Gastroesophageal Reflux (GER and GERD) in Infants and Children

• GER (gastroesophogeal reflux) in infants and children is relatively common disorder where there is reflux of stomach acid into the esophagus and oral cavity in a newborn or infant child. Generally, no therapy is necessary and the condition resolves with a “tincture of time.”
• GERD (gastroesophageal reflux disease) is a disease where reflux of stomach acid into the esophagus and oral cavity is chronic in nature. In infants and children, it is much less frequent when compared with GER. The “disease” of GERD implies the need for various therapeutic approaches in order to minimize the consequences of reflux of stomach acid into the esophagus and oral cavity.
• Signs and symptoms of GER or GERD in infants and children are overlap. Infants and children with GER have obvious reflux of breastmilk and/or formula following feeding. Usually, such infants do not appear to be in distress by such episodes.
• Signs and symptoms of GERD in infants and children include:
  • Fussiness during and after feedings
  • Cough
  • Rarely, wheezing may following feedings
  • A more forceful expulsion of stomach contents than do infants and children with GER.
• GER and GERD in infants and children are caused by immature neurologic and gastrointestinal systems. In both GER and GERD, the stomach contents area expelled from the stomach into the esophagus through the opened gastroesophogeal junction. Generally, this junction is closed and stomach contents may only travel from the stomach into the intestinal tract.
• GER and GERD in infants and children are diagnosed with a thorough history and physical exam by the child’s pediatrician. Infants with GER are thriving children and do not have recurrent agitation or forceful ejection of breast milk/formula. They maintain good weight gain. No blood or X-ray tests are indicated. Infants experiencing GERD have often a forceful ejection of stomach contents, have periods between feeding of agitation and fussiness, may have episodes of arching twisting between feedings, and may have slow weight gain due to inadequate caloric intake. Recurrent cough or (in rare cases) wheezing may be associated with GERD. In some circumstances radiology or other studies may be necessary. A consultation with a pediatric GI specialist (gastroenterologist) may be necessary.
• Treatment for GER and GERD in infants and children include mild elevation of the infant for 15-30 minutes following a feeding, serving smaller but more frequent feedings and thickening of formula or pumped breast milk with rice cereal. In older children, it is worthwhile to maintain a dietary journal to help identify GERD and food relationships. Carbonated or caffeinated beverages may be associated with GERD. In some cases, medications may be indicated.
• Natural remedies to help GER and GERD symptoms in infants and children include thickening of pumped breast milk or formula with rice cereal, smaller and more frequent feedings, elevation of the infant for 15-30 minutes following a feeding and (in rare cases) use of an “elemental” formula for infants with milk or soy protein sensitivity in association with GERD.

Gastroesophogeal reflux (GER) is the upward flow of stomach contents from the stomach into the esophagus ("swallowing tube"). While not required by its definition, these contents may continue from the esophagus into the pharynx (throat) and may be expelled from the mouth, and in infants, through the nostrils.

Gastroesophogeal reflux is different from vomiting because usually it is not associated with a violent ejection. Moreover, GER is generally a singular event in time, whereas the vomiting process is commonly several back-to-back events that may ultimately completely empty all stomach contents and yet still persist ("dry heaves"). The difference between GER and GERD (gastroesophageal reflux disease) is a matter of severity and associated consequences to the patient.

The large majority of healthy, full term infants will have episodes of "spitting up" or "wet burps," which technically qualify to be considered gastroesophogeal reflux. These infants generally do not seem in distress before, during, or after by the reflux process. Likewise, the loss of calories as an outcome of GER is inconsequential since growth parameters including weight gain are not affected. Lastly, there seem to be no short or long-term consequences of these reflux experiences. In short, infants with GER are "messy spitters."

GERD implies a much different condition. Infants and children with GERD often experience distress because of their reflux even if the refluxed stomach contents are not completely ejected from the mouth. Infants and young children may lose so many calories by expulsion that growth is compromised. Some infants or children with GERD may even become averse to feeding due to repeated associations with feeding and pain. Finally, there are a number of short and long term consequences of GERD that are not associated with infants and children with GER.

Infants with GER generally have no symptoms other than the obvious reflux of fluid out the mouth. As mentioned previously, they do not appear to have any discomfort associated with their reflux.

Infants and children with GERD may have multiple symptoms including:

• frequent fussiness during feeding or thereafter,
• frequent or recurrent cough, especially when lying down or asleep,
• recurrent rejection of the breast or bottle which may lead to poor weight gain,
• wheezing, especially when lying down or asleep,
• recurrent pneumonia, and
• descriptions of "heartburn," "chest pain," or upper midline abdominal pain. Older children may have a bitter taste (similar to that associated with vomiting) in their mouth during reflex episodes

Infants with gastroesophogeal reflux reflect the immaturity their nervous system. In most infants the junction between the esophagus and stomach is "closed," opening only to allow passage of formula or breast milk into the stomach or to allow the escape of swallowed air via burping.

During episodes of reflux, this junction is continuously open allowing a backwards flow of stomach contents into the esophagus. This reverse flow may occur as a consequence of a relatively large volume of fluid relative to a smaller stomach volume, pressure on the abdominal cavity (for example, placed face down [prone] following a feeding), or overfeeding. Infant GER occurs in over 50% of healthy infants with a peak incidence (65%) at approximately 4 months of age. Most episodes resolve by 12 months of age. GER may occur in both breastfed and/or formula fed infants. Several studies document that breast fed infants empty their stomach faster than formula fed infants and are thus less likely to experience GER symptoms.

Gastroesophogeal reflux disease also reflects a relaxation of the esophageal-stomach junction similar to infant GER. Factors that may contribute to GERD in infants and children include:

• Increased pressure on the abdomen (over eating, obesity, straining with stool due to constipation, etc.).
• Slower than normal emptying of stomach contents may predispose infants or children to GERD.
• Certain medications, foods, and beverages may also be implicated in facilitating such pathological reflux.
• Cured meats (salami, pepperoni) and carbonated and caffeinated drinks may aggravate GERD symptoms.
• Recent studies indicate that between 2% to 8 % of children 3 to 17 years of age experience GERD symptoms (detailed later).

The diagnosis of GER is based upon characteristic historical facts reported by the infant's parents coupled with an elimination of pathological conditions by a normal physical exam. It is very rare to need laboratory studies to establish or support the diagnosis. Part of the evaluation of an infant who may have GER is to rule out pyloric stenosis. Pyloric stenosis is the thickening of the region of the stomach (pyloris) as it transitions into the first section of the small intestine. Studies show that most infants with pyloric stenosis have recurrent symptoms of forceful emesis shortly after a meal. The child is generally content until just before vomiting. There is a genetic predisposition favoring the first-born male. Diagnostic evaluation includes abdominal ultrasound or barium swallow (see below). A surgical procedure provides a cure of the condition.

Pediatricians diagnosis GERD in infants and children by taking a thorough history supported by a complete physical examination enabling the elimination of other conditions that might cause similar symptoms. While rare, studies may be necessary either to establish/support the diagnosis of GERD or to determine the extent of damage caused by the repeated reflux events.

These studies may include:

1. Barium swallow/upper GI series: This X-ray study involves drinking a material (barium) that allows visualization of the act of swallowing from mouth into the stomach by the propulsive motions of the esophagus and then emptying of the barium from the stomach into the upper part of the intestinal tract. This test is designed to confirm normal anatomy and function of the areas studies.
2. pH probe studies: This test involves passage of a thin, flexible tube through the nose and into the lower regions of the esophagus. The goal is to document the frequency of reflux of stomach acid contents over a prolonged period (usually 24 hours).
3. Endoscopy: Performed by a pediatric gastroenterologist, this procedure involves the passage of an endoscope (a thin, flexible tube with a light source and camera at the leading end) from the throat, through the esophagus and into the stomach. Any damage that is caused by GERD because of stomach acid erosion can be seen through the scope. Erosion caused by refluxed stomach acid (esophagitis) is a characteristic finding.
4. Gastric emptying study: This study involves drinking a mildly radioactive dye and monitoring the speed of passage from the stomach into the upper intestinal tract. Delay in emptying of stomach contents may predispose and aggravate GERD symptoms.

Rarely, an infant with GER  generates substantial discomfort, demonstrate aversion to feeding, or show suboptimal weight gain. Conversely, toddlers and older children may experience more substantial symptoms, and thus may need a trial of lifestyle modifications including:

• mild elevation of the head of bed,
• serving smaller but more frequent meals,
• monitoring your child's diet to determine whether specific foods or drinks may tend to aggravate his or her symptoms, and
• weight reduction if indicated.

There are several groups of medications that may need to be considered in certain cases of infant GER (rare) or toddler/childhood GERD. These include:

1. Medication to lessen gas, for example, Mylicon or Gaviscon
2. Medication to neutralize stomach acid, for example, Mylanta or Maalox
3. Medication to lessen stomach acid histamine blockers, for example, ranitidine (Zantac), famotidine (Pepcid) or cimetidine (Tagamet), and proton pump inhibitors or PPIs, for example, omeprazole (Prilosec), lansoprazole (Prevacid) or rabeprazole (Aciphex)
4. Medication to promote emptying of stomach contents, for example, metoclopramide (Reglan, however, it has a number of side effects) or erythromycin (more routinely used as an antibiotic but known to have side the effect of increasing stomach contractions, but may be helpful with GERD)

The use of these medications follows a stepwise approach (from #1 to #4) based upon severity of symptoms. Consultation with a pediatric gastroenterologist may be helpful for patients whose response to the above approach is disappointing.

There are very cases where children whose GERD is so severe that a surgical procedure must be considered to manage symptoms. The procedure, called a Nissen fundoplication, involves wrapping the top part of the stomach around the lower esophagus. The displaced stomach contracts during the digestive process, and thus closes off the lower esophagus and prevents reflux. In extraordinary circumstances, a feeding tube directly into the stomach is necessary to complement the Nissen fundoplication.

Since the fundamental issue for infants with GER is "tincture of time," most infants need no specific therapy. Lifestyle adjustments that have been helpful for some infants include:

• Mild elevation of the head of the crib mattress
• Maintaining an upright position for the first 20 to 30 minutes following a feeding
• Thickening of the formula with rice cereal
• Utilization of an "elemental" formula (for example, Alimentum)
• Introduction of solid foods at the safe and appropriate age (please check with your child's pediatrician prior to initiating these processes).

Rarely, an infant may require medications to bridge the gap during the neurologic maturation process that enables your child to "outgrow" his or her GER. These medications are discussed later.

The prognosis for infants with GER is excellent. The majority of infants will have resolved their symptoms by 9 to 12 months of age. Infants who required medications during the first few months of life generally "outgrow" their medication during the end of the first year of life.

Children who experience GERD symptoms also have a favorable prognosis though it may require longer use of medications and utilization of life style changes for many months. It is important to note that classic "heartburn" symptoms may resolve, but more subtle evidence of reflux (for example, persisting cough, especially when laying face up [supine]) may develop. Your child's pediatrician is a valuable asset to help monitor for these less obvious presentations of GERD.