Mrs. White made an appointment for Kacie, her happy and thriving 3 month old daughter. According to mom, Kacie spits up, or vomits, "every ounce of formula" she seems to take in. Like clockwork, Kacie vigorously eats every 3-4 hours, polishing off every drop of formula in her bottle. After her tummy is full, mom has no trouble producing a loud burp or two that seem to rattle Kacie's toes. Very content, Kacie falls fast asleep. Within 20 minutes, she predictably spits up a large volume of uncurdled formula. This doesn't bother Kacie; in fact, she rarely wakes up as mom changes the bedding or Kacie's outfit. Kacie has gastro-esophageal reflux (GER or reflux).
Mrs. Smith has a three month old son named Thomas. She did everything she could possibly do the prepare for her first baby. She read all the books she could get her hands on about having a baby, she went to birthing classes and attended breast feeding classes...she wanted things to be just right! As we discussed Tom's problems, I saw a mom who was tired and frustrated. Tom, she told me in a dejected voice, cries all the time--non-stop. She is exclusively breast feeding and thought that it might have been something in her diet. She stopped all dairy products, gassy foods, caffeine and spicy foods, all to no avail. She tried over the counter drops for gas as well as herbal teas, but none of these helped. She was afraid that this might be colic, but there was no pattern to his crying. He simply cried every minute he was awake! It wasn't that he just cried, it was a shrill piercing cry that mom instinctively knew meant that he hurt. She felt so helpless as he was inconsolable no matter what she tried. He would turn beet red and draw his little legs up. Tom also has reflux.
How could two completely different babies have the same problem? What is reflux? GER is actually a descriptive term that refers to stomach contents that has "refluxed" or backed up into the esophagus. Virtually all babies have some degree of reflux. The severity of symptoms represents a broad spectrum from a baby who merely spits up on occasion, to a baby who ends up needing surgery because of complications from the reflux. Luckily, most babies fall in the milder category.
The esophagus is essentially a muscular tube that transports ingested food down into the stomach to be digested by it's acids and enzymes. Although there is not a true anatomical valve between the two structures, the junction is under high pressure from muscles in this region. This functions to prevent the reflux of stomach contents into the esophagus. In GER, for whatever reason, there is a laxity, or looseness, of the tone in this area. As a result, when the baby's stomach is nice and full, there is the reflux of the gastric juices back into the esophagus. For a number of different reasons, reflux usually is resolved by 9-24 months of age. This is partly due to the fact that a toddler spends more time in an upright postion, and is eating more solid foods.
In Kacie's case, the reflux was nothing more that a nuisance because of the mess it caused. She was a thriving and happy baby who was growing quite well as was evinced by her being on the 95 th percentile on her growth chart for height and weight. She also had a perfectly normal exam. Mom said that it had become the family joke that she should wear her "foul weather gear" whenever she was dressed up to go out. She could be sure that everytime she was going out the door, Kacie would manage to spit up her previous meal on mom's shoulder. With Kacie's normal history and physical, mom was assured that the reflux did not need to be treated. Sure enough, by 8 months of age the reflux had completely disappeared.
Thomas' reflux fell somewhere in the middle of the spectrum of symptoms. He too, had grown nicely, falling on the 75th percentile on his growth curve. By mom's own admission, he was a very good breast feeder, and his stools were normal...he was even a good sleeper. So why was his reflux so different from Kacie's? She spit up, not him. Why was he so miserable?
In Tom's case, the stomach contents that refluxed into the esophagus had a very high acid content. This would literally burn the esophagus and ultimately lead to more of a chronic irritation or inflammation known as esophagitis. As a result, Tom was probably in severe pain every time he would cry. The reason he did not spit up is because the volume of stomach contents that would reflux was not enough to make him do so.
After a thorough exam and detailed history to rule out other medical causes, a treatment plan was started to deal with the GER. First and foremost, mom was told that her breast milk was excellent as evidenced by his growth. She was told to thicken the feedings with rice cereal every time he got breast milk in a bottle. This would help decrease the reflux. Mom was instructed to give a small amount of antacids (Maalox, Mylanta etc.) after each feeding. Tom was then started on two medications. One was to decrease the production of the acid by the stomach, and the second was to promote the emptying of the stomach contents and to increase the tone of the lower esophagus thus preventing the reflux of the stomach contents.
Tom's mom called after two days to tell me about her "NEW" baby. He was happy and playful, just as she had dreamed he would be. The difference was like night and day. As Tom grew, we had to increase the dose of his medications to allow for his weight gain. The last time we actually adjusted his dose was at his 9 month visit. By one year, he had outgrown his dose, yet had no symptoms...or need for the medications. He was quickly weaned off all of the medicines and did not have another problem with the reflux.
These two vignettes illustrate mild and moderate GER. This condition is very common in all young infants. And while very severe cases of GER do occur, these are rare and are beyond the scope of this article.
There are also a number of medical problems that can be mistaken for GER. These include a milk-soy intolerance, some intestinal infections, and some anatomical problems. This is not the proper place to discuss these. Suffice it to say, that when a physician is entertaining the diagnosis of GER, all of these other conditions must be thought of and unequivocally ruled out in his or her mind. If there is any question, a consult with a gastro-intestinal specialist would be warranted. There are sophisticated tests that can be performed that will cinch the diagnosis.