Patient information: Gastroesophageal reflux in infants

GASTROESOPHAGEAL REFLUX OVERVIEW

Gastroesophageal reflux (GER) is the medical term for spitting up. It occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Because the stomach naturally produces some acid, reflux is sometimes called acid reflux; other terms include regurgitation and spilling.

Reflux is a normal process that occurs in healthy infants, children, and adults. Most infants have brief episodes, during which they spit up milk or formula through the mouth or nose. Uncomplicated reflux does not usually bother the infant, has a low risk of long-term complications, and does not usually require treatment.

In contrast, a few infants with gastroesophageal reflux disease (GERD) are irritable, gain weight slowly, develop recurrent pneumonia, or spit up blood. Infants with these signs and symptoms usually require further testing and may require treatment. Although most infants with gastroesophageal reflux disease improve as they grow, some children have symptoms later in childhood.

This topic review discusses the symptoms, causes, diagnosis, and treatment of infants with gastroesophageal reflux and gastroesophageal reflux disease. Gastroesophageal reflux disease in older children and adolescents is discussed separately. (See "Patient information: Gastroesophageal reflux disease in children and adolescents".)

WHAT IS GASTROESOPHAGEAL REFLUX?

When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure (figure 1). The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.

At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter (LES). When food reaches the LES, it relaxes to allow food to enter the stomach and then contracts to prevent the back-up of food and acid into the esophagus.

The ring of muscle does not close completely, allowing the liquids in the stomach to wash back into the esophagus occasionally in all individuals, and particularly in infants. Most of these episodes go unnoticed because the reflux stays in the lower esophagus.

As the infant grows and the angle of the stomach and esophagus changes, reflux naturally becomes less frequent. Spitting up disappears in over half of infants by 10 months of age, 80 percent by 18 months, and 98 percent by two years of age [1]. Infants who spit up frequently for more than three months are somewhat more likely to have gastrointestinal symptoms later in childhood [2].

Uncomplicated gastroesophageal reflux — Gastroesophageal reflux is common in infants during the first few months of life, with approximately 50 percent of infants between birth and three months having at least one episode of spitting up per day.

Infants who spit up frequently but who feed well, gain weight normally, and are not unusually irritable are usually considered to have "uncomplicated" reflux. These infants are sometimes referred to as "happy spitters". In this group, spitting up is a natural consequence of the baby's anatomy, because the short esophagus and small stomach allow liquid to escape from the stomach easily. Burping frequently during feeding and limiting activity after feeding may reduce the frequency and amount of spitting up.

Specific testing is not usually necessary for children with uncomplicated reflux. If the symptoms become worse, appear for the first time after six months of age, or do not improve by the time the child is 18 to 24 months of age, the child should be reevaluated; a consult with a pediatric gastroenterologist may be recommended.

Gastroesophageal reflux disease — Reflux becomes gastroesophageal reflux disease when acid in the reflux causes irritation or injury to the esophagus. This only occurs in a small percentage of infants who spit up frequently. The amount of reflux required to cause injury varies. In general, damage to the esophagus is more likely to occur when acid refluxes frequently, there is a large amount of reflux, or the esophagus is unable to clear away the acid quickly. The treatments for gastroesophageal reflux disease are designed to prevent one or more of these elements from occurring. (See "Gastroesophageal reflux in infants".)

Some of the signs or symptoms that may indicate GERD include refusing to eat, frequently crying or arching the neck and back as if in pain, choking while spitting up, forceful or projectile vomiting, frequent coughing, or not gaining weight. These behaviors are not normal and further testing is recommended to determine if GERD (or another condition) is the cause. (See "Patient information: Poor weight gain in infants and children".)

It is often difficult to know if an infant is in pain. In general, an infant who is crying for "normal" reasons can be consoled by comforting, distraction, or seeing to the child's needs (hunger, sleep, or a diaper change). Parents who are concerned about their infant's crying should see a healthcare provider to discuss their concerns and possible management strategies. (See "Patient information: Colic (excessive crying) in infants".)

Irritability and reflux — Many parents worry that reflux is the cause of their child's irritability or difficulty sleeping. However, clinical studies have shown that reflux does not usually cause pain, and reducing stomach acid does not improve irritability [3].

Irritability and difficulty sleeping are non-specific problems that can be related to a number of conditions. Infants who are irritable and who regurgitate frequently should be evaluated by a healthcare provider. If there are no other problems, a trial of a milk-free diet and thickened feeds may be recommended. (See 'Reflux treatment' below.)

REFLUX DIAGNOSIS

If a child is suspected of having gastroesophageal reflux disease, the first step in the evaluation is a complete medical history and physical examination. The need for further testing depends upon what is found, and may include one or more of the following:

• Laboratory testing (blood and/or urine tests)
• An x-ray study to evaluate how well the infant swallows and to evaluate the anatomy of the stomach
• A procedure, called upper endoscopy, to view the lining of the esophagus

REFLUX TREATMENT

Infants with uncomplicated reflux do not require treatment, although the following changes may be recommended if the infant is bothered by his or her symptoms. Infants with gastroesophageal reflux disease are generally treated first with lifestyle changes, including avoidance of overfeeding and tobacco smoke, a milk-free diet, and thickened feeds.

Many infants with symptoms of reflux will improve with conservative measures alone. In one study, over 80 percent of such infants partially or completely improved with conservative measures alone, including thickened feeds, avoidance of tobacco smoke, and trial of a milk-free diet (semi-elemental formula or restriction of milk from mother's diet if breastfed).

Milk-free diet — Studies report that 15 to 40 percent of infants with gastroesophageal reflux have a cow's milk protein intolerance, or "dietary protein-induced gastroenteropathy" [4]. Most children are diagnosed with this condition based upon their symptoms and how they respond to changes in diet; laboratory testing is not usually necessary.

The majority of infants with dietary protein gastroenteropathy are sensitive only to cow's milk protein, although some are also sensitive to soy protein. To eliminate these proteins from an infant's diet, breastfeeding mothers need to eliminate all milk and soy products from their own diet. In rare cases, the mother may need to eliminate other proteins, although this should only be done with the advice of a healthcare provider.

If the infant's reflux symptoms improve after a two to three week trial, it is reasonable to continue the restricted diet until the child is one year old. At this time, many children are able to tolerate milk without difficulty. If symptoms do not improve, the mother may resume her normal diet.

Formula fed infants can be given a hypoallergenic formula that does not contain milk or soy proteins (table 1). This is usually continued for one to two weeks to determine if the infant's reflux improves. If symptoms do not improve, the original formula may be restarted.

Almost all infants with a dietary protein intolerance outgrow the problem by one year of age.

Thickened feeds — Thickening formula or expressed breast milk may help to reduce the frequency of acid reflux and is a reasonable approach to reducing symptoms in a healthy baby who is gaining weight normally. For babies under three months of age, or those with allergies, it is best to consult with the child's healthcare provider before thickening feeds or changing formulas. However, thickened feeds are not usually recommended as the sole treatment for infants whose esophagus is injured as a result of acid reflux (esophagitis).

In the United States, the usual thickening agent is rice cereal; in other countries, rice starch, carob flour, or locust bean gum may be used. To thicken the feed, one ounce of formula or expressed breast milk is usually combined with one tablespoon of rice cereal. The nipple of the bottle may need to be made larger by cross-cutting it, to allow the thickened liquid to pass. Caution should be taken when the hole in the nipple is larger because the child can choke if the formula comes out too fast. For formula-fed infants, premixed "anti-reflux" formulas also are available, which contain rice starch to thicken the formula.

Women who breastfeed are encouraged to continue doing so; an infant should not be switched to formula for the purpose of thickening the feeds. Breastfeeding may reduce the risk of reflux in infants. (See "Patient information: Deciding to breastfeed".)

Positioning — Infants may have fewer episodes of acid reflux if they can be kept upright and calm for 20 to 30 minutes after a feed (ie, carried on an adult's shoulder, not placed in an infant seat). Parents should avoid over-feeding and allow the infant to stop feeding as soon as he or she seems to lose interest.

Like all infants, those with acid reflux should be positioned on the back to sleep. There is no benefit of raising the head of the crib or placing the child to sleep in a car seat. Infants should never be placed on the stomach or side to sleep as this increases the risk of sudden infant death syndrome (SIDS). (See "Patient information: Sudden infant death syndrome (SIDS)".)

Reflux medications — If an infant's symptoms do not improve after a trial of the conservative treatments discussed above, a trial of an acid-suppressing medication may be recommended. There are a number of medications available for the treatment of acid reflux in adults. However, the safety and efficacy of these medications in infants is quite different.

• Infants with uncomplicated gastroesophageal reflux ("happy spitters") do not benefit from medications that reduce stomach acid or speed emptying of the stomach.
• Infants with suspected gastroesophageal reflux disease may benefit from a brief trial of a medication that blocks the production of acid in the stomach. The trial can help to determine if reducing acid production improves the symptoms. Ranitidine (Zantac®), omeprazole (Prilosec®) and lansoprazole (Prevacid®) are best studied in infants. Omeprazole and lansoprazole are proton pump inhibitors (PPIs) and are generally more effective than ranitidine. If the symptoms do not improve significantly within a few weeks, the medication is usually stopped.
• Antacids (eg, Tums®, Maalox®) and histamine receptor blockers (eg, ranitidine/Zantac®, famotidine/Pepcid® are not as effective as PPIs in suppressing acid, but may help to control symptoms.

All of these medications, even antacids, can cause side effects and are not recommended without consulting a healthcare provider.

WHEN TO SEEK HELP

Infants with acid reflux who also have the following signs or symptoms should be evaluated by a healthcare provider:

• Bloody stools, severe diarrhea, recurrent vomiting, or vomiting blood
• Recurrent pneumonia
• Delayed weight gain
• The infant has cried for more than two hours
• Refusing to eat or drink anything for a prolonged period
• The infant is under three months of age and has forceful vomiting after each feed, but still appears hungry
• Behavior changes, including lethargy or decreased responsiveness

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our Web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to gastroesophageal reflux disease (GERD, acid reflux, heartburn)
Patient information: Gastroesophageal reflux disease in children and adolescents
Patient information: Poor weight gain in infants and children
Patient information: Colic (excessive crying) in infants
Patient information: Deciding to breastfeed
Patient information: Sudden infant death syndrome (SIDS)

Professional Level Information:
Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents
Gastroesophageal reflux in infants
Gastroesophageal reflux in premature infants
Management of gastroesophageal reflux disease in children and adolescents
Patient information: A guide to gastroesophageal reflux disease (GERD, acid reflux, heartburn)

A number of Web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/gerdinfant/)

• North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

      (www.naspghan.org/wmspage.cfm?parm1=351, available in Spanish and Portugese)

• Children's Digestive Health and Nutrition Foundation

      (http://gerd.cdhnf.org/)

• La Leche League

      (www.llli.org/FAQ/ger.html)

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