GASTROESOPHAGEAL REFLUX IN INFANTS
Gastroesophageal reflux (GER) is the medical term for spitting up. It occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Because the stomach naturally produces acid, reflux is sometimes called acid reflux; other terms include regurgitation and spilling.
Gastroesophageal reflux is a normal process that occurs in healthy infants, children, and adults. Most infants have brief episodes, during which they spit up milk or formula through the mouth or nose. Uncomplicated reflux does not usually bother the infant, has a low risk of long-term complications, and does not usually require treatment.
In contrast, in a few infants, the gastroesophageal reflux causes complications, such as slow weight gain, recurrent pneumonia, or spitting up blood. In this case, the infant is considered to have gastroesophageal reflux disease, or "GERD." Infants who have colic or who are unusually irritable should have a basic evaluation by a health care provider, but, in most cases, they do not have GERD. Although GERD typically improves as the infant grows, the symptoms occasionally continue into childhood.
WHAT IS GASTROESOPHAGEAL REFLUX?
When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure. The esophagus is made of lining and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.
At the lower end of the esophagus where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter. When food enters the top of the esophagus, the lower esophageal sphincter relaxes to allow food to enter the stomach and then closes to prevent food and acid from flowing backwards into the esophagus.
Occasionally, the ring of muscle does not close completely or relaxes at the wrong time, allowing the liquids in the stomach to wash back into the esophagus. This occurs in all individuals but is common in infants. Most of these episodes go unnoticed because the reflux stays in the lower esophagus. Infants have the most episodes of daily reflux between three and six months of age. When they start to sit up (around six months of age), the frequency of reflux often decreases.
As the infant grows, the esophagus becomes longer and the angle between the stomach and esophagus changes. These changes naturally decrease the frequency of reflux episodes. Spitting up disappears in more than 50 percent of infants by 10 months of age, 80 percent by 18 months, and 98 percent by two years of age . Infants who spit up frequently for more than three months are somewhat more likely to have gastrointestinal symptoms later in childhood .
Uncomplicated gastroesophageal reflux — Gastroesophageal reflux is common in infants during the first few months of life. Approximately 50 percent of infants younger than three months of age have at least one episode of spitting up per day.
Infants who spit up frequently but who feed well, gain weight normally, and are not unusually irritable are usually considered to have "uncomplicated" reflux. These infants are sometimes referred to as "happy spitters." In this group, spitting up is a natural consequence of the infant's anatomy. You can help reduce the frequency and amount of spitting up by burping the infants frequently during feeding and trying to keep them calm and upright for 20 to 30 minutes after feeding..
Gastroesophageal reflux disease — Reflux becomes gastroesophageal reflux disease (GERD) when acid in the reflux causes one or more problems such as asthma, failure to grow, or irritation/injury to the esophagus. This only occurs in a small percentage of infants who spit up frequently. The amount of reflux required to cause injury varies. In general, damage to the esophagus is more likely to occur when acid refluxes frequently, there is a large amount of reflux, or the esophagus is unable to clear away the acid quickly. GERD occasionally develops in infants who are otherwise completely healthy, but it is more likely in those with underlying medical conditions such as Down syndrome or neurologic problems.
Some of the signs or symptoms that may indicate GERD include refusing to eat, frequently crying or arching the neck and back as if in pain, choking while spitting up, forceful or projectile vomiting, spitting up blood, frequent coughing, or not gaining weight. It is often difficult to know if an infant is in pain. In general, we are not concerned when a crying infant can be consoled by comforting, distraction, or attending to the child's needs (hunger, sleep, or a diaper change).
Irritability and reflux — Many parents worry that reflux is the cause of their infant's irritability or difficulty sleeping. However, studies have shown that reflux does not usually cause pain and that medications to reduce stomach acid do not improve irritability.
Infants with uncomplicated reflux ("happy spitters") do not require treatment. For those who seem bothered by their symptoms, the first step is to try these lifestyle changes:
- Avoid exposure to tobacco smoke
- Avoid overfeeding
- Keep the infant in an upright position after feeding
- Trials of a cow's milk-free diet and/or thickened feeds
For many infants, the reflux will improve with these lifestyle and dietary measures alone. In one study, over 80 percent of infants partially or completely improved with thickened feeds, avoidance of tobacco smoke, and a trial of a cow's milk-free diet.
Positioning — Infants tend to have fewer episodes of acid reflux if they can be kept upright and calm for 20 to 30 minutes after a feed (ie, carried on an adult's shoulder but not placed in an infant seat). Parents should avoid overfeeding and allow the infant to stop feeding as soon as they seem satisfied or seem to lose interest.
Milk-free diet — In up to 40 percent of infants with problematic gastroesophageal reflux who seem otherwise healthy, the symptoms are triggered by cow's milk The majority of infants with food allergies are sensitive only to cow's milk protein, although some are also sensitive to soy protein and a few may be sensitive to other proteins.
A milk-free diet for infants involves:
- Breastfed infants – If the infant is breastfed, the mother needs to eliminate all cow's milk and soy products from her own diet for a two- or three-week trial.
- If the symptoms do not improve, the mother may resume her normal diet or discuss the possibility of restricting other foods with her health care provider. In rare cases, the mother may need to eliminate other proteins, although this should only be done with the advice of a health care provider.
- If the infant's reflux symptoms improve during the trial, the mother should continue the restricted diet for another month or two, then she can try reintroducing cow's milk to her diet every few months to see if the infant has outgrown the reflux problem. Most infants outgrow a cow's milk intolerance by one year of age.
- Formula-fed infants – If the infant is formula fed, they can be given a hypoallergenic formula that does not contain intact cow's milk or soy proteins, because these are the most likely culprits (table 1). This is usually continued for one to two weeks to determine if the infant's reflux improves. If this does not work, trying a corn-free formula (eg, the ready-to-feed version of Similac Alimentum) may be beneficial because a few infants are sensitive to corn protein. If symptoms do not improve, the original formula may be restarted.
Almost all infants with CMPI outgrow the problem by one year of age.
Thickened feeds — Thickening formula or expressed breast milk may help to reduce the frequency of acid reflux and is a reasonable approach to reducing symptoms in a healthy infant who is gaining weight normally. In the United States, infant cereal is usually used as the thickening agent; in other countries, rice starch, carob flour, or locust bean gum may be used. Oat infant cereal is a good choice for most infants. Be sure to check the ingredients in the infant cereal as some brands contain soy protein to which the infant may be intolerant. To thicken the feed, 1 ounce (30 mL) of formula or expressed breast milk is usually combined with up to 1 tablespoon (15 mL) of infant cereal. Nipples that allow for adjusted flow are available. For formula-fed infants, premixed "antireflux" or "spit-up" formulas also are available, which contain rice starch to thicken the formula.
Women who breastfeed are encouraged to continue doing so; an infant should not be switched to formula for the purpose of thickening the feeds. In fact, breastfeeding may reduce the risk of reflux in infants
- Probiotics-There are reports of using specific type of probiotic that can help with reflux symptoms. Bifidobacterium breveM-16V® was shown to discourage the growth of pathogens (bugs) associated with colic, help colonisation of the infant's gut with healthy bacteria, whilst reducing gastrointestinal symptoms such as colic and reflux.
- Lactobacillus rhamnosusGG® was shown to reduce crying associated with colic and reflux symptoms whilst also helping with gastrointestinal infections.
Essential Oils-are another way of alleviating symptoms. A mixture of one ounce of olive oil with 10 drops of lavender oil and 10 drops of peppermint oil can be massaged to the baby`s abdomen.