Infant Acid Reflux

It’s a sad commentary on current events when you notice that every other infant you meet seems to have GERD, gastroesophageal reflux disease. You know the scene by now. Almost everything the baby swallows gets regurgitated, which, by the way, is not quite the same as vomited. In the former, the material often goes back down; in the latter, it comes out. The acid burns on the way up, and it burns on the way back down.  The agony of it all! The apparent high incidence of GERD makes you wonder if there really are more cases, or is it merely over-diagnosed and mistaken for simple reflux?

What It Is There is confusion between GER and GERD. Reflux is just that—stomach contents back up into the esophagus and sometimes come out the mouth or nose as spit-up or vomit. Reflux is common to about half of all infants under three months of age, but commonly decreases to less than 1% by one year (Hrabovsky, 1986). The prevalence of GER peaks between one and four months and often resolves at six months.   Physiologically, normal reflux is characterized by spitting up with burps, but the child continues to feed well and thrive without respiratory or other systemic involvement.

When additional symptoms appear, such as extreme irritability, blood loss, respiratory problems, chronic cough, disturbed sleep, apnea and cyanosis in wheezing, and poor growth, GERD may be suspected. Vomiting may occur more than twice a day and  continue longer than a few weeks. At this point, the infant may arch his back during or immediately after eating. Refusal to feed is common. It’s important to call the doctor if vomiting is projectile, is green or yellow, or looks like coffee grounds.

The Cause The cause of GERD has not been pinpointed, but it’s safe to assume that the lower esophageal sphincter (LES), the muscle that closes the esophagus after swallowing and allowing food into the stomach, is not mature enough to do its job. It’s also possible that the section of the diaphragm through which the esophagus passes is poorly developed. If a baby is born with respiratory problems, xanthine drugs, such as theophylline or even caffeine, may be given to stimulate breathing. These increase gastric acid secretion and decrease LES pressure, resulting in reflux (Vandenplas, 1986).

The Diagnosis You would think that, by this point in medical history, a pediatrician would know the difference between GER and GERD, yet according to a study performed at the Pediatric Specialty Center in New Orleans, it seems that doctors are overprescribing anti-reflux medications because they think they are treating GERD when the patient may only have GER (Khoshoo, 2007). British researchers also objurgated overuse of drugs in a declaration made in their Drugs and Therapeutics Bulletin in 2009. Part of the reason for this rise in medicating is parent expectations, so blame does not sit only on the physician. Some parents don’t feel as if they’ve visited a doctor unless they leave with a prescription. It was interesting to find in the Khoshoo study that some things under the parents’ control could account for GER symptoms, including thickness of the formula, changes in formula, the amounts fed, and the position of the baby.

If GERD is suspected, anatomic abnormalities may be detected by an upper GI exam, the kind that requires a barium swallow and x-ray. Being non-invasive, this is a relatively simple procedure. However, barium is physiologically inert and cannot be used to evaluate rates of gastric emptying. Extended monitoring of esophageal pH, however, is deemed the gold standard of GERD diagnosis, and may be accomplished using specially designed electrodes just for babies (Gille, 1982) (Koch, 1981). New devices are portable and 100% sensitive, looking for a drop in pH to less than 4.0, lasting for at least eight to fifteen seconds (Mohan, 2002). In severe cases, endoscopy and/or esophageal biopsy may be employed where esophagitis is suspected, both requiring sedation and invasion, something no parent wants for his child.

Treatment Transient LES relaxation is considered the main mechanism behind infant reflux and probably has little or no effect on gastric emptying (Omari, 2002). If that is the case, thickening of formula is part of the therapeutic approach, and may be done so with a variety of food elements, including carob bean gum (Wenzl, 2003) or a tablespoon of rice cereal in two ounces of formula, reducing reflux by a considerable margin. Holding the baby more vertical while feeding is another useful approach (Cosgrove, 1998), and keeping him in that position for thirty minutes afterward offers substantial benefit.  Some studies report that cereal-thickened formula is more effective than posturing (Chao, 2007) (Vandenplas, 1998), but both are the preferred first line treatment (Baudon, 2009).

The use of pacifiers to keep a baby calm is ubiquitous. Some babies are happiest when they are sucking on something, although dependence on a pacifier might interfere with breast feeding and lead to dental problems later on. This non-nutritive sucking may increase the frequency of reflux if the baby is lying down, but generally not if sitting up (Orenstein, 1988). In some countries, pacifiers are rarely used to calm an infant. In the UAR, for example, mothers prefer to calm their offspring with soothing herbs, the commonest being anise. Fennel, gripe water (a blend of bicarbonate, ginger, dill, fennel and chamomile, sometimes containing alcohol), cumin, chamomile tea, mint, or fenugreek tea are other options (Abdulrazzaq, 2009). FYI, gripe water is regulated by the FDA in the United States, and the alcohol is out of the equation.  You can check it out here:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297971/pdf/10844880.pdf (Blumenthal, 2000). Colic Calm is one approved version available, although others may be out there.

If a child is so sensitized, cow’s milk will exacerbate GERD by inducing gastric dysrhythmia and delayed gastric emptying (Ravelli, 2001) (Nielsen, 2004). Allergy or sensitivity to cow’s milk protein cannot be determined by a single test, and neither should it be diagnosed only by clinical symptoms. Elimination-and-challenge procedures might tell all the story a parent needs. With frequency put at 3%, this is an area worth exploring with your physician (Høst, 1995, 2002), especially if your baby shows signs of distress (Ewing, 2005).

There is a hierarchy of infant reflux treatment, starting with formula thickening and postural changes and ending with drugs, the mildest of which are the H2-blockers such as Tagamet and Pepcid. The more potent proton pump inhibitors (PPIs), such as Prilosec and Prevacid, are of questionable efficacy in infants, and are presented with conflicting evidence (Higginbotham, 2010). It is suggested to save the drugs as the last resort, but to try them even before allowing your baby to be invaded by an endoscope.  H2 blockers will suppress the manufacture of stomach acid, as will PPIs, but not without side effects. With many drugs there is no dose low enough to be safe, especially in infants.  Because there is no simple tool a pediatrician can use to diagnose GERD in an infant, the Rx pad is often the first weapon. A parent’s anxiety only reassures the physician that he’s doing what’s best. Of course, marketing by the pharmaceutical companies makes it even easier to write a prescription, but that also makes it harder to distinguish between GER and GERD.

Abdulrazzaq YM, Al Kendi A, Nagelkerke N. Soothing methods used to calm a baby in an Arab country. Acta Paediatr. 2009 Feb;98(2):392-6.


Baudon JJ. Gastroesophageal reflux in infants: myths and realities. Arch Pediatr. 2009 May;16(5):468-73. Epub 2009 Mar 19.


I Blumenthal The gripe water story. J R Soc Med. 2000 April; 93(4): 172–174. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297971/pdf/10844880.pdf


Chao HC, Vandenplas Y. Effect of cereal-thickened formula and upright positioning on regurgitation, gastric emptying, and weight gain in infants with regurgitation. Nutrition. 2007 Jan;23(1):23-8.


Cosgrove M, Dodge J. Gastro-oesophageal reflux in children. Eur J Gastroenterol Hepatol. 1998 Jul;10(7):547-8.


Drug and Therapeutics Bulletin (dtb.bmj.com). 2009; 47(12): 134-137 Managing gastro-oesophageal reflux in infants Relevant BNF section: 1.1,1.2,1.3, Appendix 2


Ewing WM, Allen PJ. The diagnosis and management of cow milk protein intolerance in the primary care setting. Pediatr Nurs. 2005 Nov-Dec;31(6):486-93.


Gille P, Aubert D, Cingotti M, François JY, Prihnenko N, Spiroux M, Jouan M. Infant esophageal pH monitoring Chir Pediatr. 1982 Mar-Apr;23(2):69-72.


Grant L, Cochran D. Can pH monitoring reliably detect gastro-oesophageal reflux in preterm infants? Arch Dis Child Fetal Neonatal Ed. 2001 Nov;85(3):F155-7; discussion F157-8.


Higginbotham, Tanner W, PharmD Effectiveness and Safety of Proton Pump Inhibitors in Infantile Gastroesophageal Reflux Disease Ann Pharmacother March 2010 vol. 44 no. 3: 572-576


Høst A, Jacobsen HP, Halken S, Holmenlund D. The natural history of cow's milk protein allergy/intolerance. Eur J Clin Nutr. 1995 Sep;49 Suppl 1:S13-8.


Høst A. Frequency of cow's milk allergy in childhood. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):33-7.


Hrabovsky EE, Mullett MD. Gastroesophageal reflux and the premature infant. J Pediatr Surg. 1986 Jul;21(7):583-7.


Iacono G, Carroccio A, Cavataio F, Montalto G, Kazmierska I, Lorello D, Soresi M, Notarbartolo A. Gastroesophageal reflux and cow's milk allergy in infants: a prospective study. J Allergy Clin Immunol. 1996 Mar;97(3):822-7.


Khoshoo V, Edell D, Thompson A, Rubin M. Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007 Nov;120(5):946-9.


A. Koch, R. Gass Continuous 20–24 hr esophagealpH-monitoring in infancy * Journal of Pediatric Surgery. Volume 16, Issue 2, April 1981, Pages 109–113


Mohan N and Soni A Gastro-esophageal reflux in neonates. Journal of Neonatology. 2002; 16(3): 257-266


Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Arch Pediatr Adolesc Med. 1997 Jun;151(6):569-72.


Nielsen RG, Bindslev-Jensen C, Kruse-Andersen S, Husby S. Severe gastroesophageal reflux disease and cow milk hypersensitivity in infants and children: disease association and evaluation of a new challenge procedure. J Pediatr Gastroenterol Nutr. 2004 Oct;39(4):383-91.


Omari TI, Barnett CP, Benninga MA, Lontis R, Goodchild L, Haslam RR, Dent J, Davidson GP. Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease. Gut. 2002 Oct;51(4):475-9.


Orenstein SR. Effect of nonnutritive sucking on infant gastroesophageal reflux. Pediatr Res. 1988 Jul;24(1):38-40.


Ravelli AM, Tobanelli P, Volpi S, Ugazio AG. Vomiting and gastric motility in infants with cow's milk allergy. J Pediatr Gastroenterol Nutr. 2001 Jan;32(1):59-64.


M P Tighe, R M Beattie Perspective Managing gastro-oesophageal reflux in infancy Arch Dis Child 2010;95:243-244 doi:10.1136/adc.2009.170407


Yvan Vandenplas, D. De Wolf, L. Sacre Influence of Xanthines on Gastroesophageal Reflux in Infants at Risk for Sudden Infant Death Syndrome Pediatrics Vol. 77 No. 6 June 1, 1986: pp. 807 -810


Vandenplas Y. A critical appraisal of current management practices for infant regurgitation. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi. 1997 May-Jun;38(3):187-202.


Yvan Vandenplas, MD, Jere Ziffer Lifshitz, MS, Susan Orenstein, MD, et al Nutritional Management of Regurgitation in Infants J Am Coll Nutr. August 1998; vol. 17 no. 4: 308-316


Van Howe RS, Storms MR. Gastroesophageal reflux symptoms in infants in a rural population: longitudinal data over the first six months. BMC Pediatr. 2010 Feb 11;10:7.


Wenzl TG, Schneider S, Scheele F, Silny J, Heimann G, Skopnik H. Effects of thickened feeding on gastroesophageal reflux in infants: a placebo-controlled crossover study using intraluminal impedance. Pediatrics. 2003 Apr;111(4 Pt 1):e355-9.

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