Gastroesophageal Reflux in Infants
Article updated and reviewed by Daniel A. Rauch, MD, FAAP, Associate Professor of Clinical Pediatrics, Associate Residency Program Director and Director of Pediatric Hospitalist Service, New York University on May 17, 2005.
The backwash of stomach contents into the esophagus, commonly called reflux, occurs when the lower esophageal sphincter (LES) is very weak or, more commonly, when it inappropriately relaxes. Gastroesophageal reflux (GER), often manifested as regurgitation (spitting up or vomiting) in infants and not necessarily a cause for concern, must be distinguished from gastroesophageal reflux disease (GERD), which may present without any regurgitation and needs to be treated.
The esophagus is the tubelike structure that connects the mouth to the stomach. At the point where the esophagus joins the stomach, the esophagus is kept closed by a specialized muscle called the lower esophageal sphincter (LES). This muscle is important because the pressure of the stomach is normally higher than that in the esophagus. The muscle of the LES relaxes after swallowing to allow passage of food into the stomach, but then it quickly closes again.
The occurrence and severity of reflux depends on LES dysfunction, but are also affected by the type and amount of fluid brought up from the stomach, by the clearing action of the esophagus, by the neutralizing action of saliva, and by other factors.
Although many infants have minor degrees of GER, about 1 in 300 to 1,000 infants have GERD, that is, significant reflux and associated complications.
Mild GER may be a developmental stage, as most infants will outgrow it without any intervention or any untoward effects. Parenting behaviors, such as overfeeding and certain positioning, such as sitting, as well as environmental factors, such as tobacco smoke exposure, can exasperate GER.
In some children, reflux may be caused by abnormal anatomy of the esophagus. Reflux may also occur when the stomach is too full and the infant increases abdominal pressure by coughing, crying, or defecating. The small capacity of the infant's esophagus predisposes to vomiting.
Chronic reflux and vomiting can be harmful to the infant. The acid from the stomach can irritate the esophagus, and the infant may cry each time he or she is fed, leading parents to call the problem "colic." This kind of crying happens during or just after feeding.
Patients with cerebral palsy, Down's syndrome, and other causes of developmental delay have an increased incidence of reflux. GER is a presenting symptom for Hiatal hernias and gastric outlet obstructions (stomach blockage), such as pyloric stenosis.
In most affected infants, excessive vomiting occurs during the first week of life, and almost all have symptoms by week 6
Vomiting or spitting-up alone, without any other symptoms, and normal growth and development, should be classified as GER.
Symptoms in addition to, or instead of, regurgitation suggest GERD. There may be rumination (repetitive gagging, regurgitation, mouthing and reswallowing of food) or deficits in growth and weight gain. The reflux of acid can cause direct injury to the esophagus including esophageal bleeding, ulcers, or stricture (narrowing). Esophagitis can present with chest pain, irritability, anemia, and feeding difficulties.
GERD can initially manifest itself with respiratory symptoms (breathing problems) including pneumonia due to aspiration (food into the lungs), and asthma. Young and premature infants may present with apnea (lack of breathing) and/or bradycardia (low heart rate), leading to an apparent Acute Life Threatening Event.
GERD may also cause seizure-like movements, or Sandifer Syndrome.
Diagnosis is based on the medical history, physical examination, and sometimes additional diagnostic tests, particularly when regurgitation is not a symptom. Some tests may be radiologic, such as barium swallow or upper GI study; nuclear, such as a milk scan; physiologic, such as a pH probe to directly measure acid reflux in the esophagus; or direct observation by esophagoscopy.
Medical treatment is not necessary for simple GER. Depending on the parents level of anxiety associated with the GER, the child may simply grow out of it without any intervention or may benefit from some conservative, non-medical management. Parents can reduce known risk factors by eliminating tobacco smoke from their child’s environment. Feedings can be made smaller in volume and more frequent if necessary. Infants can be held upright for at least 30 minutes after feeds and avoid sitting position. Infants with significant reflux may benefit from sleeping prone (on the belly), but this change from the recommended “Back-to-sleep” position should only be done after consulting with the doctor. Thickening an infant's formula with cereal may decrease crying and the volume of vomiting.
In older infants and children, the head of the bed should be raised a few inches above the level of the feet when sleeping, and the child should be kept upright during the day as tolerated.
For GERD, there are medical treatments in addition to the conservative modalities. Some medications induce faster gastric emptying, so that there is less of an opportunity to reflux. These medications include Metoclopramide (Reglan), Cisapride (Propulsid), and Erythromycin. Antacids reduce the acidity of reflux and include Aluminum Hydroxide, Cisapride (Propulsid), Ranitidine (Zantac), Famotidine (Pepcid), and Omeprazole (Prilosec).
If intensive medical therapy does not improve symptoms, then surgical treatment may be necessary, including consideration for a Nissen fundoplication which is designed to tighten the LES.
Do tests need to be done to diagnose reflux?
What is the cause of the reflux?
Will you be prescribing any medications?
What are the side effects?
What antacids do you recommend?
How often can the antacids be taken?
Are there any complications of reflux?
What changes in feeding do you recommend?
Editorial review provided by VeriMed Healthcare Network.