Click here to Download and print in WORD

GER in Infants

To print page click here to download in WORDGER_in_Infants_files/GERD_in_Infants2009.docx
Please click here to return to the Table of ContentsTable_of_Contents.html

Please click here to return to the Table of Contents

 

   

                                       JUDY DAVIS M.D.,F.A.A.P.

1095 E Warner Ave, #102

Fresno,CA 93710

Phone 559-412-8184  Fax 559-438-1174



GASTROESOPHAGEAL REFLUX IN INFANTS


Gastroesophageal reflux (which causes recurrent vomiting), is a very common problem and is related to transient relaxations of the lower esophageal sphincter (muscle) and/or delayed gastric emptying.  The lower esophageal sphincter is found between the bottom part of the esophagus (tube between mouth and stomach) and upper part of the stomach.  It acts to prevent stomach contents from washing up into the esophagus.  When this sphincter does not work properly or when food does not empty out of the stomach normally, vomiting and regurgitation occur.  Vomiting or reflux resolves as the infant grows older and the sphincter becomes more competent and the stomach begins to empty more rapidly.  Also, in most infants the recurrent vomiting is not detrimental to normal growth and development.


Treatment is required in only 15% of children with recurrent vomiting due to reflux.  Treatment is used to prevent complications of gastroesophageal reflux.  These complications can include irritability and sleeplessness due to irritation of the esophagus from stomach acid constantly being washed up into the esophagus.  Irritation of the esophagus may be so severe as to lead to blood loss, anemia, and rarely, narrowing (stricturing) of the esophagus. 


Reflux can also result in lung problems including apnea (cessation of breathing), recurrent pneumonia, bronchitis, recurrent wheezing, chronic cough, or asthma.  Occasionally, poor growth can develop from reflux due to food being lost through vomiting and also in some cases, infants refuse food due to the pain experienced with reflux, which is usually worse after eating.  Other complications can include recurrent ear infections, sinusitis, sore throat and hoarseness. 


A variety of tests may be used to rule out gastroesophageal reflux.  These may include an x-ray study called a barium swallow (upper GI) which allows the physician to evaluate the anatomy of the esophagus, stomach and upper intestine,  to rule out other causes of recurrent vomiting.


A more sensitive method to rule out reflux is the pH probe or Bravo capsule, which measures the amount of time the esophagus is exposed to an acid environment over a 24-hour to 48 hour period.  Most of the time, this study can be done at home with a small tube placed in the child’s nose and into the esophagus and attached to a small box which records information over an 18-24 hour period. Alternatively, a Bravo capsule can be attached to the lower esophagus during an upper endoscopy and it will measure the percentage of time acid washes up into the esophagus from the stomach over a 24-48 hour time period.  The pH probe study may be preceded by esophageal manometry which helps us locate the sphincter between the esophagus and stomach and also gives us some information on how well the esophagus and lower esophageal sphincter perform. 


Occasionally a gastric emptying time is done to assess whether the stomach empties more slowly than normal, whether stomach contents are refluxed into the esophagus and if aspiration of stomach contents into the lungs occurs.


If any of the above studies identify that gastroesophageal reflux is present, upper endoscopy may be done to rule out esophagitis.  Endoscopy is a safe procedure which involves sedating the infant so that he/she will not be aware of the procedure taking place and will not be in any pain during the procedure.  A thin, flexible tube is placed through the infant’s mouth into the esophagus.  Through the lens of the instrument, the esophageal tissue can be evaluated for inflammation and also tissue can be obtained (by pinch biopsy) for evaluation of esophagitis under the microscope.


After gastroesophageal reflux with complications (poor growth, extreme irritability, esophagitis, pulmonary problems, etc.) has been diagnosed, therapy will be instituted.  A conservative approach will be attempted first which includes:  (1) Small, frequent feedings (limiting volume of formula).  (2) Thickening the formula (1 tablespoon of rice cereal for every 2-ounces of formula).  (3) Keeping the child upright after feedings for 20-30 minutes.  (4) Laying the child on his/her back or side with head elevated (using a harness/wedge is a very effective method).  An infant seat should not be used by patients with reflux as it can worsen reflux. A reflux harness/wedge can be purchased online at www.tuckersling.com .


If these conservative methods fail, various medications are used which include metoclopramide (Reglan) erythromycin, or Urecholine (bethanechol) which tightens the lower esophageal sphincter or  improves gastric emptying which decreases the frequency and volume of vomiting.  Occasionally, there are side effects (extreme irritability, sleepiness) associated with metoclopramide.  Rarely a stiffening of the tongue, back and neck muscles can occur with metoclopramide.  This can be treated by stopping the metoclopramide and giving Benadryl for 24-hours at this dose _________, every 6-hours.  Notify your doctor if these symptoms occur.  Bethanechol and metoclopramide should be given 20-30 minutes before feedings to be most effective. Bethanechol should not be given to children with asthma, as it can worsen asthma symptoms. Reglan should not be given to children with seizures, as it can worsen seizure activity. These medications are not as effective in reducing reflux symptoms as the medications that decrease stomach acid production.


Occasionally, agents which stop stomach acid production are necessary.  These are cimetidine (Tagamet), nizatidine (Axid), ranitidine (Zantac), omeprazole (Prilosec and Zegerid), lansoprazole (Prevacid), rabeprazole (AcipHex), esomeprazole (Nexium), dexlansoprazole (Dexilent) and pantoprazole (Protonix). These agents are used in cases where esophagitis is present or when the frequency of reflux does not seem to be responding to medical management with Reglan or bethanechol.  These medications are used because they help tighten the lower esophageal sphincter and increase the healing rate of esophagitis by decreasing the acidity of the stomach contents.  Usually medical management is successful; however, sometimes surgery (fundoplication) is necessary in severe cases of reflux unresponsive to medical management.

If your child does require medical management for his/her gastroesophageal reflux, he/she will be seen in the clinic on a regular basis and monitored for appropriate weight gain and development, evidence of irritability and sleeplessness, pain, anemia and pulmonary problems including apnea, asthma and recurrent pneumonia.  Repeating pH probe studies and endoscopy may be necessary to ascertain the effectiveness of medical therapy. 



If this handout has not answered all of your questions, please call our clinic and one of the members of the Gastroenterology Department will be happy to answer your questions. You can also go to my web page where there are more handouts on reflux and links to medical web sites with more information on reflux.





Judy J. Davis, M.D., F.A.A.P.

Fellow American Academy of Pediatrics

Fellow Sub-Board American Academy of Pediatric Gastroenterology

American Board of Nutrition

Clinical Professor, Department of Pediatrics, University of California,

San Francisco


Revised 6/17