William Spivak, M.D.
Gastroesophageal Reflux Disease (GERD)
SYMPTOMS OF GERD IN INFANTS AND CHILDREN
Irritability/heartburn Arching of the neck or back
Chest pain Wheezing
Disturbed sleep pattern Coarse breathing
Poor appetite or suck Pneumonia
Failure to thrive Poor weight gain
Night-time Cough Sour taste in the mouth
What is GER?
GER refers to the abnormal rise of food or gastric juices from the stomach up the esophagus. It may be associated with vomiting, but often -- most typically in older children, adolescents and adults--the only symptom may be the sensation of "heartburn" behind the sternum (breast bone) caused by gastric acid going up the esophagus. However, some children, adolescents and adults with acid refluxing up the esophagus do not experience heartburn; nonetheless, they may have other symptoms of GER, such as those listed above.
What physiological factors lead to Reflux
Normally, the lower esophageal sphincter (LES), the muscle between the esophagus and stomach, prevents food from going from the stomach up into the esophagus. The LES acts as a one-way gate (or sphincter) relaxing during swallowing and allowing the passage of food from the stomach to the esophagus. In infants, this muscle is often not completely functional; intermittant relaxations of the LES occur even without swallowing. Therefore, food, formula and gastric fluid may come up the esophagus and out of the mouth.
A certain amount of reflux is normal in infants. Thus, spitting up is not pathological GER, since small infants normally spit up after feeding or when burped. Abnormal GER refers to delayed acid clearance that occurs as a result of prolonged relaxation of the LES. Alternatively, since esophageal peristalsis (co-ordinated muscle contraction) normally sweeps refluxed fluid out of the esophagus, abnormal esophageal motility (poor or ineffective peristalsis or muscle contractions) will result in prolonged reflux. Salivary output and swallowing are diminished at night; since they are important for esophageal acid clearance, prolonged reflux is more common at night.
What are the Symptoms of GER in Infants
Forceful or projectile vomiting is certainly abnormal in all infants and is one of the symptoms of GER. However, similar to the way adults can have heartburn and not vomit, infants can have reflux without vomiting. One of the most common symptoms of GER is irritability during and after feedings. These symptoms can be identical to the symptoms of colic; indeed, reflux is one of the causes of infantile colic. Certain symptoms, such as those listed below, should make physicians and parents suspicious that the baby’s irritability is reflux-related.
How is reflux treated?
Several forms of therapy are available and depend on the severity of symptoms and the age of the patient. With an infant, the formula is usually thickened with rice cereal and the nipples of the bottle are cross-cut (or a fast-flow nipple is used) to allow easy flow of formula. Since milk allergy is a common cause of reflux in infants, a hypoallergenic formula is often begun. The head of the crib is elevated when possible . During the daytime, the baby is kept upright as much as possible so that gravity will lessen the degree of reflux. In severe cases of reflux, antacids (such as Maalox or Mylanta) or Zantac are given. Reglan works by increasing LES tone and improving gastric emptying. Since Reglan has a high incidence of significant side effects when used in theraputic doses, it should be reserved for infants with the most severe symptoms that do not respond to other therapies. Propulsid also increase LES tone, but is no longer available in the US because it can causes cardiac arrhythmias. Prilosec or Prevacid (also know as Proton Pump Inhibitors or PPI's) can also be used to block acid secretion in reflux. However, because these drugs are extremely potent blockers of acid secretion, they may interfere with the absorbance of Zinc, Calcium and Iron which require an acid environment in the stomach for optimal absorption. Studies in adults have documented interference with absorption of these divalent cations, although in adults the problem does not seem to be clinically significant. However, in infants, where Calcium, Iron and Zinc absorption is crucial and any interference with absorption may be relevant, these drugs may have a detrimental effect. An acidic environment in the stomach is also important for the activation of digestive enzymes and the prevention of bacterial and fungal growth in the GI tract. Since clinical studies have not yet looked at this issue in infants, it would be wise to limit the use of PPI's to infants that have significant clinical reflux (not just colic or irritability) that does not respond to other treatments,
Diagnostic Tests For GER
Tests for the Evaluation of GER
What is an Esophageal pH Study?
In infants with mild symptoms, for example spitting and irritability without failure to thrive, a therapeutic trial of thickened feedings and antacids may be diagnostic and therapeutic if the baby improves. If there is no improvement or if the infant presents with more severe symptoms such as pneumonia, apnea or failure to thrive, a full diagnostic evaluation is important. This includes an Upper GI series (not just an esophogram) to exclude hiatus hernia, malrotation, pyloric stenosis, duodenal web and other abnormalities. The presence of mild reflux on the Upper GI may be normal, however, spontaneous reflux to the thoracic inlet beyond the first year of life correlates well to a positive esophageal pH study. The absence of reflux on an Upper GI may be present in 50% of infants with a positive pH study.
What is an Esophageal pH Study?
This is a simple test that is well tolerated in infants and children. The goal of the test is to determine the severity of reflux and to determine whether symptoms go along with episodes of reflux. A thin soft 6Fr tube with a pH sensor at the tip is rapidly passed transnasally and positioned slightly above the gastroesophageal junction. Once the tube is inserted, there is little to no discomfort. The free end of the tube is atttached to a small, battery powered digital device that continuously records pH over a 24 hr period. In most cases, the test can be performed as an outpatient and the child eats and sleeps at home normally. Although there are many ways of interpreting the test, continuous reflux for greater than 5 minutes during sleep, or a correlation between symptoms and reflux would be considered a postive test.