Gastro-esophageal Reflux
Recently I got a call from a family friend about her four-month-old grandson who was living in another state. She was concerned because the baby was having stomach issues that were causing sleepless nights for his parents.
Always being a fussy baby things recently took a turn for the worse. Although he did spit up Grandma did not feel it was more than usual. He seemed to be in pain and drew his legs up whenever he ate. The baby would frantically pull off the breast and arch his back. Assuming he was just gassy they have been giving him gas drops, but to no avail. The doctor said that he was gaining weight well but may have a milk-protein allergy. Therefore mom has been avoiding cow’s milk in her diet and has been eliminating dairy foods in order to see if that would help. In case he may be colic they tried drops for this too, but without any success. When it seemed he may be getting better things regressed over the past few weeks.
This is a classic presentation of a baby that has gastro-esophageal reflux, or GER.
The esophagus is the tube that connects the throat with the stomach. The stomach is a “sac”, or large reservoir, that helps break down the food through its acids to prepare the passage through the intestines. No absorption of food takes place in the stomach. Basically when we swallow food it passes down the esophagus into the stomach. After a while it passes into the intestines.
The lining of the esophagus is pH neutral, meaning that it is essentially neither acidic nor basic. The stomach is VERY acidic which aides in breaking down of the food.
There is no actual valve that separates the esophagus from the stomach. But the junction of the two is usually under high pressure to prevent the stomach contents from “refluxing” or moving back into the esophagus. GER occurs when the junction separating the two is lax or loose which allows the acidic stomach contents to reflux back into the esophagus.
Some babies who have GER are happy, thriving, and contented but merely spit up all the time. The moms frequently need changes of clothes because of these “happy spitters”. If they are growing well and are happy, little needs to be done.
But some babies have GER whereby the acidic contents from the stomach refluxes back up into the esophagus. This becomes irritable causing a chemical burn, or esophagitis. This can be very painful, hence these babies are constantly fussy and miserable. It is known as gastro-esophageal reflex disease, or GERD. Not all of these babies will necessarily spit up. They may want to eat frequently as the milk helps neutralize the acid from the stomach. But as the milk refluxes into the esophagus and is painful, they pull off and arch their back. It can seem to be a vicious cycle. Sometimes, as they are eating, there may be a gulping sound as if the milk is refluxing up. They have to double swallow. Some babies with GERD have a hoarse voice from the irritation of the vocal cords. They can seem gassy or colicky and are oftentimes inconsolable causing much angst for the parents and family.
Treatment of GER/GERD must be individualized to the child as every case is different and unique.
The first step is what we refer to as “GER precautions”. Mom should feed the baby with the head elevated at a 20 degree incline and never have the baby lying flat. The baby should be kept upright for 10-15 minutes after eating. The head of the crib or bassinet should be elevated at 20 degrees as well. If mom is bottle feeding, she should insure that the milk is not coming out of the nipple too fast, or too slow. A good rule of thumb is when the bottle is turned upside down the milk should flow at a rate of one drop a second. In babies that have GER, these measures should make a big difference.
In babies that have GER with esophagitis, or GERD, the treatment must be tailored to his individual needs. The doctor may want to prescribe an acid blocker. This will neutralize the acid and allow the irritated and inflamed esophagus to heal. There are many different agents that can be use. If indicated, the doctor may instruct the parent to thicken the milk (if bottle fed) with rice cereal. This will minimize the refluxing back into the esophagus. One-half to one teaspoon of rice cereal for every ounce of milk is recommended. In more severe cases of GERD a pro-kinetic agent can be prescribed. This will stimulate the stomach to contract and help propel the stomach contents into the intestines.
Most babies outgrow their reflux by nine months of age.
It is not uncommon for a baby with GER to have the symptoms seem to get worse by around four months of age. Developmentally they start doing “crunches” and try to turn over. This increases the intra-abdominal pressure which exacerbates the reflux. I think this is what was happening with my friend’s grandson.
GER and GERD are very common.
The bottom line is that each baby must be dealt with individually. Simple GER precautions may be all that is necessary to have a happy baby. If more treatment is indicated, they must be followed closely. One must insure that the baby is growing appropriately, maintaining normal urine output and stooling. If medications are prescribed for the reflux these are determined by the weight of the baby. We are talking about small amounts of medication. As the baby gains weight, it is not long before he outgrows the current dose. This must be monitored closely. The medications may be working nicely but after a couple of weeks the reflux seems to be back to where it was before. If so, the doctor should re-check the baby’s current weight and re-adjust the dosing based on this new weight.