Gastroesophageal 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 :

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 ).

The main symptom of gastroesophageal reflux is

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 .

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.

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.

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