What is acid reflux (GERD)?
Gastroesophageal is pronounced gas-troh-i-sof-uh-jee-uh l
Acid reflux is a common condition that occurs when the contents of the stomach, including stomach acid, flow back into the food pipe known as the oesophagus. This reflux, or backwash can irritate the lining of the oesophagus.
The oesophagus is a tube that connects the stomach to the mouth. There is a valve at the bottom of the tube that opens up to let food down into the stomach. This valve is supposed to close properly after the food is in the stomach so as to not allow the contents of the stomach, including stomach acid, to come back up into the oesophagus. If this valve is not developed properly or does not function as it should, this results in acid reflux. Having said this, it is understandable that reflux usually occurs during or after a meal.
Reflux can cause pain in the chest area, often referred to as heartburn although it is important to note that heartburn does not have anything to do with the heart. In infants, reflux may lead to regurgitation and posseting (spitting up). Posseting, often referred to as GER – gastro-oesophageal reflux, involves non-forceful and effortless regurgitation of milk into the oesophagus, which is commonly seen in infants and can be very normal. GER only becomes a problem when the infant is persistently in pain from the reflux and possibly not gaining weight as he/she should, in which case, a medical opinion should be obtained and a possible diagnosis of GERD considered.
GERD is known as gastroesophageal reflux disease and is diagnosed when the patient battles with persistent, frequent, symptomatic acid reflux with or without complications, needing treatment. The differences between the two conditions are defined by their severity; GERD being more serious, long-standing and needing medical intervention whilst GER is less severe, usually of shorter duration and can be totally normal.
GER usually begins when the infant is less than two months old, however, by the age of 18 months, infants should have outgrown the condition. Older children with symptoms of persistent GER or GERD need to be assessed by a medical practitioner. The following information explores what you need to know about acid reflux and GERD in infants and children, the causes, symptoms, complications, diagnosis and treatment. We will then finish off with answers to some of the questions you may have.
What causes GERD and acid reflux in infants and children?
As previously mentioned, acid reflux in infants is common. The reason for this is due to the immaturity of the muscle between the stomach and oesophagus, known as the lower oesophageal sphincter, or LES. At birth, this muscle is still a little under-formed and thus allows for stomach contents and acid to flow back upwards into, and possibly out of, the mouth. In time, the LES will function properly by opening when your infant swallows and closing when the infant is not eating or drinking, keeping the stomach contents in place.
There are several factors that can contribute to acid reflux in infants, some of which cannot be avoided, these include:
- Infants being born prematurely or of low birth weight – the LES is then very premature and underdeveloped
- Infants lying flat on their backs most of the time
- Infants having an almost completely liquid diet (only breastfeeding or formula)
In some cases, acid reflux in infants and children can be the result of more severe conditions, these include:
- Food intolerances- Food allergies such as a food intolerance to cow’s milk (lactose) can sometimes be a trigger for reflux.
- Pyloric stenosis- This is when the valve between the small intestine and the stomach is malfunctioning, which prevents the stomach contents from being emptied into the small intestine. This leads to pressure build up in the stomach which may result in vomiting and complications of reflux including, dehydration and weight loss.
- Eosinophilic oesophagitis- In some cases, a condition known as eosinophilic oesophagitis, which is when a specific white blood cell type, known as eosinophil, builds up in the lining of the oesophagus and in turn damages the oesophagus.
Conditions which impair muscle and nerve development – This leads to an impaired swallowing ability which may involve reflux (e.g. Cerebral palsy, which is a condition that appears in infancy or early childhood and affects muscle coordination and body movement).
What are the symptoms of GERD and acid reflux in infants and children?
As stated, reflux or GER, should not be a cause for concern. However, when this reflux is persistent and results in the below-mentioned symptoms and signs without showing signs of improvement, then it is advised that you make an appointment to see your doctor.
With infants, it can be more difficult to detect the symptoms of GERD as they cannot verbally communicate yet. There are however a number of visual cues that can be detected. Young children are more likely to communicate their discomfort or pain to you.
The signs and symptoms of GERD in infants are the following:
- Spitting up constantly and showing signs of discomfort when doing so.Showing signs of unusual irritability during or after eating, usually with uncontrollable crying
- Difficulty in gaining weight
- Refusing to eat or drink (breast milk in young infants) - especially in older babies as they associate feeding with the pain of the reflux
- Spitting up yellow or green fluid
- Spitting up material that looks like grounds of coffee or spitting up blood
- Beginning to spit up food at the age of six months or older
- Having blood in the stool
- Experiencing a difficulty in breathing or coughing and wheezing frequently
- Recurring bouts of pneumonia
The signs and symptoms of GERD in children are the following:
- Expressing feelings of chest or abdominal pain above the belly button (navel)
- Experiencing burning or pain in their chest, this is also known as heartburn
- Frequently coughing, wheezing or having hoarseness
- Excessive and uncomfortable belching
- Experiencing frequent nausea
- Feeling pain when lying down
- Experiencing discomfort or pain when swallowing food
- Tasting stomach acid in their throat
- Feeling as though food is getting stuck in their throat
Some of these symptoms can be treated easily with the help of a medical professional. The key is to diagnose the child as early as possible.
When to call a doctor
It is understandable that having a sick infant, or even a small child, can be an overwhelming situation to be in, especially for first time parents, therefore, should you have any medical concerns or wish to find out more about any aspect of your child’s health, then it is advised that you speak to your medical professional in order to put your mind at ease.
You should call your healthcare provider should your infant or child:
- Has reflux and is struggling to gain weight
- Shows signs similar to those of pneumonia or asthma (these include trouble breathing, coughing or wheezing)
What are the complications GERD and acid reflux in infants and children?
- Reflux in infants typically resolves by itself without resulting in any additional issues or complications for the infant. However, should the infant or child suffer from GERD, then he or she may start to show signs of poor growth and development.Other complications are very rare in infants and children.
- If the oesophagus is exposed to stomach acid for an extended period of time and this remains untreated, then the lining of the oesophagus may change and areas of the oesophagus may become damaged or narrower due to inflammation and tissue trying to repair itself. This can lead to oesophageal strictures or precancerous conditions, although the development of these complications is very uncommon in children.
- There are some studies that show that infants who have more frequent episodes of spitting up, may be more at risk of developing GERD in the later years of their childhood.
What are the risk factors associated with GERD in infants and children?
As mentioned previously, GERD is commonly seen during a baby’s first year of their life and will often resolve on its own. However, your child has a higher risk of developing GERD if she or he has one of the following conditions1:
- Neuromuscular conditions, for example, muscular dystrophy or cerebral palsy
- Down syndrome
How is GERD diagnosed in infants and children?
The doctor will start with a physical exam of the infant or child and ask about the symptoms that they are displaying. You may be asked to keep a diary of the amount your infant or child eats and how often they are bringing up their food/milk. In most cases, further testing/investigations are not necessary but if your infant or child is having severe symptoms, further tests may be ordered. These include:
- Lab tests– If an alternate cause for the recurring vomiting or poor weight gain is suspected by the healthcare professional, then urine and/or blood tests may be of benefit.
- Ultrasound– This is an imaging test that can be used to identify if the child or infant has pyloric stenosis.
- Oesophageal pH monitoring– In order to determine the acidity of the oesophagus, the infant or child will be asked to swallow a thin, long tube that has a probe at the tip. This will stay in the oesophagus for 24 hours whilst the child or infant is closely monitored (usually whilst staying in the hospital). This tool measures the acidity of the oesophageal contents and can also help to determine whether any breathing problems are caused by GERD.
- Upper GI endoscopy– This test uses a flexible, thin and lighted tube with a camera at the end of it, known as an endoscope. It is passed through the infant or child’s mouth and into the oesophagus, stomach and small intestine. This enables the healthcare professional to visualise any inflammation or problems, especially in the oesophagus. Samples of the tissue can also be taken for analysis. This test is typically done whilst the infant or child is under sedation or anaesthesia.
- X-rays / barium swallow / upper GI series– These are imaging tests that are able to detect any abnormalities within the digestive tract. In some cases, the infant or child is given a contrast liquid known as barium to swallow, which highlights the stomach and oesophagus as well as the upper area of the small intestine.
- Gastric emptying – Some infants and children who have GERD suffer from a slow emptying of their stomach which may be a contributing factor for acid reflux. In this test, the child or infant will drink milk or eat food that has been mixed with a radioactive chemical. This chemical, which is typically harmless to the recipient, is studied as it flows through the digestive tract, using a specialised camera to track it.
How is GERD and acid reflux treated in infants and children?
There are a number of ways acid reflux can be treated. Doctors typically recommend that acid reflux, or GER, which is often to be expected in infants and often does not result in serious health concerns, be treated through lifestyle changes and measures initially. Should no improvement be seen after these changes have been implemented, then medication will be prescribed as the diagnosis is usually that of GERD.
The following are a number of lifestyle measures to be taken:
For infants (younger than two years old):
- Feeding your infant in a more upright position. If possible, try not to bounce or play too much with your infant for about 30 minutes after feeding. This technique will aid the stomach contents in staying in place. Also, try to minimise activities such as tummy time for a little while after a feed. Gentle movements and gentle play will all help.
- When bottle-feeding your baby, ensure that the teat of the bottle is always filled with the milk. This will ensure that your baby does not swallow too much air while he or she is eating. It may also be beneficial to try different teats in order to find one that allows for your baby’s mouth to make an effective seal around it during feeding.
- Taking the time to burp your infant after feeding. Frequent burping during and after feeding allows air to move out of the digestive tract and can stop the infant from spitting up.
- Feeding your infant in smaller quantities and more frequently.
Remember, reflux or GER (gastroesophageal reflux) is to be expected in infants. If the reflux is not disrupting the infant’s growth or health in any way, then just keep a number of burp cloths with you and ride it out as it should only last for the first six months (sometimes up to a year) of the infant’s life. After which, acid reflux will significantly decrease.
For older children (two years and older):
- Elevate the head of your child’s bed as this will aid in digestion.
- Keep the child upright for the first two hours after eating.Serve several smaller meals for the duration of the day, as opposed to three larger meals will allow for easier digestion.
- Ensure that your child does not overeat as this may be the cause of reflux.
- Encourage regular exercise for your child, but not immediately after a meal.
- Limit food and drinks that seem to worsen the reflux such as dairy, caffeine, carbonated drinks or high-fat foods.
If you notice that the reflux is not improving through the above lifestyle changes, then your doctor may recommend the use of medication.
Medications that neutralise or decrease the stomach acid
- Histamine-2 (H2) blockers – Some examples of these include Pepcid, Tagamet, Zantac or Axid
- Antacids – Maalox or Mylanta
- Proton-pump inhibitors – Prilosec, Prevacid, Zegerid, Protonix and Nexium
Antacids can result in a number of side effects such as diarrhoea and H2 blockers may cause drowsiness in some children.
Surgery for GERD in infants and children
In most cases, surgery is not required as a means of treatment for acid reflux in infants and children. Surgery may, however, be recommended if your child is not gaining weight as a result of vomiting, has constant breathing issues or is suffering from severe irritation of the oesophagus. This type of surgery is known as fundoplication and is commonly conducted as a laparoscopic procedure as this is less painful and allows for a faster recovery.
During this procedure, small incisions will be made in the child’s abdominal region (tummy). From here, a small tube with a camera at the end of it will be placed into one of these incisions to give the doctor a visual of the area which is fed to a video screen. Surgical tools will then be placed through the other incisions to execute the surgery required.
In this procedure, the top area of the stomach is made to wrap around the oesophagus in order to form a cuff that is able to contract and close off the oesophagus when the stomach contracts. This prevents reflux.
This procedure is known to be effective but comes with risks. It is advised that you discuss the risks as well as the benefits of the surgery with your doctor.
Tube feeding for infants and children with GERD
Some infants suffering from reflux may also have been born prematurely, have a low weight at birth or have other underlying conditions such as heart disease, all of which may result in fatigue. As such, these infants will often get tired after eating or drinking, even when this is done in small amounts.
Other infants may vomit after having the recommended amount of formula. Infants such as these will often do better when they are fed smaller amounts of formula or breastmilk.
In both of the aforementioned cases, tube feeding may be a solution recommended by your doctor in order to prevent malnourishment. With tube feeding, breastmilk or formula will be administered via a tube that is placed in the infant’s nose. This is known as a nasogastric tube. This tube will then allow food to enter the oesophagus or food pipe, and eventually the stomach. A feeding tube can either be used in addition to bottle feeding or as a replacement for bottle feeding.
FAQs you may have about GERD in infants and children
Do infants outgrow acid reflux?
The simple answer is yes. The majority of infants will outgrow their reflux by the time they reach the age of one. With less than five percent of infants continuing with the symptoms as toddlers.
As a mother who is breastfeeding, does my diet impact my infant’s acid reflux?
It is important to maintain a well-balanced and nutritional diet as a mother who is breastfeeding. It is suggested that you consume an extra 500 calories per day.
It is vital to note how your baby reacts to dietary changes. Acid reflux in breastfeeding infants has been linked to dairy products consumed by the mother. If your infant develops acid reflux, it is best to try to identify the specific foods that may be contributing to the reflux. If you know an allergy runs in your family, then it is best that you speak with your doctor. Lactose intolerance is one of the most common allergies and causes of acid reflux in infants. The best way to detect the causes of your baby’s reflux is through the process of elimination in your diet.
You can do this by avoiding all dairy products for no less than seven days, and if you notice a change in your baby’s behaviour and an improvement in their acid reflux, then it is likely that the infant has an issue with digesting breast milk that contains lactose.
Do breastfed infants spit up?
Spitting up is normal for infants regardless of whether they are breastfed or given formula, and can resolve as the baby matures. If your baby’s reflux worsens or affects their health, they may have GERD.
Why do babies throw up after burping?
If your infant vomits after burping, it often means that their tummy is full. Reflux may result in your baby bringing up a little bit of milk after feeding and may also result in hiccups.
How do I get my infant to stop spitting up?
By avoiding interruptions, bright lights, distractions and interruptions during feeding, your baby will be able to digest their food more effectively. It is best to burp your baby every three to five minutes during a feed. Try not to feed your infant when he or she is lying down and hold them in a more upright position for 20 to 30 minutes after each feed.
What are the symptoms of silent reflux in babies?
Frequently vomiting or spitting up and showing visible signs of discomfort after eating are commons signs of GERD. However, silent reflux is when the stomach contents that come back up through the oesophagus are re-swallowed and do not result in pain or spitting up. Common symptoms of this in infants include gagging, frequent burping, choking, bad breath or hiccoughing after eating.
What causes hiccups in a new-born infant?
Hiccups are the result of the diaphragm contracting suddenly which is triggered by a stimulation or irritation of the diaphragm muscle. This is normal and very common in infants and nothing to be concerned about unless associated with severe and uncomfortable reflux.
- Health Encyclopaedia. GERD (Gastroesophageal Reflux Disease) in Children. Available: https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P01994. [Accessed 29.08.2017]