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| |    Gastroesophageal Reflux (GER) in Infants by Robert Needlman, M.D., F.A.A.P. reviewed by Lynn Cates, M.D., F.A.A.P. All babies spit up some of the time. Some spit up or have what many parents call "wet burps" after every feeding. However, about one baby in five has a condition called gastroesophageal reflux, or GER, in which stomach acid squirts up into the esophagus much more often than usual, causing discomfort (in the form of heartburn) or other problems. GER usually starts during the first few weeks and goes away by one or two years. (Older children and adults can also develop GER, but for different reasons.) Understanding the terminology Like many medical terms, gastroesophageal reflux simply describes the problem: "Gastro" refers to the stomach; "esophageal" refers to the esophagus, the tube that connects the mouth to the stomach. And "reflux" means that the liquid stomach contents are squirting (that is, "fluxing") backward. Instead of squirting down into the intestines, they squirt up into the esophagus. Some doctors distinguish between gastroesophageal reflux and gastroesophageal reflux disease (GERD). They call it GERD when the reflux of stomach acid is bad enough to cause damage to the esophagus. Acid can also get into the lungs, causing chronic cough or pneumonia. Causes of GER In infants, the main cause of GER seems to be poor coordination between the esophagus and stomach. With age, this coordination usually improves and the GER goes away. Normally, there is a muscle that closes off the top of the stomach, where the esophagus empties in. This muscles squeezes tight, keeping stomach acids from getting up into the esophagus. But the muscle has to relax to allow food to enter from above. Gastroesophageal reflux occurs when the muscle relaxes too much of the time. Poorly coordinated movement of the esophagus and slower-than-usual emptying of the stomach can also lead to reflux. Premature babies and infants with neurological problems, such as cerebral palsy, often develop GER. Signs of GER Babies with GER often spit up a lot. However, babies can have serious GER without a lot of spitting up if the stomach contents don't usually reach the mouth. Infants with GER tend to be irritable and fussy because of the associated discomfort or pain. They may arch their backs and stiffen their bodies, act colicky, sleep poorly, or have a chronic cough. Poor weight gain can be a sign of serious GER. By the same token, a baby who spits up a lot and fusses some, but who is gaining weight normally, has a less urgent problem. How doctors make the diagnosis If an infant shows typical symptoms of GER (for example, spitting, arching, and poor weight gain), the doctor might diagnose him without using any special tests. In other cases, doctors can use an acid sensor (called a pH probe), which actually sits in the baby's esophagus for a day and records every instance when acid sloshes up. There are also x-ray movies (fluoroscopy) that can show liquid sloshing back up the esophagus. The most accurate way to tell if stomach acid has irritated or damaged the esophagus is, simply, to look. Pediatric gastroenterology specialists use an endoscope--a thin, flexible fiber-optic telescope--to look at the lining of the esophagus and take biopsies if necessary to show acid damage. Which tests (if any) get used depends on the child's age and symptoms. Treatments The first line of treatment is to position the baby upright more of the time, especially after feeding. Carrying him in a front pack or sling works well for this. Infant seats can also help, but be careful that the baby is not slumping over, putting pressure on the stomach and making the reflux worse. When the baby is lying down, the head of his crib mattress should be propped up about 20 to 30 degrees so that gravity can help to keep the stomach contents down. Babies should still sleep on their backs, to prevent SIDS. Frequent, smaller feedings are important to help minimize stomach pressure. Some doctors recommend thickening the infant's formula with cereal. But this can sometimes make matters worse, because if this thicker material refluxes, it will likely stick to the esophagus more, perhaps causing more irritation. Also, it isn't possible to thicken breast milk, unless the mother first pumps it into a bottle. Certain foods, such as caffeine, chocolate, and garlic, promote reflux, so breastfeeding mothers should consider cutting these foods out of their diets. If none of these treatments works, there are a number of medications that often help. Some work by strengthening the muscle at the bottom of the esophagus, or by speeding up the emptying of the stomach into the intestines. Others reduce acid production in the stomach. (These are the same medications adults take for severe heartburn.) It's important to take these medications as prescribed by the doctor so they'll be safe and effective. In very severe cases, if medical treatment and the passage of time do not take care of the problem, a surgical operation can make it more difficult for stomach contents to reflux. By far, though, most children get better before there is any need for surgery.
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