Gastroesophageal reflux (GER) is the return of stomach contents from the stomach to the esophagus.  This may result in a spit-up or vomiting.  Most infants spit-up food and/or milk at some point in the first year of life.  The most common scenario is this:  A newborn begins spit-ups at about 1-4 weeks of age, with worsening spitting until 4 months of age, and then stops spitting up completely by 12 to 18 months of age.  

 

 

A “spitty” baby can create a great deal of stress for a family for some of the following reasons:

• parents must change the infants (and their own) clothes multiple times per day
• the entire house smells like sour milk
• the carpeting and upholstery has dozens of stinky milk stains
• half of each $15 can of milk formula ends up in the baby’s lap or on the floor
• friends and relatives are constantly saying “Your baby isn’t right… you should do something.”  (while you are thinking… “I am doing everything I can, thank you… why don’t you hold ‘little old faithful’ after this next feed…”

 

What causes GER? 

The lower esophageal sphincter (LES) is a normal muscular narrowing at the junction of the esophagus and the stomach where swallowed food is ideally prevented from exiting the stomach in the wrong direction.  All infants, and adults for that matter, have reflux of some of the stomach contents into the esophagus after eating.  This so-called “physiologic reflux” is quickly returned to the stomach by contraction of the esophagus.  Infants with abnormal GER will have reflux that results in stomach contents that leave the mouth or that stays in the esophagus for an extended period of time (more than about 3-6 minutes total per hour).  GER can be caused by: 

• abnormal relaxation of the LES
• delayed emptying of the stomach
• compression of the stomach
• excessive stomach gas
• poor infant positioning after meals
• overfilling the stomach
• illness

What are the symptoms of GER? 

The stomach contains hydrochloric acid.  It is no surprise that one of the major symptoms of GER is pain or discomfort (see Esophagitis).  For most infants, GER is easily diagnosed by listening to the parent’s story and by counting the number of milk stains on mother & father’s shirts.  Infants with GER may appear irritable or reluctant to feed despite being hungry.  Some infants will arch the back in a maneuver that is sometimes confused with a seizure (Sandifer’s reaction). For severe GER, infants may develop pneumonias, poor weight gain or breathing problems. 

Red Flags

• Severe symptoms
• Persistent spit-ups prior to 2 months of age
• Yellow or green discoloration of the spit-up material
• Blood in the spit-up materialBreathing problems
• Turning blue with episodes
• Poor weight gain
• Taking 10 seconds or longer to recover 

Are there tests for GER? 

Yes.  While many cases of GER do not require testing for diagnosis, some tests are available for complex cases.

• pH probe – this is likely the best test for evaluating GER.  A wire is inserted through the nose into the lower part of the esophagus and left in place for 8-24 hours.  The wire measures the acid level in the esophagus over time.
• Nuclear medicine reflux scan – this test is good but is limited due to the limited time of the study.  An infant is fed a radioactive meal (the amount of radioactivity is very minimal and safe) and then she is placed under a scanner for 1-2 hours.
• Upper GI fluoroscopy – this test helps determine if there is a blockage in the esophagus, stomach or first part of the small intestines.  The infant is fed a contrast material and a “live-action” x-ray is used to watch the meal move through the gastrointestinal tract.
• Upper gastrointestinal endoscopy – this procedure requires sedation or anesthesia and is usually performed by a Pediatric Gastroenterologist.  The effects of GER may be seen, such as Esophagitis.  A lighted, flexible tube camera is inserted through the mouth and advanced to the first part of the small intestines.  The endoscopist can look at the surface of the gastrointestinal tract and also can take small biopsy samples for evaluation by a pathologist.

What is the treatment for GER? 

See GER precautions below.

Medicines are sometimes used:

• Prevacid® or similar proton pump inhibitor – these medicines reduce the production of stomach acid.  This does not directly inhibit GER but GER that is less irritating to the esophagus may indirectly cause a decrease in GER frequency or severity.  This medicine can be given as a liquid or the dissolvable tablets can be dissolved in a small amount of milk or water.

 

• Zantac® or similar acid blocker – like Prevacid® these medicines reduce acid production.  Unfortunately Zantac® does not taste good to many infants and children.

 

• Reglan® (a.k.a. metoclopramide) – this medicine increases GI motility.  It is used less frequently due to the potential for side effects.

 

• Erythromycin – this is an antibiotic that may be used in very small doses to help improve emptying of the stomach.  It is usually reserved for older infants and children with know delayed emptying of the stomach.

Surgery is rarely necessary and is reserved for severe or complex cases.  The most commonly-performed procedure is a fundoplication. 

Prevention 

“GER precautions” – Most parents have tried many of these things before seeing a Pediatrician or specialist.

• Frequent burping (example - after every ounce of milk)
• Smaller, more frequent feedings (example - 6 ounces or more in a 2 month old infant is likely too much)
• Keeping the infant upright for 30 minutes after feeding
• Avoid putting the infant in a car seat for the first 30 minutes after feeding (the car seat position puts pressure on the stomach and can make GER worse)
• Adding rice cereal to bottled milk feeds.  Rice cereal is usually added to an infant’s diet at around 4 months of age, but is sometimes added sooner.
• Using an “anti-reflux” formula such as Enfamil AR®. 

Note 

It is recommended to lay infants who are less than 6 months of age on their backs to sleep.  This has been shown to reduce the incidence of sudden infant death syndrome (SIDS).  This includes infants with GER.