Reflux… details for parents who want to understand what their doctor was talking about.
Defining Infant Reflux
Reflux is a normal condition in most babies. In fact, everyone, adults included, refluxes at various points during the day, usually after meals. The terms, “reflux,” “gastroesophageal reflux”, or “GER” refer to the backflow of stomach contents into the esophagus. When discussing reflux, most parents and patients are thinking of acid reflux. It is important to note that reflux may be acidic or non-acidic. It may be composed of liquid or gas.
When you see a baby spitting up, the refluxed material is coming all the way from the stomach, up the esophagus and out the mouth. Spit up, though sometimes forceful and startling for a parent, is common and not harmful to a baby. Babies that frequently spit up but are growing well and thriving are often referred to as “happy spitters.” These babies generally do not require treatment.
A peak in reflux symptoms is seen around age 4 months, with over half of all infants exhibiting some symptoms. Reflux resolves in most infants by 12-18 months.
When Reflux Becomes A ProblemIf reflux is accompanied with poor weight gain, extreme discomfort, vomiting, significant sleep problems, refusal to take milk, or respiratory symptoms, it is referred to as complicated reflux or gastroesophageal reflux disease (GERD). This condition is much less common in babies than uncomplicated reflux. Although uncomplicated reflux is very common in babies, many parents are concerned that their child is in discomfort and seek treatment. Similarly, many pediatricians end up treating for reflux unnecessarily, despite the fact that acid-reducing medications have never been proven effective in infants with reflux.
Symptoms of RefluxMany parents may come across signs or symptoms of GERD in their research across the internet. This can be very confusing since many of the symptoms or behaviors of GERD, like arching of the back or intermittent fussiness, overlap with those seen in babies without GERD. Some more concerning signs or symptoms of reflux (but not diagnostic of GERD) include:
- Poor weight gain
- Refusal to drink milk
- Respiratory symptoms, like recurrent pneumonia
- Persistent forceful vomiting
- Disturbance in sleep
Causes of RefluxNormal, physiologic reflux is thought to be caused by relaxation of the muscle between the esophagus and stomach, the lower esophageal sphincter (LES). In infants, the LES is thought to strengthen with time as reflux diminishes. After meals and with certain foods, the LES may relax more, contributing to physiologic reflux in infants, children, and adults. In adults and older children, certain medical conditions, obesity, and lifestyle are associated with reflux. In children, underlying medical conditions, like neurologic syndromes, genetic disorders, and anatomic abnormalities contribute to pathologic reflux. These children more often need diagnostic studies and intervention as compared to children without any underlying conditions.
Diagnosis of RefluxIt is wise to consult with your health care provider before assuming your child has GERD. Since many of the symptoms and behaviors of babies with complicated reflux are present in normal infants, distinguishing GERD from uncomplicated (normal) reflux is a challenge for both parents and healthcare providers. There is no single test or set of tests that confirms the diagnosis of reflux. In the vast majority of cases, the history a parent gives guides a health care provider’s management. However, in some atypical or more severe cases of suspected GERD, your doctor may order some tests:
- Upper GI series (or barium swallow): This radiologic study is done to make sure that your baby’s anatomy is normal, since in some rare cases, congenital problems of the stomach or intestines can cause symptoms seen in GERD. The test is performed by having your baby drink some fluid that is then seen over a series or X-rays. If the fluid flows through your baby’s gut as expected, the radiologist will see a normal outline of your baby’s stomach and upper intestine. Note that fluid is often seen flowing back up into the esophagus during this study. This is expected since some level of reflux is normal in everyone. In other words, seeing reflux during an upper GI series is not diagnostic of reflux. Considerations: Though not invasive, it is important to note that an upper GI series will expose your child to some radiation, as all tests involving X-rays or CT scans do. Also, after this study, your baby’s stool may be whitish in color. This is due to the barium passing through and it is not a cause for concern.
- pH probe: pH is a measure of acidity. A pH probe placed inside the esophagus can measure the acidity present. This is a slightly more invasive study that may help your doctor diagnose your baby’s condition if symptoms are severe or persistent. It is done under the care of a pediatric gastrointestinal specialist. A pH probe is physically inserted through your baby’s nose into his esophagus. The probe is usually left in place for 18-24 hours to measure the frequency and duration of acid in the esophagus. This test is not diagnostic of GERD since the presence of reflux or acidity in the esophagus is not necessarily correlated with symptoms. Considerations: A pH probe involves the placement of a probe inside your child’s esophagus via his nose. Though there are rarely severe complications, the placement of the probe can be uncomfortable, especially if your child resists. It is sometimes difficult to keep the probe in place if a child does not cooperate. Correct placement of the probe may be confirmed by X-ray though this is not usually necessary. Children may need to fast prior to placement of the probe.
- Esophageal impedance testing: This test measures the presence of refluxed material in addition to pH monitoring. As such, it can differentiate between is acidic and non-acidic reflux and also between liquid or gas reflux. Additionally, impedance testing can evaluate whether a baby’s symptoms are actually associated with reflux episodes. This may be important in situations where a baby does not respond to typical treatment. For example, if a baby’s symptoms are seen during non-acidic reflux episodes, it clarifies for parents and doctors why acid-reducing medications may have been ineffective. Considerations: Esophageal impedance testing, like a pH probe, involves the placement of a probe through your child’s nose and into his esophagus. This may be uncomfortable for your child. Usually patients are asked to fast for several hours prior to the placement of the probe.
- Upper endoscopy: This test is reserved for very severe cases. A pediatric gastroenterologist performs endoscopies in an outpatient center or hospital. A baby is placed under anesthesia and a camera is inserted into the esophagus. Photos and biopsies of the esophagus, stomach and intestines can be taken. Both the appearance of the tissue as well as evaluation of the biopsies can help determine the cause and severity of a child’s symptoms. Considerations: For this procedure, your child will be placed under anesthesia. Though routine, both the procedure and anesthesia carry risk. Your gastroenterologist will discuss these in detail prior to undergoing the procedure. Prior to the procedure, patients are asked to fast.
ManagementMost cases of uncomplicated reflux are managed with little or no intervention. Often, the reassurance from a healthcare provider that your baby is healthy and thriving is treatment enough. In more severe or bothersome cases, however, your doctor may offer a variety of solutions, including some of the following:
- Use of a hypoallergenic formula if formula feeding or a restricted diet if breastfeeding. In some babies, symptoms of reflux are attributed to a reaction against certain food proteins. Your doctor may ask you to try a hydrolyzed formula, one in which the cow’s milk proteins are broken down and less likely to cause a reaction. In the case of breastfed babies, mother’s may be asked to avoid cow’s milk, soy, and eggs. In either case, a trial of 1-2 weeks should result in improved symptoms. If there is no change in symptoms, your doctor may advise you return to your regular formula or diet, respectively.
- Reducing the volume of feeds. In a formula fed baby, reducing the amount of formula given at any one time may alleviate symptoms. Similarly, in a breastfed infant, taking breaks to burp may be helpful.
- Positioning. Holding your baby upright after feeding may reduce symptoms. NOTE: even if your baby spits up regularly, it is still advised that he sleep on his back on a firm, flat surface unless specifically instructed by a doctor.
- Thickening of feeds. Some healthcare providers may advise thickening of milk. This can be done with infant cereal (usually rice cereal) or marketed thickeners. Please note that commercially available thickeners have been associated with serious side effects, including death, in babies. Please discuss with your doctor before altering your baby’s milk.
- Acid suppressing medications. The use of acid suppressing medicines in the treatment of reflux relies on the theory that acid is the problematic factor. Reducing acidity does not change the volume of reflux or spit up, and this is often disconcerting to parents who expect treatment to reduce spit up. In one study, though acid was reduced with medication, the presence of fussiness was similar in both the treated and untreated groups. The two most common classes of drugs used in the treatment of infant reflux are H2 antagonists (or H2 blockers) and proton pump inhibitors, PPIs. H2 antagonists work by blocking H2 receptors in the cells lining the stomach. This results in reduced acidity (a higher pH) in the stomach. PPIs work by blocking the pump that pushes acid into the stomach. Both these treatments reduce the pH of the stomach. This may be benign in many cases, but concerns regarding side effects remain and treatment should be limited to severe cases. It is important to remember that the stomach is acidic for a reason. Stomach acid helps absorb many nutrients and the acidity helps kill off or fight infection. Use of PPIs is associated with increased risk of pneumonia and infection. This risk may also pertain to children. There is also a risk of reduced absorption of nutrients, including iron, B12, magnesium and calcium. This is especially concerning in children since iron and B12 deficiency can both cause anemia and magnesium and calcium are essential for bone health. PPIs are not FDA approved for treatment of reflux in infants under a year old and have not been found effective in a meta analysis of their use. However, most pediatricians and pediatric gastroenterologists use these medications off label and despite the lack of data, PPIs are recommended as the medication of choice for doctors attempting to treat reflux in children. If you are prescribed a PPI, it is important to discuss the possibility of side effects with your doctors.
- Surgery: Surgical treatment for reflux in infants and children is reserved for the most extreme cases. It is uncommon for children without underlying medical problems to require surgical management.
Some parents may find this infographic, prepared by Colic Calm, helpful in understanding proton pump inhibitors and their prevalent use.
The American Academy of Pediatrics recently published guideline for the management of reflux in children. This is intended for health care providers.
What Parents Are Saying
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“My baby was unfortunately diagnosed with Acid Reflux. I was quite desperate to find something that could help him because he was not sleeping much at all either day or night and appeared to be in so much discomfort that was heartbreaking.”
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