflux Symptoms

  • Burning sensation in your chest. “Heartburn” is the most common symptom of acid reflux. Heartburn feels like a burning in your chest anywhere from the top of your stomach into your throat. The pain may be worse if you bend over or lie down.3,8
  • Bitter taste in your mouth. Acid reflux can cause a sour, salty, hot or acidic taste in the back of your mouth.3,8
  • Difficulty swallowing.3,8
  • Chest pain. Chest pain is not a typical symptom of acid reflux, but may be the only symptom that you have. The chest pain associated with acid reflux so closely resembles the chest pain associated with heart problems that you would be more likely to see your cardiologist first. Once your healthcare provider is sure that you don’t have any heart problems, or, that it is not a heart problem that is causing your pain, you may be sent to a gastroenterologist (stomach specialist) for evaluation.3,8
  • Cough and sore throat. GER and GERD may cause a cough, sore throat or hoarseness.3,8

Diagnosis of Acid Reflux

The diagnosis of acid reflux is usually based on symptoms alone.9 If the usual remedies provide relief, the diagnosis is confirmed. If symptoms resolve with treatment, no tests are necessary.

  • Upper endoscopy. If your symptoms do not improve with the usual medications, the first test your health care provider would order would be an upper endoscopy. During an upper endoscopy, a skinny, flexible tube with a camera and light at the tip is put through your mouth, into your esophagus, stomach and upper intestine. The camera allows your doctor to see if there is any inflammation, damage or other lesions (such as ulcers, tumors, or polyps) in your esophagus, stomach or upper intestine which may be causing your symptoms. Depending on the findings, this test can help determine whether or not you have GERD. The test is usually done under sedation to avoid discomfort.9
  • Manometry. Manometry is used to measure the function of the muscles in your esophagus and the tone of your LES. During the test, a catheter (a thin tube) is passed through your nose, down your throat, then into your esophagus and stomach. Sensors along the catheter test the strength of your LES and esophageal muscles.9
  • 24-hour pH study. The 24-hour pH study detects stomach acid refluxing into your esophagus. The test can determine how often reflux is happening, and for how long the acid stays in the esophagus during a 24-hour period. During the test, a thin tube is passed through your nose, down your throat, and then into your esophagus. A monitor at the end of the tube measures pH. The tube remains in place for 24 hours, during which time you record your symptoms.9

Remember, these diagnostic tests are used more to identify complications and to exclude other causes of your symptoms than it is to diagnose GERD itself.9

Special Cases of Acid Reflux

Acid Reflux in Babies

Gastroesophageal reflux is not uncommon (is normal) in infants as they have small stomachs and tend to eat large amounts with each feeding, usually while lying down. Symptoms of GER in an infant include “spitting up,” or even more forceful vomiting right after eating. Most babies do not require treatment, and will grow out of this within a year.10

Symptoms of GERD in an infant (child less than one year of age) include11:

  • Refusing to eat
  • Vomiting
  • Respiratory symptoms such as coughing, choking and wheezing
  • Irritability
  • Poor sleep
  • Poor weight gain

In a breastfed infant, acid reflux is first addressed by changing the mother’s diet. Initially, the mother should eliminate all dairy and eggs from her diet. If the infant’s reflux symptoms improve, the mother should continue to exclude these foods from her diet.11

If the infant continues to experience symptoms of GER or GERD, it may be necessary for the mother to exclude other foods from her diet. After excluding dairy and eggs, a sequential trial of excluding wheat, peanuts, tree nuts and fish. This dietary exclusion continues until the offending food or foods is identified.12

Changing the type of infant formula may produce relief of GER or GERD symptoms in infants who are formula-fed. Formula-fed infants with GER or GERD may benefit from a hydrolyzed protein or amino acid-based formula.13

As finding relief is often a game of trial and error, other tricks can be tried. Sometimes, reducing the amount of breastmilk or formula at every feeding while increasing the frequency of feedings can help. Keeping the infant upright during and after feedings may help as well.13

Formula-fed babies have a higher risk of GER and GERD than breastfed babies.11

Acid Reflux in Children and Adolescents

Acid reflux and GERD are easier to diagnose in children and adolescents than in infants because their symptoms are more likely to resemble the symptoms of adults with GER and GERD.14

Symptoms of GER and GERD in children and adolescents include14:

  • Heartburn or stomach pain
  • Frequent vomiting
  • Difficulty swallowing
  • Respiratory symptoms such as chronic cough and hoarseness
  • Asthma
  • Frequent pneumonia
  • Dental erosion

If necessary, some of the tests that are done for adults can also be performed on infants, children and adolescents.14

Acid Reflux in Pregnancy

Acid Reflux in Early Pregnancy

Acid reflux in early pregnancy is usually caused by progesterone – one of the pregnancy hormones. Progesterone causes the muscles of the esophagus, including the LES, to relax. As the LES relaxes, stomach contents more easily escape into the esophagus.15

Tips to reduce the symptoms of acid reflux in early pregnancy include115:

  • Eating small, frequent meals
  • Reducing the amount of fluid consumed with meals
  • Trying not to eat or drink for at least three hours before going to bed
  • Avoiding triggers
  • Increasing physical activity
  • Taking over-the-counter antacids, such as TUMS
  • Asking your doctor for prescription medication

Acid Reflux in Later Pregnancy

Acid reflux in the third trimester is theoretically a mechanical issue. Upward displacement of the stomach puts pressure on the lower esophageal sphincter, which is already relaxed due to progesterone. The upward pressure of the growing pregnancy pushes open the LES, allowing stomach contents to flow upwards into the esophagus.15

Women pregnant in the third trimester with GER or GERD may benefit from15:

  • Sleeping with the head of the bed elevated, or sleeping in an upright position
  • Eating small, frequent meals instead of a few large meals every day
  • Avoiding offending foods
  • Taking an over-the-counter antacid, such as TUMS
  • Taking prescription medications if nothing else works.

Acid Reflux Treatment and Remedies

The first approach to treating acid reflux is usually lifestyle modification – changing the things you do (or don’t do) and the things you eat.16

Your doctor may recommend16-17:

  • Diet modification – Some foods commonly cause acid reflux to flare up. Avoid chocolate, coffee, peppermint, fatty foods, spicy foods, tomatoes and tomato products, and alcohol
  • Stop smoking
  • Obtain and maintain normal weight (obesity, being overweight, increases risk of acid reflux)
  • Avoid large meals. Eat small, frequent meals instead.
  • Avoid lying down for at least three hours after eating

If lifestyle modifications are not effective, you may need to take medication on an “as needed” basis.16

Over-the-counter antacids are one type of medication used to treat acid reflux. Antacids do not reduce the production of stomach acid. Antacids neutralize stomach acid, providing immediate heartburn relief.16

Some over-the-counter antacids include16,18:

  • TUMS
  • Maalox
  • Mylanta
  • Alka-Seltzer
  • Milk of Magnesia
  • Rolaids

H2 Blockers as a Treatment for Acid Reflux

H2 blockers (also called H2 antagonists, H2 receptor blockers, or histamine antagonists) are another type of over-the-counter medication. H2 blockers block acid from being produced in the stomach.16

Some examples of H2 blockers include16:

  • Pepcid (famotidine)
  • Tagamet (cimetidine)
  • Zantac (ranitidine)

Proton pump inhibitors as a Treatment for Acid Reflux

Proton pump inhibitors (PPIs) also block the production of acid in the stomach.16 In addition, PPIs reduce the risk of bleeding ulcers, which can be a complication of GERD.16

Some examples of proton pump inhibitors includex16:

  • Nexium (esomeprazole)
  • Prevacid (lansoprazole)
  • Prilosec (omeprazole)
  • Protonix (pantoprazole)

Proton pump inhibitors can be purchased over-the-counter, or obtained with a prescription from your healthcare provider.16

Complementary and Alternative Medications and Therapies to Treat Acid Reflux

Various complementary and alternative therapies have been tried to treat the symptoms and prevent complications from GER and GERD. There is not as much scientific support for these therapies as there is for medications.

Some of these therapies include:

  • Papaya enzyme—contains papain, an enzyme that theoretically aids digestion.20
  • Citrus fruits—high in vitamin C. It is likely that eating citrus fruits can reduce the risk of esophageal cancers, probably due to the anti-inflammatory and anti-oxidants properties of citrus fruits.21
  • Aloe juice—like citrus fruits, has antioxidant and anti-inflammatory properties.22
  • Chewing sugar-free gum—chewing gum increases saliva, which increases swallowing. Swallowing may help flush the contents of the esophagus back into the stomach.23

Surgery and Other Procedures to Treat Acid Reflux

Surgery to treat GERD is considered a last resort. Surgery is considered only if all other therapies have failed.16

  • The most common surgery for treating GERD is a procedure called a fundoplication. During a fundoplication, the surgeon tightens the LES. When the LES closes more tightly, less stomach acid can reflux into the esophagus.16
  • A newer procedure can be done without a surgical incision. During this procedure, an endoscope is inserted through your mouth and into your stomach. The endoscope which is used during the procedure has a tiny electrode at the end of it. The electrode uses radiofrequency energy (intense heat) to dull the nerves in the lower part of the esophagus.16
  • The LINX procedure involves placing a magnetic ring to reinforce the lower esophageal sphincter.24
  • Gastric bypass surgery may be recommended for people who are severely obese, especially if there is some certainty that the person’s GERD is caused by obesity.24

Acid Reflux Diet: Foods That Cause Acid Reflux and Foods to Avoid

Different foods affect different people in different ways. A type of food that causes you to have acid reflux may have no effect on your friends or family members. There are some foods which cause acid reflux more commonly. These foods include17,25:

  • chocolate
  • coffee
  • peppermint
  • fatty food
  • tomatoes
  • citrus foods
  • alcohol
  • spicy foods

Prevention of Acid Reflux

The best way to prevent acid reflux is by staying healthy overall. Obtaining and maintaining a normal weight is one of the most significant things you can do to prevent GER and GERD.27 Get adequate exercise every week. Eat a balanced diet that is full of fresh vegetables and fruits, whole grains and lean proteins.27

Barrett’s Esophagus and Acid Reflux: How Are They Related?

Barrett’s esophagus is a condition in which the tissue lining of the esophagus is replaced with tissue that is more similar to the lining of the intestines. The cause of Barrett’s esophagus is unclear. Many people with Barrett’s esophagus have GERD, and therefore have symptoms of GERD. Barrett’s esophagus has no specific symptoms itself.26,27

Barrett’s esophagus is considered to be a precancerous condition of the esophagus. Barrett’s can be a complication of long-standing gastroesophageal reflux disease. When acid reflux causes chronic inflammation in the esophagus, the cells that line the esophagus change. These cellular changes can cause pre-cancer, and even cancer. Pre-cancer and cancer can be diagnosed by taking biopsies from the esophagus. Barrett’s esophagus is treated with proton pump inhibitors (similarly to GERD). The surgeries done to treat GERD will also often treat Barrett’s. Should cancer develop, you would need treatment by a specialist.27-29

Acid Reflux FAQs

  • Is acid reflux serious? Acid reflux that occurs from time to time is not considered serious.2 Chronic acid reflux, or gastroesophageal reflux disease (GERD), can be serious if untreated. Chronic exposure to stomach acid can cause damage to the esophagus. The damage may be in the form of erosion, causing ulcers which may or may not bleed.2 The damage may lead to Barrett’s esophagus, a condition in which the tissue lining the esophagus is replaced with tissue that is more similar to the lining of the intestines. Barrett’s esophagus is a precancerous condition associated with long-term (usually >10 years) GERD.26-29
  • Is acid reflux genetic? Acid reflux is a normal experience that most people experience from time to time. GERD (gastroesophageal reflux disease), which is the chronic experience of acid reflux, appears to have a complex genetic component.30 Genetics alone does not cause GERD. Lifestyle habits – especially obesity and smoking – also contribute to an individual’s chance of developing GERD.2,30
  • Can heartburn be a sign of something serious? Heartburn, especially if it is relieved with an antacid, is not usually a sign of something serious.2 For some women, however, symptoms similar to heartburn might actually indicate a heart attack.31
  • Is acid reflux ever treated with surgery? Acid reflux does not require surgery. Gastroesophageal reflux disease may be treated with surgery if your reflux is not relieved with lifestyle changes and medications.16
  • Does milk help acid reflux? There is no scientific evidence to support drinking milk for the relief of acid reflux. Children who are allergic to milk protein may experience GERD as a result of exposure to milk and other dairy products.32
  • My doctor told me that I have GERD, but he didn’t order any tests. How does he know I have GERD and not something else? There are no “gold standard” tests used to diagnose GERD. If you have typical GERD symptoms (heartburn, etc) and your symptoms get better with the usual medications, a diagnosis of GERD is made. Testing is only done if your symptoms are not typical, or do not respond to usual medications.9
  • If I have indigestion during pregnancy, does that mean that my baby will have a lot of hair? Once thought to be just an old wife’s tale, there have been some scientific studies that confirm that women who have frequent heartburn during pregnancy actually do give birth to babies with more hair!33
  • What causes GERD? It is unclear exactly what causes GERD. While we know that acid reflux happens because of relaxation, weakness or malfunction of the lower esophageal sphincter, it is not always clear what causes these problems with the LES.3 There may be several underlying reasons why the LES doesn’t work properly to keep stomach acid contained within the stomach. Some neurologic diseases can cause the LES to relax. Medications, such as those used to treat asthma, high blood pressure, allergies, pain, and depression can cause LES relaxation.3 Smoking, and a condition called a hiatal hernia, can also cause problems with the way the LES functions.3
  • Could medications I am taking be causing GERD? Some medications might cause heartburn, including pain relievers such as ibuprofen, naproxen and aspirin. Some antibiotics, medications used to treat overactive bladder, certain antidepressants and other medications can worsen GERD.3
  • What are the long term effects of taking H2 blockers or PPIs? Both H2 blockers and PPIs (proton pump inhibitors) reduce the amount of acid produced in the stomach. Stomach acid has some beneficial effects, like helping the body absorb calcium. Stomach acid also protects against some types of infections. People who take PPIs for long periods of time are more likely to break their hip and wrist bones, or fracture their spines.16
  • How will I know if my GERD is causing more serious problems? What are some of the symptoms of more serious problems? Your healthcare provider should monitor your GERD for signs that it might be causing more serious problems. Symptoms of more serious problems include coughing up blood and vomiting after meals.3

REFERENCES

1. National Institute of Diabetes and Digestive and Kidney Diseases. The Digestive System and How It Works. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/digestive-system-how-it-works
Accessed August 18, 2017.

2. National Institute of Diabetes and Digestive and Kidney Diseases. Definition and Facts for GER and GERD. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-facts
Accessed August 1, 2017.

3. National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms & Causes of GER & GERD. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/symptoms-causes
Accessed August 18, 2017.

4. Boeckxstaens G, El-Serag H, Smout AJ, Kahrilas P. Republished: symptomatic reflux disease: the present, the past and the future. Postgraduate Medical Journal 2015; 91(1071):46-54. doi: 10.1136/postgradmedj-2013-306393rep. Accessed August 18, 2017.

5. Vaishnav B, Bamanikar A, Maske P, Reddy A, Dasgupta S. Gastroesophageal relux disease and its association with body mass index: clinical and endoscopic study.
Journal of Clinical & Diagnostic Research. 2017; 11(4): OC01–OC04. doi: 10.7860/JCDR/2017/24151.9562. Accessed August 18, 2017.

6. Zhao Y, Encinosa W. Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005. HCUP Statistical Brief #44. 2008. Agency for Healthcare Research and Quality.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.pdf

7. National Institute of Diabetes and Digestive and Kidney Diseases. Digestive Diseases Statistics for the United States. Last updated 2014.
https://www.niddk.nih.gov/health-information/health-statistics/digestive-diseases
Accessed August 1, 2017.

8. University of Virginia Health System. Gastroesophageal Reflux Disease (GERD)/Heartburn. Last updated 2017.
https://uvahealth.com/services/digestive-health/digestive-conditions/gastroesophageal-reflux-disease-gerd-heartburn
Accessed August 18, 2017.

9. National Institute of Diabetes and Digestive and Kidney Diseases. Diagnosis of GER & GERD. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/diagnosis
Accessed August 18, 2017.

10. Campanozzi A, Boccia G, Pensabene L, et al. Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey. Pediatrics 2009; 123(3): 779-82. doi: 10.1542/peds.2007-3569.

11. Randal, A (ed). AAP releases guideline for the management of gastroesophageal reflux in children. American Family Physician 2014; 89(5):395-397. http://www.aafp.org/afp/2014/0301/p395.html

12. Hill DJ, Roy N, Heine RG, et al. Effect of a low-allergen maternal diet on colic among breastfed infants: a randomized, controlled trial. Pediatrics 2005; 116:e709–e715.

13. Baird DC, Harker DJ, Karmes AS. Diagnosis and treatment of gastroesophageal reflux in infants and children. American Family Physician. 2015;92(8):705-717.

14. Lightdale JR, Gremse DA. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013; 131(5): e1684-95. doi: 10.1542/peds.2013-0421. http://www.aafp.org/afp/ 2015/1015/p705-s1.html

15. Body C, Christie J. Gastrointestinal diseases in pregnancy. Gastroenterology Clinics of North America. 2016; 45 (2): 267-283.

16. National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for GER & GERD. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/treatment
Accessed August 18, 2017.

17. National Institute of Diabetes and Digestive and Kidney Diseases. Eating, Diet, & Nutrition for GER & GERD. Last updated 2014. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/eating-diet-nutrition Accessed August 18, 2017.

18. U.S. Food and Drug Administration. OTC Panel Submissions (Indices Only): 01 – Antacid. Last updated 2009.
https://www.fda.gov/regulatoryinformation/dockets/ucm113470.htm Accessed August 18, 2017.

19. U.S. Food and Drug Administration. Proton Pump Inhibitors Information. Last updated April 2016. https://www.fda.gov/Drugs/DrugSafety/ucm213259.htm Accessed August 18, 2017.

20. Muss C, Mosgoeller W, Endler T. Papaya preparation (CaricolR) in digestive disorders. Biogenic Amines 2012; 26(1): 1-17.

21. Wang A, Zhu C, Fu L, et al. Citrus fruit intake substantially reduces the risk of esophageal cancer: a meta-analysis of epidemiologic studies. Medicine 2015; 94(39): e1390. http://doi.org/10.1097/MD.0000000000001390

22. Panahi Y, Khedmat H, Valizadegan G, Mohtashami R, Sahebkar A., Efficacy and safety of Aloe vera syrup for the treatment of gastroesophageal reflux disease: a pilot randomized positive-controlled trial. Journal of Traditional Chinese Medicine 2015; 35(6): 632-636.

23. Moazzez R, Bartlett D, Anggiansah A. The effect of chewing sugar-free gum on gastro-esophageal reflux. Journal of Dental Research 2005; 84(11): 1062-5.

24. Kethman W, Hawn M. New approaches to gastroesophageal reflux disease. Journal of Gastrointestinal Surgery 2017. doi 10.1007/s11605-017-3439-5. Accessed August 18, 2017.

25. Sethi S, Richter, JE. Diet and gastroesophageal reflux disease: role in pathogenesis and management. Current Opinion in Gastroenterology 2017; 33(2): 107-111. doi 10.1097/MOG.0000000000000337.

26. National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts for Barrett’s Esophagus. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus/definition-facts
Accessed August 19, 2017.

27. National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms & Causes of Barrett’s Esophagus. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus/symptoms-causes
Accessed August 19, 2017.

28. National Institute of Diabetes and Digestive and Kidney Diseases. Diagnosis of Barrett’s Esophagus. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus/diagnosis
Accessed August 19, 2017.

29. National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for Barrett’s Esophagus. Last updated 2014.
https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus/treatment
Accessed August 19, 2017.

30. Bohmer AC, Schumacher J. Insights into the genetics of gastroesophageal reflux disease (GERD) and GERD-related disorders. Neurogastroenterology & Motility 2017; 29(2). doi: 10.111/nmo.13017.

31. McSweeney JC, Rosenfeld AG, Abel WM, et al. Preventing and experiencing ischemic heart disease as a woman: state of the science. Circulation 2016; 133:1302-1331. doi 10.1161/CIR.0000000000000381.

32. Ferreira CT, de Carvalho E, Sdepanian VL, et al. Gastroesophageal reflux disease: exaggerations, evidence and clinical practice. Jornal de Pediatria 2014; 90(2): 105-118. doi 10.1016/j.jped.2013.05.009.

33. Costigan KA, Sipsma HL, DiPeitro JA. Pregnancy folklore revisited: the case of heartburn and hair. Birth 2006; 33(4): 311-4. doi 10.1111/j.1523-536X.2006.00128.x

Comments

No comments

New Articles

Experts notesMedicine
Open source health care resources.
June 25, 201901,709

These changes mirror and support organizational changes in the health care industry. Whether...

Experts notesMedicine
Openhealth — Open source software in health care.
June 25, 201901,381

Around the world, health care software is moving from hospital-centered departmental systems, to...