By Lisa B. Fletcher, M.D. with Blue Springs Pediatrics

As an expectant parent, we envision a beautiful, chubby, happy bundle of love that nurses every 3-4 hours and sleeps and smiles in between. And then they start puking on you!!! What’s this you ask? It’s making you smell sour and exponentially increasing your laundry efforts. Though your pets might appreciate it, every parent just wants it to stop! WE DO TOO!!!

Pediatricians are commonly asked about spitting up in newborns and infants.

This is probably one of the most common problems we evaluate in this age group. It’s a problem that can cause a lot of parental distress. So what are the differences in a child with simple spitting up, GER: gastroesophageal reflux, and a child who actually has GERD: gastroesophageal reflux disease? Let’s discuss the characteristics of both.

GER

This is the passage of gastric contents into the esophagus and is a normal physiologic process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause symptoms or esophageal injury or result in other complications.

GER is extremely common in healthy infants. Studies show that stomach contents may reflux into the esophagus 30 or more times daily in infants. Many, but not all, of these reflux episodes result in spitting up or vomiting. Studies show that 50% of infants birth to age 3 months reflux, 60% of infants 4 months of age reflux, and 20% of infants age 6-7 months reflux. GER decreases near the end of the first year of life and is not common in children over 18 months of age.

So, when your read the results of these studies you realize that you are not alone in your experience! Many parents have lived through the same thing.

GERD

In contrast, gastroesophageal reflux disease (GERD) occurs when the reflux episodes are associated with complications such as esophagitis or poor weight gain. The range of symptoms and complications of GERD in children vary with the age of the child. The evaluation of an infant with frequent regurgitation focuses on determining if an underlying disease is causing the symptom and/or if the reflux is causing secondary complications.

To generalize: the baby with true GERD is having bad heart burn all of the time. It hurts to eat, and it hurts when they spit up. Sometimes these babies have other special health circumstances: prematurity, genetic abnormalities or anatomic differences. These are things we are looking for to determine if the baby is at risk.

Common complications include the following:

• Irritability
• Poor weight gain
• Recurrent pneumonia
• Barrett’s esophagus (inflamed distal esophagus)
• Esophageal Stricture

So how can we tell which diagnosis is correct?

Uncomplicated GER can be diagnosed in infants who have no warning signs, good weight gain, feeding well, not unusually irritable, and have a normal physical examination. Most infants presenting with frequent GER will fall into this category; they are sometimes referred to as “happy spitters.” The history and physical examination usually are sufficient for establishing the diagnosis, and specific laboratory testing is not required.

Some of the Warning Signs that would trigger further investigation are as follows:

• Nonspecific symptoms
  • Prolonged vomiting
  • Profound lethargy
  • Significant weight loss
• Symptoms of gastrointestinal obstruction or disease
  • Vomiting bile
  • Projectile vomiting in an infant three to six weeks of age
  • Bloody vomiting
  • Rectal bleeding
  • Significant abdominal bloating and tenderness
• Symptoms or signs suggesting a brain abnormality or systemic disease
  • Bulging fontanel
  • Headache, positional triggers for vomiting or vomiting on awakening
  • Altered consciousness, seizures, or focal neurologic abnormalities
  • History of head trauma

Evaluation of the infant with Warning Signs

Depending on the history and physical exam, evaluations could include radiographic imaging, blood work, and referrals to different pediatric specialists.

Treatment of GER

Lifestyle measures that may be helpful include feeding breast milk as much as possible to infants who are fed both breast milk and formula, avoiding tobacco smoke, and avoiding overfeeding. Other conservative measures to improve the symptoms that may be worthwhile include a trial of thickened feeds, upright positioning after feeds, or a limited two-week trial of a hypoallergenic diet (intolerance of cow’s milk or other dietary protein may have similar symptoms).

Pharmacotherapy is not indicated for infants with uncomplicated reflux (GER) based on lack of efficacy and several safety concerns. Studies show that acid-suppressing medications are not effective in infants for treatment of symptoms such as regurgitation and irritability. Even in infants with frequent regurgitation, prone positioning for sleep is not recommended, because of an increased risk for sudden infant death syndrome (SIDS).

Treatment of GERD

Avoidance of cow’s milk and soy protein: Food protein intolerance (typically to cow’s milk) sometimes has a clinical presentation that mimics GERD. Breastfed infants can be treated with careful elimination of all cow’s milk proteins and beef from the mother’s diet. Major sources of soy protein may need to be eliminated as well.

In formula-fed infants, we suggest switching to an extensively hydrolyzed formula. If there is a strong suspicion of a food protein intolerance (because of bloody stools or symptoms of eczema) and the infant does not respond to a hydrolyzed formula, a trial of an amino acid-based (“elemental”) formula or elimination of other dietary proteins may be necessary.

Infants who respond to the dietary change are generally maintained on a milk-free diet until one year of age, at which time many (although not all) infants will have become tolerant to the protein. Infants who do not respond to dietary restriction initially may respond to a trial of other lifestyle changes as outlined below.

Thickening feeds – A trial of thickening feeds is worthwhile for most infants with problematic reflux, except perhaps in infants who are preterm or overweight.

Positioning therapy – Keeping an infant upright (on a parent’s shoulder) for 20 to 30 minutes after a feed seems to reduce the likelihood of regurgitation

Pharmacotherapy  – Acid-suppressing medications are indicated in the following situations:

A limited trial of acid suppression (e.g. two weeks) is recommended for infants with mild esophagitis on endoscopic biopsies in addition to the lifestyle changes described.

A three- to six-month course of acid suppression for infants with moderate or severe esophagitis documented by endoscopic biopsies, in addition to the lifestyle changes described.

Medicines used for GERD

1. Proton pump inhibitors: PPI’s are drugs that decrease acid production in the stomach by inhibiting the proton pump in the stomach.The PPIs omeprazole, lansprazole, esomeprazole and pantoprazole have all been studied in young children. Omeprazole and esomeprazole are approved by the FDA for use in infants older than one month of age with erosive esophagitis. However, there are safety concerns about the use of PPIs. These include short-term acid rebound after stopping the drug and increased risks for diarrhea, and possibly pneumonia.In addition, a large study found an association between the use of acid-suppressing medications (H2RAs or PPIs) in young infants less than six months old and later development of allergic disease. Moreover, there are theoretical reasons to consider vitamin B12 and iron deficiency in children chronically taking PPIs. Finally, studies in adults have raised theoretical concerns that long-term use of PPIs may be associated with increased risk for osteoporosis.

2. Histamine 2 receptor antagonists – H2RA’s are medicines that decrease acid production in the stomach by competitively binding a histamine receptor. This includes Axid, Pepcid, Tagamet, and Zantac. H2RAs are a reasonable alternative to PPIs for a short-term trial of acid suppression. They are less effective than PPIs in reducing gastric acidity but more effective than placebo. The safety concerns mentioned above also apply here.
3. Antacids – Antacids are alkaline drugs that neutralize the acidic pH of the stomach. Antacids are not generally useful in the treatment of GER in infants. Chronic use of antacids in infants can be associated with aluminum toxicity, milk-alkali syndrome, or rickets and should be avoided.
4. Prokinetic agents – Prokinetic drugs increase the speed at which food leaves the stomach. Prokinetic agents currently have a minimal role in the treatment of GER in infants.  The few prokinetic agents with any established efficacy also have significant safety concerns, including central nervous system side effects for metoclopramide and cardiac arrhythmias for cisapride, which resulted in its removal from the market in the United States and Canada.

Conclusions:

Reflux and vomiting are common occurrences in infants less than one year of age. This is a normal physiologic process that occurs in healthy infants. Most episodes are brief and do not cause symptoms or esophageal injury or result in other complications.

Increased research in the past decade has supported a more supportive approach to refluxing infants with no warning signs. Infants with warning signs may need a more in depth evaluation with radiography, lab studies, and a referral to the appropriate pediatric specialist. Lifestyle changes, avoidance of cow milk and soy proteins in the infant’s diet, thickening of feeds, and positioning after feeds are safe and been shown to offer significant improvement in symptoms.

Studies on pharmacotherapy, (PPI’s and H2RA’s), have identified associated complications and side effects which has led to more vigilant stewardship of their use.

The take home message is if your baby is growing well and reasonably happy, then avoiding medicine is the goal. Ultimately, we are trying to help this baby grow into the strongest, healthiest, smartest, happiest, most successful and independent adult possible with no late effects of medicine that we may not have needed to use. In the practice of medicine, symptoms often require less intervention and I believe this is a good example.

So here’s to smelling like sour milk, wearing baby puke to work like a badge of honor, surviving the mountain of laundry, and knowing that after they turn a year you will be home free… or at least done with the reflux and on to other toddler adventures!!!