Gastroesophageal reflux occurs in almost all infants, manifesting as wet burps after feeding and/or spit-ups (the non-forceful return of milk or gastric contents to the esophagus, pharynx, and mouth). The incidence of gastroesophageal reflux increases between 2 months and 6 months of age (likely due to an increased volume of liquid at each feeding) and then starts to decrease after 7 months. Gastroesophageal reflux resolves in about 85% of infants by 12 months and in 95% by 18 months. Gastroesophageal reflux disease (GERD), ie, reflux that causes complications, is much less common.
Etiology of Reflux in Infants
The most common cause of GERD in infants is similar to that of GERD in older children and adults Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more :
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 agents such as cigarette smoke or caffeine (in beverages or breast milk). The baseline esophageal pressures is normally negative, whereas the baseline stomach pressure is positive. 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. For example, the pressure gradient may increase in infants who are overfed (an excessive volume of food causes a higher gastric pressure) and in infants who have chronic lung disease (lower intrathoracic pressure increases the gradient across the LES) and may increase because of positioning (eg, sitting increases intra-abdominal and gastric pressure).
Other causes include food allergies Food Allergy Food allergy is an exaggerated immune response to dietary components, usually proteins. Manifestations vary widely and can include atopic dermatitis, gastrointestinal or respiratory symptoms... read more , most commonly cow's milk protein 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 Urea Cycle Disorders Urea cycle disorders are characterized by hyperammonemia under catabolic or protein-loading conditions. There are many types of urea cycle and related disorders (see the table) as well as many... read more , galactosemia Galactosemia Galactosemia is a carbohydrate metabolism disorder caused by inherited deficiencies in enzymes that convert galactose to glucose. Symptoms and signs include hepatic and renal dysfunction, cognitive... read more , hereditary fructose intolerance Fructose Metabolism Disorders Deficiency of enzymes that metabolize fructose may be asymptomatic or cause hypoglycemia. Fructose is a monosaccharide that is present in high concentrations in fruit and honey and is a constituent... read more ) or an anatomic abnormality (such as pyloric stenosis Hypertrophic Pyloric Stenosis Hypertrophic pyloric stenosis is obstruction of the pyloric lumen due to pyloric muscular hypertrophy. Diagnosis is by abdominal ultrasonography. Treatment is surgical. Hypertrophic pyloric... read more or malrotation Malrotation of the Bowel Malrotation of the bowel is failure of the bowel to assume its normal place in the abdomen during intrauterine development. Diagnosis is by abdominal x-ray. Treatment is surgical repair. (See... read more ).
Complications of GERD
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, pharynx, 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 Eosinophilic Esophagitis Eosinophilic esophagitis is a chronic immune-mediated disease of the esophagus resulting in eosinophil-predominant inflammation of the esophagus; it can cause reflux-like symptoms, dysphagia... read more ) may cause mild, chronic blood loss and lead to esophageal stricture and food refusal. Laryngeal and airway irritation may cause respiratory symptoms such as tachypnea, wheezing, or stridor. Aspiration may cause recurrent pneumonia.
Symptoms and Signs of Reflux in Infants
The main symptom of gastroesophageal reflux is
Frequent regurgitation (spitting up, wet burps)
Caregivers often refer to this spitting up as vomiting, but it is not actually vomiting because it is not due to gastric peristaltic contractions. The spit-ups appear effortless and not particularly forceful.
Infants in whom reflux has caused GERD have additional symptoms, such as irritability, feeding refusal, and/or respiratory symptoms such as chronic recurrent coughing Cough in Children Cough is a reflex that helps clear the airways of secretions, protects the airway from foreign body aspiration, and can be the manifesting symptom of a disease. Cough is one of the most common... read more or wheezing Wheezing and Asthma in Infants and Young Children Wheezing is a relatively high-pitched whistling noise produced by movement of air through narrowed or compressed small airways. It is common in the first few years of life and is typically caused... read more and sometimes stridor Stridor Stridor is a high-pitched, predominantly inspiratory sound. It is most commonly associated with acute disorders, such as foreign body aspiration, but can be due to more chronic disorders, such... read more . 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. GERD can cause iron deficiency anemia Iron Deficiency Anemia Iron deficiency is the most common cause of anemia and usually results from blood loss; malabsorption, such as occurs in celiac disease, is a much less common cause. Symptoms are usually nonspecific... read more .
Diagnosis of Reflux in Infants
Typically upper gastrointestinal (GI) series
Sometimes esophageal pH measurement or endoscopy
Infants who have effortless spit-ups, who are growing normally, and who have no other symptoms (sometimes referred to as "happy spitters") have physiologic gastroesophageal reflux 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 reflux include forceful emesis, abdominal distention, emesis containing blood or bile, fever, poor weight gain Failure to Thrive (FTT) in Children Failure to thrive in children is weight consistently below the 3rd to 5th percentile for age and sex, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in 2 major... read more , blood in the stools, persistent diarrhea Diarrhea in Children Diarrhea is frequent loose or watery bowel movements that deviate from a child’s normal pattern. Diarrhea may be accompanied by anorexia, vomiting, acute weight loss, abdominal pain, fever,... read more , iron deficiency anemia Iron Deficiency Anemia Iron deficiency is the most common cause of anemia and usually results from blood loss; malabsorption, such as occurs in celiac disease, is a much less common cause. Symptoms are usually nonspecific... read more , and abnormal/delayed development or neurologic manifestations (eg, bulging fontanelle, seizures, hypotonia, hypertonicity). Infants with such findings require prompt evaluation. Bilious emesis Nausea and Vomiting in Infants and Children Nausea is the sensation of impending emesis and is frequently accompanied by autonomic changes, such as increased heart rate and salivation. Nausea and vomiting typically occur in sequence;... read more in an infant is a medical emergency because it may be a symptom of intestinal malrotation Diagnosis Malrotation of the bowel is failure of the bowel to assume its normal place in the abdomen during intrauterine development. Diagnosis is by abdominal x-ray. Treatment is surgical repair. (See... read more , which leads to a midgut volvulus Intestinal Obstruction Intestinal obstruction is significant mechanical impairment or complete arrest of the passage of contents through the intestine due to pathology that causes blockage of the bowel. Symptoms include... read more .
Infants with repeated, forceful emesis should not be presumed to have reflux and should be evaluated for other disorders (see Nausea and Vomiting in Infants and Children Evaluation Nausea is the sensation of impending emesis and is frequently accompanied by autonomic changes, such as increased heart rate and salivation. Nausea and vomiting typically occur in sequence;... read more ) by doing, for example, pyloric ultrasonography to assess for pyloric stenosis Diagnosis Hypertrophic pyloric stenosis is obstruction of the pyloric lumen due to pyloric muscular hypertrophy. Diagnosis is by abdominal ultrasonography. Treatment is surgical. Hypertrophic pyloric... read more or brain imaging to assess for causes of elevated intracranial pressure (eg, brain tumor Overview of Central Nervous System Tumors in Children Central nervous system tumors are the most common solid cancer in children < 15 years old and are the leading cause of childhood death due to cancer. Diagnosis is typically by imaging (usually... read more ).
Irritability, a common symptom of GERD, 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 but no severe complications may be given a therapeutic trial of acid-reducing medication for GERD. Improvement or elimination of symptoms suggests that GERD is the diagnosis. If the infant continues to improve, other testing is likely unnecessary. Infants with suspected food allergy Food Allergy Food allergy is an exaggerated immune response to dietary components, usually proteins. Manifestations vary widely and can include atopic dermatitis, gastrointestinal or respiratory symptoms... read more can also be given an extensively hydrolyzed (hypoallergenic) formula for 2 to 4 weeks to see whether the symptoms are caused by a food allergy.
Infants who do not respond to a therapeutic trial, or who present with signs of complications of GERD (eg, iron deficiency anemia) may require further evaluation. Typically, an upper GI contrast x-ray 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, and thus are suspected of having gastroparesis, a liquid gastric emptying scan may be appropriate.
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 Ambulatory pH Monitoring Ambulatory 24-hour esophageal pH monitoring with or without intraluminal impedance testing is currently the most common test for quantifying gastroesophageal reflux (see the American College... read more ). 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 and is needed because some patients may be still affected by reflux even when the acid is properly buffered by medication and the refluxate is not acidic.
Upper GI endoscopy and biopsy are sometimes done to help diagnose infection or food allergy and to detect and quantify the degree of esophagitis. Laryngotracheobronchoscopy may be done to detect laryngeal inflammation or vocal cord nodules. Previously, the presence of lipid-laden macrophages and/or pepsin in bronchial aspirates was thought to help diagnose reflux and aspiration. However, lipid-laden macrophages are now recognized to be of no benefit, and pepsin measurement has low sensitivity and specificity.
Treatment of Reflux in Infants
Sometimes acid-suppressive therapy
For infants with gastroesophageal reflux, the only necessary treatment is to reassure caregivers that the symptoms are normal and will be outgrown.
Infants with GERD do require treatment, typically beginning with conservative measures.
Smaller, more frequent feedings
Sometimes hypoallergenic formula
For breastfed infants, changing the mother's diet
As a first step, most clinicians recommend reviewing proper feeding techniques (eg, volume of feedings, proper burping, positioning); if correction of technique is not enough, feedings can be thickened by adding 10 to 15 mL (1/2 to 1 tbsp) of rice cereal to 30 mL of formula. Thickened formula seems to reflux less, particularly when the infant is kept in an upright position for 20 to 30 minutes after feeding. Thickened formula may not flow through the nipple properly, so the nipple orifice often must be enlarged to allow adequate flow.
Providing smaller, more frequent feedings helps keep the pressure in the stomach down by giving the stomach less volume and the chance for better emptying and often minimizes the amount of reflux. However, it is important to maintain an appropriate total amount of formula per 24-hour 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.
If conservative measures fail, a hypoallergenic formula should be used in formula-fed infants for 2 to 4 weeks because these infants may have a food allergy. Hypoallergenic formula (hydrolyzed protein formulas) can even be helpful for infants who do not have a food allergy by improving gastric emptying.
Cow's milk protein allergy can occur in breastfed infants and can be a cause of GERD. A trial of placing the mother on a strict cow's milk protein–free diet for several weeks may be helpful. If symptoms do not respond, referral to a gastroenterologist is recommended.
All children should be kept away from caffeine and tobacco smoke.
After feeding, infants are kept in an upright, non-seated position for 20 to 30 minutes (sitting, as in an infant seat, increases gastric pressure and is not helpful).
For sleeping, left lateral positioning and elevation of the head of the crib are no longer recommended because of safety concerns. Regardless of the presence of reflux, the only recommended sleeping position for infants is supine, which has been shown to reduce the risk of sudden infant death syndrome (SIDS) Sudden Unexpected Infant Death (SUID) and Sudden Infant Death Syndrome (SIDS) Sudden unexpected infant death (SUID) is a term used to describe any unexpected and sudden death in a child less than 1 year of age, which often occurs during sleep or in the infant's sleep... read more and other sleep-related death.
Three classes of drugs have been used in infants with GERD who do not respond to feeding modification and positioning:
The North American and European specialty societies recommend that infants and children with GERD unresponsive to feeding and positioning modifications be given a proton pump inhibitor (PPI) (1 Treatment references Gastroesophageal reflux is the movement of gastric contents into the esophagus. It may be physiologic or pathologic. When pathologic, it is also known as gastroesophageal reflux disease (GERD)... read more ). If PPIs are unavailable or cannot be used, an H2 blocker can be given. These medications are not recommended simply for treatment of crying/distress and/or visible regurgitation. A typical PPI used is lansoprazole orally once a day. For infants who respond, the medication is continued for several months and then tapered and stopped.
Promotility (prokinetic) medications are theoretically beneficial by speeding gastric emptying and thus reducing the volume of gastric contents and amount of time the contents are present to be refluxed. Possible agents include baclofen, bethanechol, domperidone, erythromycin, and metoclopramide. The North American and European specialty societies recommend against use of promotility medications as first-line treatments, although baclofen may be tried before doing surgery on infants who are unresponsive to acid-blocking medications (1 Treatment references Gastroesophageal reflux is the movement of gastric contents into the esophagus. It may be physiologic or pathologic. When pathologic, it is also known as gastroesophageal reflux disease (GERD)... read more ). Of the other agents, bethanechol, domperidone, and metoclopramide are not recommended because of their potential for adverse effects. For infants who have gastroparesis, low-dose erythromycin may be used to hasten gastric emptying (2 Treatment references Gastroesophageal reflux is the movement of gastric contents into the esophagus. It may be physiologic or pathologic. When pathologic, it is also known as gastroesophageal reflux disease (GERD)... read more ). Some clinicians are using amoxicillin/clavulanic acid for its promotility properties, but this is not included in the North American and European specialty societies guidelines.
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 lower esophageal sphincter.
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/vomiting also may have to be corrected surgically.
1. Rosen R, Vandenplas Y, Singendonk M, et al: Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 66(3):516-554, 2018. doi: 10.1097/MPG.0000000000001889
2. Tillman EM, Smetana KS, Bantu L, Buckley MG: Pharmacologic Treatment for Pediatric Gastroparesis: A Review of the Literature. J Pediatr Pharmacol Ther 21(2):120-32, 2016. doi: 10.5863/1551-6776-21.2.120
Most reflux in infants does not cause other symptoms or complications and resolves spontaneously by age 12 to 18 months.
Gastroesophageal reflux disease (GERD) is diagnosed when reflux causes complications such as esophagitis, respiratory symptoms (eg, cough, stridor, wheezing, apnea), iron deficiency anemia, or impaired growth.
Clinicians recommend prescribing a therapeutic trial of feeding modifications and after-feeding positioning if GERD symptoms are mild.
Consider testing with an upper gastrointestinal contrast x-ray series, gastric emptying scan, esophageal pH probes, or endoscopy for infants with more severe GERD symptoms or for whom a therapeutic trial is not helpful.
If the response to therapy is not satisfactory, consider gastroparesis and measure gastric emptying using a gastric emptying scan.
Acid suppression with a proton pump inhibitor or H2 blocker may help infants with significant GERD.
Most infants with GERD respond to medical therapy, but a few require surgical therapy.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition: Pediatric gastroesophageal reflux clinical practice guidelines (2018)
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