Reflux

Reflux or Gastroesophageal Reflux (GER) is relatively common in infants. Often starting when the baby is two- to four-weeks-old and ending between one and two years of age, it can continue into childhood and beyond. Severity can vary greatly from frequent spit-ups to Gastroesophageal Reflux Disease (GERD) in which frequent reflux and vomiting causes severe irritation and pain, feeding refusal and/or respiratory problems.

Causes

In infants reflux is usually due to an immature GI Tract. Normally when swallowing occurs the muscles of the esophagus contract from top to bottom, pushing food into the stomach. When the swallow is complete the Lower Esophageal Sphincter (LES) between the stomach and the esophagus closes completely, shutting the food and stomach acid into the stomach. For children with reflux the LES does not close completely or relaxes too soon, allowing the stomach's contents to travel back into the esophagus, causing pain.

Symptoms

Frequent vomiting
Burning sensation in chest, neck and throat
Gas and abdominal pain
Excessive drooling
Frequent burping, "wet" burps
Frequent crying, "painful" crying, fussiness after meals
Regurgitation and re-swallowing
Swallowing noises, choking, gagging
Frequent coughing, unexplained colds, wheezing or respiratory infections/pneumonia if the refluxed liquids are passing into the windpipes or lungs
Refusal to eat or eating limited amounts
Failure to gain weight
Wanting to eat constantly
Excessive drooling

Complications

In severe cases reflux may be categorized as GERD or Gastroesophageal Reflux Disease. Children may have severe inflammation, irritation and redness of the esophagus (esophagitis), narrowing of the esophagus, Barrett's esophagus, weakening of tooth enamel and issues of the throat and airways, including repeated pneumonia due to aspiration of refluxed liquids into the lungs.

For some infants with GERD, feeding is so painful, they refuse to eat. This may lead to inadequate growth. The child may be diagnosed as failure to thrive (FTT).

Diagnosis

In most cases reflux can be diagnosed by a doctor by simply discussing symptoms with parents or caregivers. In more severe cases or GERD doctors may request one or more of the following tests.

Barium Swallow Radiograph

The child swallows a solution of barium and then a series of x-rays are taken of the esophagus, stomach and upper small intestine. The barium shows up clearly on the x-ray, so the doctor may more clearly see problems in the esophagus such as obstructions, narrowing, stricture, ulcers, hiatal hernia or erosions of the surface tissues.

Upper G.I. Endoscopy

The doctor feeds an endoscope, a thin, flexible tube with a lens, into the esophagus, stomach and upper small intestine. The doctor can look for any problems such as ulcers, strictures (narrowing of the esophagus), Barrett's esophagus and inflammation in the upper GI tract. Biopsies of tissue may be taken to confirm reflux.

Gastric Emptying Study

The child drinks milk or eats food mixed with a safe radioactive chemical. Then a series of x-rays are taken following the food or drink through the upper GI tract. This can help determine whether the stomach is slow to empty (motility issue), and if refluxed liquids are entering the lungs (aspirating).

pH Probe

A thin tube with a probe at the tip is fed through the nose and into the esophagus. The probe is positioned in the lower esophagus. The frequency of reflux is monitored over time, usually 24 hours. Some doctors may suggest keeping a log of the child's behavior to see if symptoms match incidents of reflux. This is considered to be the best test to diagnose reflux.

Treatments

Lifestyle Changes

In most cases of GER, simply making lifestyle changes can greatly alleviate symptoms of reflux.

For infants:

Elevate the head of the crib or bassinet - gravity can help keep stomach contents in the stomach
Hold the baby upright for 30 minutes after a meal
Do not put the baby in a car sear for 30 minutes after a meal nor have the baby sit up - these positions can increase reflux
Give smaller, more frequent meals
Breastfeed

Smaller, more frequent meals naturally occur when breastfeeding
Breast milk empties from the stomach twice as quickly as formula
Breast milk is a natural antacid

If bottle feeding, it may help to give the baby an elemental formula such as Nutramigen or Alimentum if the reflux is due to a milk protein allergy
If your pediatrician agrees, it may help to thicken bottle feedings with a small amount of cereal or to use a formula such as Enfamil AR or Simulac Sensitive RS with added rice as the thicker consistency may stay down better.
Burp the baby more frequently
Give the baby a pacifier, which may increase saliva production and sooth reflux pain
Make sure the baby's diaper is not too tight, and have the baby wear loose clothes
If the infant is old enough and your pediatrician approves feed the baby solid foods, which may stay down better than liquids

For older children:

Elevate the head of the child's bed by 30 degrees
Serve several small meals through the day
Don't feed the child for several hours before bedtime
Limit food and drinks that may make reflux worse including acid-containing foods such as caffeinated beverages, citrus fruits and juices, tomato products, chocolate and licorice, spicy foods and fatty or fried foods
Do have the child eat foods that pass through the stomach more quickly, such as smoothies, pureed foods, low fat foods and soft foods
Don't have the child drink liquids with a meal, as fluids pass more easily back up into the esophagus
Have the child take small bites and chew well to help speed gastric emptying
Keep the child still after a meal
Keep the child upright for at least two hours after a meal
Have the child chew gum or drink water to alleviate symptoms
Have the child exercise regularly
Keep the child's weight down as obesity can lead to increased reflux
Avoid non-steroid, anti-inflammatory aspirin-containing medicines

Medications

For children with GERD, who are not growing well or eating enough, or who have complications such as damage to the esophagus or aspiration (fluids entering the lungs), medication may be necessary.

Antacids, such as Maalox can be used for short term relief of symptoms. They help reduce gas, reduce reflux and neutralize stomach acid. They should not be used long-term as they may cause diarrhea, constipation or if used over a long period of time rickets (thinning of the bones). Also, stomach acid helps digest proteins, kill germs from food and drinks and promotes the growth of beneficial bacteria in the intestines. Reducing stomach acid for prolonged periods can have undesirable consequences.
Histamine-2 (H-2) Receptor Antagonists, such as Tagamet and Zantac prevent the stomach from secreting stomach acid. These medicines do not reduce or eliminate reflux, but rather reduce the level of acid in the stomach contents by inhibiting one of three receptors that affect acid production. This can reduce pain and inflammation in the esophagus. Zantac is most commonly prescribed in cases of infant reflux because it is effective and has few side effects. These medicines are not effective in cases of issues with motility, and in fact can make motility issues worse.
Proton-Pump Inhibitors (PPIs), such as Nexium, Prevacid and Prilosec reduce the production of acid by blocking the enzyme in the stomach that produces acid, effectively inhibiting stomach acid production. PPIs may also be more effective than antacids at healing esophagitis and controlling the pain of reflux.
Prokinetic agents, such as Reglan and Erythormycin can help if the child's issue is related to motility, or the movement of food through the GI tract. Reglan speeds digestion. It has many side effects, some serious and some drug interactions. Erythromycin is an antibiotic usually used for bacterial infections. It causes the stomach to contract, which can ease reflux, but should not be used long-term.

Nissen Fundoplication

Nissen Fundoplication may be necessary in the most serious cases of GERD in which lifestyle changes and medications do not work and the effects of the GERD are serious. Nissen Fundoplication is a surgery in which the upper curve of the stomach, the fundus, is wrapped around the esophagus and sewn into place, so when the stomach contracts, the esophagus is constricted keeping the stomach contents in the stomach. The surgery can be done laparoscopically.

Nissen Fundoplication is very effective in reducing GERD symptoms and in healing esophagitis. Over time symptoms may return. Other complications include trouble swallowing, increased gas and trouble burping.