Gastroesophageal Reflux in Infants
(Gastroesophageal Reflux Disease [GERD])
Gastroesophageal reflux (GER) is the movement of gastric contents into the esophagus. Gastroesophageal reflux disease (GERD) is reflux that causes complications such as irritability, respiratory problems, and poor growth. Diagnosis is often made clinically, including by trial of dietary change, but some infants require an upper GI series, use of esophageal pH and impedance probes, and sometimes endoscopy. GER requires only reassurance. Treatment of GERD begins with modification of feeding and positioning; some infants require acid-suppressing drugs such as ranitidine or lansoprazole. Antireflux surgery is rarely needed.
GER occurs in almost all infants, manifesting as wet burps after feeding. Incidence of GER increases between 2 mo and 6 mo of age (likely due to an increased volume of liquid at each feeding) and then starts to decrease after 7 mo. GER resolves in about 85% of infants by 12 mo and in 95% by 18 mo. GERD is much less common.
The most common cause of GERD in infants is similar to that of GERD in older children and adults―the lower esophageal sphincter (LES) fails to prevent reflux of gastric contents into the esophagus. LES pressure may transiently decrease spontaneously (inappropriate relaxation), which is the most common cause of reflux, or after exposure to cigarette smoke and caffeine (in beverages or breast milk). The esophagus is normally at a negative pressure, whereas the stomach is at a positive pressure. The pressure in the LES has to exceed that pressure gradient to prevent reflux. Factors that increase this gradient or decrease the pressure in the LES predispose to reflux. The pressure gradient may increase in infants who are overfed (excessive food causes a higher gastric pressure) and in infants who have chronic lung disease (lower intrathoracic pressure increases the gradient across the LES) and by positioning (eg, sitting increases gastric pressure).
Other causes include food allergies, most commonly milk allergy. A less common cause is gastroparesis (delayed emptying of the stomach), in which food remains in the stomach for a longer period of time, maintaining a high gastric pressure that predisposes to reflux. Infrequently, an infant can have recurrent emesis that mimics GERD because of a metabolic disease (eg, urea cycle defects, galactosemia, hereditary fructose intolerance) or an anatomic abnormality (such as pyloric stenosis or malrotation).
Complications of GERD are due mainly to irritation caused by stomach acid and to caloric deficit caused by the frequent regurgitation of food.
Stomach acid may irritate the esophagus, larynx, and, if aspiration occurs, the airways. Esophageal irritation may decrease food intake as infants learn to avoid reflux by eating less. Significant esophageal irritation (esophagitis) may cause mild, chronic blood loss and esophageal stricture. Laryngeal and airway irritation may cause respiratory symptoms. Aspiration may cause recurrent pneumonia.
Frequent regurgitation (spitting up) is the main symptom of GER. Caregivers often refer to this spitting up as vomiting, but it is not because it is not due to peristaltic contractions. The spit ups appear effortless and not particularly forceful.
Infants with GERD may be irritable and/or have respiratory symptoms such as chronic recurrent coughing or wheezing and sometimes stridor. Much less commonly, infants have intermittent apnea or episodes of arching the back and turning the head to one side (Sandifer syndrome). Infants may fail to gain weight appropriately or, less often, lose weight.
Infants who have effortless spit ups, who are growing normally, and who have no other symptoms (sometimes referred to as "happy spitters") have GER and require no further evaluation.
Because spitting up is so common, many infants with serious disorders also have a history of spitting up. Red flags that infants have something other than GERD include forceful emesis, emesis containing blood or bile, fever, poor weight gain, blood in the stools, persistent diarrhea, and abnormal development or neurologic symptoms. Infants with such findings require prompt evaluation as described elsewhere in The Manual. Bilious emesis in an infant is a medical emergency because it may be a symptom of malrotation of the intestines and midgut volvulus.
Irritability has many causes, including serious infections and neurologic disorders, which should be ruled out before concluding that the irritability is caused by GERD.
Infants who have symptoms consistent with GERD and no severe complications may be given a therapeutic trial of medical therapy for GERD; improvement or elimination of symptoms suggests GERD is the diagnosis and that other testing is unnecessary. Infants can also be given an extensively hydrolyzed (hypoallergenic) formula for 7 to 10 days to see whether the symptoms are caused by a food allergy.
Infants who fail to respond to a therapeutic trial, or who present with signs of complications of GERD, may require further evaluation. Typically, an upper GI series is the first test; it may help diagnose reflux and also identify any anatomic GI disorders that cause regurgitation. Finding barium reflux into the mid or upper esophagus is much more significant than seeing reflux into only the distal esophagus. For infants with regurgitation hours after eating, who may have gastroparesis, a liquid gastric emptying scan, which uses a radiolabeled liquid, is an alternative to an upper GI series.
If the diagnosis remains unclear or there is still a question of whether reflux is actually the cause of symptoms such as coughing or wheezing, a pediatric gastroenterologist may do tests using esophageal pH or impedance probes (see Ambulatory pH Monitoring). Caregivers record the occurrence of symptoms (manually or by using an event marker on the probe); the symptoms are then correlated with reflux events detected by the probe. A pH probe can also assess the effectiveness of acid-suppression therapy. An impedance probe has the ability to detect nonacid reflux as well as acid reflux.
Upper GI endoscopy and biopsy are sometimes done to help diagnose infection or food allergy and detect and quantify the degree of esophagitis. Laryngotracheobronchoscopy may be done to detect laryngeal inflammation, vocal cord nodules, and evidence of lipid-laden macrophages on bronchial aspirates in patients with significant respiratory symptoms.
For infants with GER, the only necessary treatment is to reassure caregivers that the symptoms are normal and will be outgrown. Infants with GERD require treatment, typically beginning with conservative measures.
As a first step, most clinicians recommend thickening feedings, which can be done by adding 1/2 to 1 tbsp rice cereal/30 mL formula. Thickened formula seems to reflux less, particularly when the infant is kept in an upright position for 20 to 30 min after feeding. Thickened formula may not flow through the nipple properly, so the nipple orifice may need to be cross-cut to allow adequate flow.
Providing smaller, more frequent feedings helps keep the pressure in the stomach down and minimizes the amount of reflux. However, it is important to maintain an appropriate total amount of formula/24-h period to ensure adequate growth. In addition, burping the infant after every 1 to 2 oz can help decrease gastric pressure by expelling the air the infant is swallowing.
A hypoallergenic formula can be given to infants who may have a food allergy. Hypoallergenic formula can even be helpful for infants who do not have a food allergy by improving gastric emptying. All children should be kept away from caffeine and tobacco smoke.
After feeding, infants are kept in an upright, nonseated position for 20 to 30 min (sitting, as in an infant seat, increases gastric pressure and is not helpful). For sleeping, the head of the crib can be raised about 15 cm (6 in); if the head of the crib is raised, infants should be secured in a sling fitted over the mattress or wedge to keep them from rolling or sliding down to a horizontal position on the lower end of the crib.
Three classes of drugs can be used in infants who do not respond to feeding modification and positioning:
Typically, treatment of GERD is begun with an H2 blocker such as ranitidine 2 mg/kg po bid to tid. If the infant responds, the drug is continued for several months and then tapered and stopped (if possible). If infants fail to respond to H2 blockers, a PPI such as lansoprazole can be considered, although there are few data on PPI use in infants. PPIs are more effective at suppressing gastric acid than are H2 blockers and are given only once/day. For infants with GERD and an acute symptom such as irritability, a liquid antacid can be used.
Infants who have gastroparesis may benefit from a promotility drug in addition to acid-suppressive therapy. Erythromycin is one of the most commonly used promotility drugs for this situation. Metoclopramide was used previously but does not seem as effective and can have significant adverse effects. More recently, amoxicillin/clavulanate has also been used for its promotility properties.
Infants with severe or life-threatening complications of reflux that are unresponsive to medical therapy can be considered for surgical therapy. The main type of antireflux surgery is fundoplication. During this procedure, the top of the stomach is wrapped around the distal esophagus to help tighten the LES. Fundoplication can be very effective at resolving reflux but has several complications. It can cause pain when infants vomit (eg, during acute gastroenteritis), and if the wrap is too tight, infants may have dysphagia. If dysphagia occurs, the wrap can be dilated endoscopically. Some anatomic causes of reflux also may have to be corrected surgically.
Most reflux in infants does not cause other symptoms or complications and resolves spontaneously by age 12 to 18 mo.
GERD is diagnosed when reflux causes complications such as esophagitis, respiratory symptoms (eg, cough, stridor, wheezing, apnea), or impaired growth.
Prescribe a therapeutic trial of feeding modifications and positioning if GERD symptoms are mild.
Consider testing with an upper GI series, gastric emptying scan, esophageal probes, or endoscopy for infants with more severe GERD symptoms or for whom a therapeutic trial is not helpful.
Acid suppression with an H2 blocker or PPI may help infants with significant GERD.
Most infants with GERD respond to medical therapy, but a few require surgical therapy.