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Gastroesophageal Reflux

By Alex N. Anton, MD
February 2011

You may have just left the office and were told that your child might have something called ‘Reflux’ and now would like some details on what that diagnosis may mean. Gastroesphageal reflux (GER) is an effortless regurgitation of stomach contents. It occurs when food in the stomach backs up (refluxes) into the esophagus during or after a meal. The esophagus is the tube that connects the mouth to the stomach. Normally, a muscle at the bottom of the esophagus relaxes to allow food to enter the stomach. This muscle then tightens to keep the stomach contents from coming up into our mouth when the stomach squeezes to force food into the intestines.

In some children, this muscle doesn’t tighten enough allowing undigested food to reflux into the esophagus and up into the mouth, resulting in spitting up and vomiting. Because the stomach secretes an acid to help digest our food, backflow of this acidic fluid into the esophagus can cause pain. GER can occur when babies cough, cry, or strain.

GER is common in healthy infants. More than half of all babies experience it in the first 2-3 months of life, but most stop spitting up/vomiting within a couple of months.  Almost all infants with GER will experience resolution of their symptoms by 12-16 months of age. As the infant grows, the lower esophageal muscle becomes stronger, keeping the food in the stomach. On rare occasions, the condition may persist until the age of four.

 


 

What are the symptoms of Gastroesophageal Reflux?

Not all infants with GER will have vomiting/spitting up and not all infants that vomit have GER. This is where your child’s health care provider plays an important role in establishing a correct diagnosis and a treatment plan.

An infant with mild GER may experience:

  • Spitting up
  • Vomiting
  • Coughing
  • Irritability
  • Lip smacking
  • Arching of back
  • Choking
  • Noisy breathing
  • Poor feeding

 

In a small number of babies, GER results in symptoms that cause concern. These symptoms include:

  • Failure to gain weight
  • Irritability or refusing to feed
  • Wheezing and other breathing problems
  • Chronic and nighttime cough
  • Recurrent pneumonia
  • Apnea (a period of no breathing)

 

How is GER diagnosed?

The diagnosis of GER can be quite variable. For mild cases that are straightforward, a careful examination and response to proper positioning and therapy is sufficient. A “pH probe” can be used to measure the degree of reflux and to correlate this with possible symptoms of choking, cough, and apnea. This test consists of passing a small tube through the nose and positioning the probe just above the stomach to measure the presence, timing, and degree of GER. For more severe or complicated cases, a barium swallow x-ray may be done. Also known as an upper GI series, a baby swallows barium that will outline the esophagus, stomach, and upper intestines. This study also helps exclude other causes of vomiting such as structural abnormalities of the stomach or intestines that can cause a partial obstruction and vomiting.


 

How is GER treated?

The treatment for reflux depends on the infant’s age and severity of symptoms. Some babies will not need any treatment if their condition is mild and resolves by itself. Smaller quantities of milk given more frequently and upright positioning after feedings can help decrease the chances of regurgitation. Babies that are otherwise thriving and gaining weight, but are very irritable and continue to vomit despite these measures, may initially require that their feedings be thickened with rice cereal (see Table 1).

For infants that are very uncomfortable, have difficulty sleeping or eating, choking that interferes with breathing or sleeping, or does not gain weight adequately, a trial of medication (H2 blocker or Proton Pump Inhibitor) may be recommended.

 

Specific Instructions for Infants with GER

  1. Try not to overfeed. Try decreasing the volume of each feed and increase the frequency of feedings. Talk with your infant’s doctor about the amount of breast milk or formula that your infant is eating and how often.
     
  2.  If you feed your baby with a bottle, add between one-half to one teaspoon of rice cereal per ounce of breast milk or formula. If the mixture is unable to pass through the bottle’s nipple, enlarge the nipple size or cut a small “x” at the tip.
     
  3. Burp your infant halfway through a feeding, and again at the end of each feeding.
     
  4. Whenever possible, hold your infant upright in your arms for 30 minutes after feedings.