It’s not unusual for young infants to experience gastroesophageal reflux (GER), which occurs when food from the stomach comes back up to the esophagus. Fortunately, most infants with GER tend to outgrow the symptoms before reaching 1 or 2 years old. Dr. Bornstein discusses GER symptoms, causes, and treatment.
DEFINITION:
An excessive amount of spitting up
SYMPTOMS:
- Spitting up or throwing up food after feeding. The food can come out of the mouth or nose and happens after almost every feeding.
This may be associated with:
- Heartburn
- Abdominal pain.
Some children will arch their backs during reflux to get the food back down the esophagus.
CAUSES:
Gastroesophageal reflux is caused by a weakness in the lower esophageal sphincter, the muscle at the bottom of the esophagus just before the stomach. The muscle should contract closed after feeding and not allow food to come back up the esophagus. Sometimes, the muscle is small and weak and cannot hold the food in the stomach.
DIAGNOSIS:
The diagnosis is usually made by the history of spitting up, arching the back, and irritability after feeding. These symptoms may occur alone or in combination with each other. Studies can also be done to look for reflux. An upper GI series or barium swallow can diagnose reflux. The baby will swallow a chalky-white substance called barium. A video x-ray can then show the barium going down the esophagus and into the stomach and duodenum. If there is reflux, the barium will be shown coming back up the esophagus. A technetium reflux scan can also show reflux. The infant drinks formula or breast milk with technetium added. A special camera can then follow the technetium to see if it comes back up to the esophagus. A pH probe is another test. A probe is placed through the nose and into the esophagus above the stomach. An x-ray will confirm the position. Every time food is refluxed up the esophagus, the pH probe will read a drop in pH since the stomach contents are very acidic. This probe can be left in the esophagus for 12 to 24 hours, and the total acidity can be determined. Finally, an endoscopy can be performed. This is where a scope is placed down the mouth and into the esophagus and stomach. The doctor can then look at the walls of the esophagus to see if there is any damage resulting from the acid reflux.
CONTAGION:
Gastroesophageal reflux is not a contagious illness.
TREATMENT:
There are many treatments for reflux, and the treatment choice will depend on the severity of the reflux and the response to each treatment.
- Position the infant in such a way as to let gravity help. This means having a baby upright after feeding and avoiding things that place pressure on the abdomen, such as an infant seat or swing where a baby may slump down.
- Changing the feedings. Sometimes a change in the formula will help, or for breastfed babies, a change in the mother’s diet. The formula can also be thickened by adding one teaspoon of rice cereal to each ounce of formula. The nipple hole may need to be enlarged to allow the thick formula to get through. Also, smaller, more frequent feedings may be of benefit.
- Using medications. The medicines include antigas, antacids, and anti-reflux medicines. Antigas include medicines with simethicone, such as Mylicon, Gaviscon, or Little Tummies. Antacids include two groups: the first group absorbs acids such as Mylanta, Maalox, or sucralfate (Carafate). The second group prevents acid secretion: such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), omeprazole (Prilosec) or lansoprazole (Prevacid). Anti-reflux medicines include metoclopramide (Reglan) and bethanechol (Urecholine).
- A Nissen Fundoplication, a surgical procedure, can be done for extreme cases.
The outcome is excellent. Infants will eventually grow out of reflux as they get bigger, and the lower esophageal sphincter enlarges and strengthens.
DISCUSSION:
All infants spit up to some extent. The diagnosis of reflux is only given when the spitting up becomes excessive. As long as a child gains weight and grows, the reflux is more of a messy nuisance than a medical problem. The infant will eventually grow out of it. Some children with neurologic problems may have more difficulty reflux when they lose weight or when the food gets into the lungs, causing aspiration pneumonia. Most reflux is diagnosed by observing symptoms rather than performing a study. An upper GI is the most common study since it will differentiate reflux from more severe pyloric stenosis. Once diagnosed, the least treatment opted for, the better, since all medicines can carry some side effects. If treatment is necessary, the most common treatment is the combination of an antacid and reflux medicine. A dosage can usually be started and continued until the child grows out of the reflux. This will usually be by three to six months of age. In more severe cases, the dosage must be increased as the child gains weight until six to twelve months. Medication is rarely needed after one year of age. If neurologic problems are causing the reflux, a Nissen Fundoplication may be necessary to allow the child to gain weight.
ONE DOCTOR’S OPINION:
Reflux is very messy and very annoying. I only treat it if the parents have complaints or the child seems to be suffering. I usually go by history, but I will do an upper GI if pyloric stenosis is possible. I usually only do studies if the child is losing weight or the medications are not helping. Ultimately this is a common, temporary nuisance that will pass with time.
This blog was written by Dr. Michael Bornstein, who has 30 years of experience as a pediatrician.
Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.
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