Acid Reflux in Infants and Children (GERD in Infants and Children)

Acid Reflux in Infants and Children (GERD in Infants and Children)

What is acid reflux (GERD)?

Gastroesophageal is pronounced gas-troh-i-sof-uh-jee-uh l

Acid reflux is a common condition. It is also referred to as heartburn, however, heartburn is actually a symptom of acid reflux. Heartburn refers to the burning sensation or pain that is felt in the chest area. It is important to keep in mind that heartburn does not actually have anything to do with the heart.

GERD is known as gastroesophageal reflux disease. This is diagnosed when someone experiences acid reflux more than twice a week. It is a chronic digestive condition and refers to when stomach acid, and sometimes the contents of the stomach flow back into the food pipe known as the oesophagus, from the stomach. This reflux, or backwash, will irritate the lining of the oesophagus and this is known as acid reflux or GERD. This normally happens during or after a meal and often causes pain in the chest area (heartburn) and in some instances, may also lead to regurgitation and vomiting.

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, after which it closes so as to not allow the contents of the stomach and stomach acid to come back up. If this valve closes or opens at the wrong time, this can result in acid reflux.

What is GERD and acid reflux in infants and children (paediatric GERD)?

For a child to be considered an infant, they must be between the ages of birth to two years old. To be classified as a child, they must be between the ages of two years and 12 years old.

When an infant or a child vomits or spits up their food, they are likely to be displaying the hallmark symptom of acid reflux – spitting up. This is considered to be a common condition amongst infants and does not typically result in any other symptoms or complications. This little spit up is known as gastroesophageal reflux, which is referred to as GER. GER is common and is to be expected amongst infants.

GERD, which is gastroesophageal reflux disease, is a more serious condition and is a form of spitting up, it is also less common amongst infants. Remember that acid reflux, or GER, is often normal in infants, however, should this develop into frequent vomiting that causes discomfort and pain whilst feeding, this may lead to weight loss and is then classified as GERD.

Both GER and GERD refer to the upward motion of the contents of the stomach, which includes stomach acid moving into the oesophagus and sometimes up into and out of the mouth. The differences between the two conditions are defined by their severity, GERD being more serious and chronic, and their lasting effects, GER being more short-term. Older children are also susceptible to GER and GERD. However, most babies grow out of GER as they get older and it is considered unusual for an infant to experience acid reflux after the age of 18 months old.

Please note that should your infant be suffering from acid reflux (GER), this is completely normal and can be expected to occur multiple times a day when feeding. If your infant is content, growing well and is healthy, then there is no need for concern. In rare cases, acid reflux can be linked to a medical issue such as a food allergy or a blockage in the digestive system. When GER leads to weight loss, creates clear discomfort and impacts the quality of life and health of your infant, then this should be seen as a red flag as your infant may have developed GERD – the more frequent and serious episodes of GER.

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 some questions you may have.

Once again, please bear in mind that GER is a perfectly normal form of spitting up during feeding or after your infant has fed. There is no need to be alarmed if your infant is spitting up a few times a day. It is only when this reflux reaches a point where it causes health concerns for your infant that you should seek medical attention.

Having an infant 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 the expectations of being a parent when it comes to your baby’s health, then it is best that you speak to your medical professional in order to put your mind at ease.

The following article should be deemed as a guideline and not a professional opinion, however, this information should serve as a means of education and assist you along the path of parenthood.

Just to clarify, the difference between GER and GERD is:

GER, gastroesophageal reflex, which is also known as reflux, acid reflux, heartburn or acid indigestion, happens when the contents of the stomach (can be food or some stomach acid), rise up through the oesophagus and cause the infant or child to spit up their milk, formula or food. This is normal amongst infants younger than one year, and specifically before the age of six months old. When GER develops into frequent, more severe episodes, this can impact the health of the infant or child and is a cause for concern. This is known as GERD, gastroesophageal reflux disease. GERD can lead to the damage of the oesophageal lining and should be treated immediately.

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 brings up stomach acids that irritate the oesophagus or throat and cause the following symptoms and signs, then it is advised that you see your doctor.

With infants, it can be more difficult to detect the symptoms of GERD as the infant cannot verbally communicate yet. However, there are a number of visual cues that can be detected. Young children, however, are more likely to communicate their discomfort or pain.

 Acid reflux

The signs and symptoms of GERD in infants are the following:

  • Showing signs of unusual irritability during or after eating
  • Difficulty in gaining weight
  • Spitting up constantly and with force, this causes the stomach contents to project out of the infant’s mouth, this is known as projectile vomiting
  • 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
  • Refusing to eat or drink (breast milk in young infants)
  • Having blood in the stool
  • Experiencing a difficulty in breathing or chronically coughing and wheezing
  • 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
  • Having excessive belching
  • Experiencing frequent nausea
  • Feeling pain when they are lying down
  • Experiencing discomfort or pain when swallowing food
  • Tasting stomach acid in their throat
  • Feeling like 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.

What causes GERD and acid reflux in infants and children?

Acid reflux in infants is common due to the muscle between the stomach and the oesophagus, known as the lower oesophageal sphincter, or LES, not having reached maturity and therefore being under-formed. This allows for the stomach contents and acid to flow back upwards into, and possibly out of, the mouth. In time, the LES will only open when your infant swallows and will, therefore, remain closed when the infant is not eating or drinking. Thus, 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 are:

  • Infants being born prematurely – 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 are:

  • GERD (gastroesophageal reflux disease) - When acid reflux becomes more serious and prevents the infant from feeding or the child from eating and causes visual signs of discomfort, this is known as GERD which can lead to the damage of the oesophagus and weight loss for the infant or child.
  • 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 narrowed, this prevents the stomach contents from being emptied into the small intestine which may result in vomiting, dehydration and weight loss. This condition also results in an infant always seeming hungry.
  • Eosinophilic esophagitis - In some cases, a condition known as eosinophilic esophagitis, 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.

What are the complications GERD and acid reflux in infants and children?

Reflux in infants normally resolves by itself without resulting in any other 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. There are some studies that should 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.

When the oesophagus is exposed to stomach acid over a prolonged period of time, this can lead to a precancerous condition known as Barrett’s oesophagus. This may even lead to cancer of the oesophagus. However, this is very rare in children.

How is GERD diagnosed in infants and children?

The doctor will typically start with a physical exam of the infant or child and ask about the symptoms that they are displaying. If the infant is healthy and growing accordingly to a growth chart, the doctor will normally send you and the infant or child home, as their symptoms are mild and do not require treatment for the child or infant.

However, should the infant or child show issues with discomfort as well as issues regarding their growth and diet history, additional tests may be conducted, should the doctor not immediately diagnose the infant or child with GERD.

Additional, yet occasionally conducted tests may include:

  • Lab tests – Urine and blood tests often help to rule out or identify the possible causes of the recurring vomiting as well as the poor weight gain.
  • Ultrasound – This is an imaging test that can be used to identify if the child or infant has pyloric stenosis. This is a condition where the opening between the small intestine and the stomach thickens and can, therefore, block food from entering into the small intestine. This can be fixed through surgery.
  • Oesophageal pH monitoring – In order to determine the acidity of the child or infant’s oesophagus, the infant or child will be asked to swallow a thin and long tube that has a probe at the tip. This will stay in the oesophagus for a duration of 24 hours whilst the child or infant is closely monitored (usually whilst staying in the hospital). This tool also helps 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 as well as the small intestine. 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 as it can be an intrusive procedure.
  • 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, 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 the 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 receiver, 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 to be expected in infants and often does not result in serious health concerns, be initially treated through lifestyle changes and measures, if no improvement is seen after these have been implemented, then medication will be prescribed as the diagnosis is normally 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 the upright position. If possible, also try to hold your infant in the sitting position for about 30 minutes after feeding. This technique will utilise the force of gravity in order to aid the stomach contents to stay in place. Try not to jiggle or move the baby during this time as it is vital that the food settles.
  • 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, the acid reflux will significantly decrease.

For older children (two years and older):

  • Elevating the head of your child’s bed will aid in digestion.
  • Keep the child upright for the first two hours after eating.
  • Serving 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.
  • Limit food and drinks that seem to worsen the reflux such as dairy, caffeine, carbonated drinks or high fat foods.

Bottle fed baby

Reflux is also a common occurrence for infants and may also be seen in young children.

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 – 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.

 Proton Pump Inhibitor diagram

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. It can be necessary in more severe cases though and the most common surgery performed is known as a fundoplication.

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.

FAQ 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 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 important to note how your baby reacts to dietary changes. Acid reflux has been known to have a link to dairy products consumed by the mother. If your infant develops acid reflux, it is best to identify the certain 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 or pyloric stenosis. This typically develops four to six weeks after birth. However, pyloric stenosis is uncommon in breastfed babies.

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. If your infant violently vomits, known as projectile vomiting, on a regular basis, then consult with your doctor as your baby may have developed GERD (gastroesophageal reflux disease).

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 the 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 your infant could be 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. A number of paediatricians believe that hiccups in infants are caused by a drop in the infant’s temperature or through feeding.

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