Gastroesophageal Reflux

"Gastroesophageal reflux" or GER or just plain "reflux" is where the stomach (gastric) contents come up into the esophagus.The other term for that is regurgitation.GERD, where a "D" is added to indicate reflux disease, when the GER is more troublesome and causes more than simple spitting.

Symptoms in Infants

  • Spitting up, or it just rolls out of babies' mouths.  Can be after feedings or hours later
  • Discomfort and crying, often improving when they are held upright
  • Can hear or see them trying to re-swallow what's come up
  • Gagging, choking, wheezing
  • Feeding difficulties
  • Repeated ear or respiratory infections
  • Tilting the head to the side
  • Silent reflux is when one or more of these last symptoms happen, but the baby isn't spitting

Causes in Infants

Almost all babies have some spitting because they have:

  • Smaller, less stretchable stomachs
  • The angle the stomach and esophagus make with each other allows stomach contents to come back easily (that's regurgitation)
  • Less strength (or tone) of the valve (the lower esophageal sphincter) between the esophagus and stomach

Symptoms in Older Children and Teens

  • Heartburn or chest pain
  • Stomach pain, especially after eating
  • Re-swallowing
  • Difficulty swallowing
  • Wheezing, coughing with asthma or reactive airway disease
  • Aspiration, particularly in kids who have disabilities or swallowing problems  
  • Repeated respiratory or sinus infections
  • Dental problems with the enamel or cavities

These problems are present because the "valve" between the stomach and stomach (the lower esophageal sphincter) is weak or no longer functions properly.  As a result, stomach acid and juices and the stomach contents can reflux into the esophagus and cause significant damage, enough that the esophagus may develop scars that interfere with the passage of food into the stomach or the damage can irritate the tissue enough that esophageal cancer can develop.

Testing and Treatment

Several different tests are available to make the diagnosis, determine how severe the condition is and to monitor the effectiveness of treatment.Treatment options range from dietary and lifestyle modifications to blocking acid production, whether it’s a young infant or older teenager with active symptoms.Surgery remains an option as well to prevent further esophageal or lung damage.

And 95% completely outgrow the condition by 13 months of age.  But until then, they spit--often a teaspoon to a tablespoon right after feedings.  But it can be hours later or larger amounts (an entire bottle at times).  Some can come through the nose or cause a brief cough or sputter.  When it’s merely like that, it’s GER (meaning, the return of stomach (gastro-) contents into the esophagus).

GERD: Reflux is always simple

If 95% outgrow GER by 13 months, that means 5% or 1 out of every 20 babies continue on with spitting, and sometimes the problems that can accompany it.  What's coming up can irritate or damage the esophagus or end up in the passageways of the lungs and ear canals.  That can even begin in early infancy. That’s when it’s the more significant GERD.  Six (6) warning signs that the baby has GERD are:

  • Poor weight gain
  • Excessive crying or irritability
  • Head usually tilted to one side
  • Feeding problems
  • Respiratory problems:
    • wheezing, apnea, noisy or difficult breathing,
    • repeated respiratory or ear infections
  • Symptoms that continue beyond that 13 month period

Sometimes these symptoms occur when the baby isn’t spitting.  He or she may have a feeding problem or pneumonia without any regurgitation.  That’s silent reflux, and as you might suspect, the GERD becomes much harder to detect.  Additionally, there are babies who do not have reflux as their main problem.  Instead the spitting or vomiting is part of a larger problem with a separate set of warning signs and symptoms.
Tests and medicines to help are available.Both testing and the treatment needed depend on the extent of the reflux symptoms. Spitting constantly or with GERD symptoms requires more attention than the child who smiling while having occasional "wet burps" during the day.

Nutrition in Infant GER and GERD

Dietary treatment is often the first step.  Some babies are spitters because they are overfed, getting too much at a meal. They do better with small, frequent meals--and with keeping their heads up after a meal, so that gravity can help keep the formula down.
Others improve with a small amount of cereal added to the formula, which thickens the liquid, making it less likely to return.  Thickening has an additional benefit for lower weight infants.  The extra cereal at 5 calories per teaspoon will quickly add to the babies’ weight.  In the same way, those extra calories can quickly add too much weight to the baby.  Both Enfamil and Similac both make formulas (Enfamil AR and Similac Spit Up) that have the same effect without the extra calories.  They substitute rice starch for lactose, keeping the calories the same as routine cows’ milk based formula.  But they need normal stomach acid in order to turn the starch into a thicker for the formula, so it's important that an acid blocker isn't used at the same time.
Another important note is that some babies will try to avoid their feedings turning their heads away or arching backwards.  They may be developing feeding issues as a result of their GERD -- this is often a reason for further evaluation.