Infant Acid Reflux

baby-scratching-his-noseIt’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.

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*These statements have not been evaluated by the FDA.
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