Reflux: "Happy Spitter" versus "Baby in Pain"

(sorry for any typos, I wanted to get this out as fast as I could. I will be doing final edits but wanted to get it out.  Thank you for understanding and happy reading!)

Given this was one of the most commonly requested topics, you can imagine how widespread reflux is in the pediatric population.  What makes it even more confusing is that many pediatricians and even pediatric GI doctors differ in how they diagnose and treat reflux.  After reviewing the latest guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, I hope I can help you all understand the current recommendations. I have to admit, I still think there will be a wide range in management decisions, but I hope this will, at least, will enable you to have an informed discussion with your child's doctor.


Believe it or not, Gastroesophageal reflux(GER) occurs in more than two-thirds of healthy infants and one of the main topics of discussion in 1/4 of all routine 6-month old well child visits. Reflux (GER) is defined as the passage of gastric contents into the esophagus(tube connecting mouth to stomach) and is something that is considered to be a normal process that occurs several times a day in healthy infants, children, and adults.  These episodes tend to occur after meals, last less than 3 minutes, and cause few or no symptoms.  Reflux can also be associated with vomiting(defined as forceful expulsion of gastric contents).

Gastroesophageal reflux disease(GERD) is GER with complications or troublesome symptoms. These symptoms include persistent vomiting, poor weight gain, pain with eating, abdominal or chest pain, and inflammation of the esophagus. Sometimes, these symptoms are non-gastrointestinal. Symptoms such as persistent cough, dental erosion, laryngitis, sore throat, sinusitis, recurrent ear infections, and even wheezing in infancy can be caused by reflux.

Common symptoms of GERD in infants include regurgitation ("spitting up") or vomiting associated with irritability, feeding refusal, poor weight gain, pain with eating/painful swallowing, and arching of the back during feedings.  In infants, it can also be associated with coughing, choking, wheezing, or cold-like symptoms.

The incidence of GERD is reportedly lower in breastfed infants than in formula fed infants.  GERD is considered to peak to affect 50% of infants around 4 months of age and decline to affect only 5-10% of infants at 12 months of age.

Common symptoms in children ages 1-5 include spitting up, vomiting, abdominal pain, decreased eating or feeding refusal.  In this age group, GERD can cause troublesome symptoms without interfering with growth.

Older children and adolescents are most likely to resemble adults and present with "heartburn", stomach pain, chest pain, night-time pain,  pain with eating, and "sour burps".  The older children and adolescents can also present with pneumonia, sore throat, hoarseness, chronic sinus infections, or dental erosions.

Diagnosis:

For most children, a simple office visit and exam are sufficient to reliably diagnose uncomplicated reflux and to initiate treatment strategies.  According to the new guidelines, diagnostic testing/imaging is not necessary.  Further studies are sometimes warranted when patients present with  more concerning symptoms.  These include, but are not limited to, vomiting green/black liquid, bleeding, consistent forceful vomiting, fever, lethargy  enlarged liver or spleen, bulging fontanelle (soft spot on baby's head), very small/very large head, seizures, or abdominal distension.

Diagnostic studies range from x-rays to probes that are inserted into the stomach.  The most commonly used modality used to be the Upper GI series. In this study, infants/children would drink barium and the radiologist would take continuous x-ray pictures. Although this is still used, the new guidelines state that routine performance of this test is not justified for diagnosing reflux or GERD alone.  However, your doctor still may use it to diagnose other GI abnormalities so don't worry if it is still ordered.

The other tests/probes principally ordered and performed by GI specialist and I will defer that discussion to them.

Management

Now here is where the guidelines may be different from what your doctor has prescribed or done with your child.  I will stress that this blog is not meant to convince you to change your baby/child's management. Hopefully, it will help you and your doctor have an educated discussion.  Please go with the doctor you trust here.

Non-Medicine:

Infants

The new guidelines describe several treatment options for treating children with reflux and GERD.  The new guidelines focus on life-style changes because they can minimize symptoms for both infants and children.

For infants, lifestyle changes may include a combination of feeding changes and positioning changes.  Modifying mom's diet for breastfed infants, changing formulas, reducing feeding volume while increasing the frequency of feed may all be effective strategies to address GERD.  One big change is that the new guidelines emphasize that milk protein allergy can cause a clinical picture similar to GERD.  Therefore, a 2- to 4- week trial of maternal exclusion diet that restricts at least milk and egg is recommended in breastfeeding infants even before trialing the baby on medication.  It is important to note here that this applies only to infants who are having severe symptoms and not to "happy spitters" with reflux.   For infants who are formula fed, the recommendation is to change to extensively hydrolyzed protein or amino-acid based formula (such as neocate, allimentum, etc).  Note, the recommendations do not recommend changing to soy formula   This is because a significant number of infants who have problem with cows' milk protein will also have problems with soy.  Making this change is extremely difficult for most families. If the baby is milk-protein intolerant, this will likely change at about 12-15 months of age.  Most breast feeding mothers have a hard time limiting milk and egg for that long.  Those of you whose babies are formula fed might have a hard time affording the special formula (although, some insurance companies will offset the cost).  These are some of the reasons why it hasn't always been used first line in the past.

For non-preterm infants > 1 month of age, parents can also try thickening feeding wither by adding up to 1 tablespoon of dry rice cereal per 1 oz of formula or changing to commercially thickened (added rice) formulas.  This is recognized as a reasonable management strategy for otherwise healthy infants with both regular reflux and GERD. In studies who have looked at this technique, it is seen that thickened feedings decrease the observed regurgitation rather than the actual number of reflux episodes.  Therefore, this may be more beneficial for the "happy spitters" than the babies who have GERD.

Lifestyle changes are also noted to help infants with GERD. These include keeping the baby in the completely upright position or even laying them on their bellies (not to sleep)  In studies looking at this, there was a significant decrease in reflux events in infants in the lying on their bellies.  However, the guidelines state that the risk of SIDS outweighs the benefits of babies sleeping on their bellies. It is suggested that this might be better for children older than 1 year because of the decreased risk of SIDS at that age.

Children

Lifestyle changes are stressed here as the most important first-line intervention.  This includes weight loss for overweight children, avoiding caffeine, chocolate, and spicy foods. It is also important for this and other health reasons to make sure your teenager is not smoking or consuming alcohol.  Interestingly, 3 independent studies have demonstrated decreased reflux episodes with chewing sugarless gum after eating.

Medicine:

There are multiple different classes of medications that are used for reflux.  Each of them has their pros and cons.  Again, I want to stress that this discussion does not circumvent a discussion with your doctor.

1) Antacids: These include Over-the-Counter medicines like Tums, Rolaids, etc..  These are used to directly buffer stomach acid.  There is limited evidence that on-demand use of antacid s can lead to symptom relieve in infants and children.  Historically, they have been viewed as a safe first approach to the treatment of GERD. It is important to note that , like most medicines, there can be problems if they are used in excess.  These complications can include aluminum toxicity, renal failure, and elevated calcium levels.   Therefore, please discuss this with your doctor before using these medicines.

2)Histamine Receptor 2 receptor agonists (H2RAs):  These include Ranitidine (Zantac), Famotidine, Cemetidine.  These work by decreasing the secretion of acid in the stomach.  Randomized controlled pediatric trials have shown this class to be superior to placebo in treatment of certain complications of GERD.   They have also been found to be quite effective if administered 2-3 times per day instead of one.  Again, there can be long-term complications with this class of medicine.  Children on long-term cimetidine have been shown to have increased risk of liver disease. This has not been seen with the other medicines in this class, but it is conceivable that it could happen.

3) Proton Pump Inhibitors (PPIs):  These include medicines like Prevacid, Protonix, Nexium.  These medicines have been found to be one of the best options for treatment of GERD.  They also work by decreasing acid secretion in the stomach.  The timing of dosing of most PPIs is important and should be given approximately 30 minutes before meals (for older children in whom you are able to plan this).  Just like with all medicines, there are side effects including diarrhea, constipation.

4) Prokinetic (increasing gut movement) agents - This includes medicines like Reglan.  To date, the adverse effects of these medicines outweigh the benefits and they are typically not used as first line, if at all in children unless there are other specific reasons to do so.

OVERVIEW: (the quick version)

1) Reflux is very common (75% of health infants)

2) Always discuss any concerns you have with your doctor!

3) For infants who are "Happy Spitters", those with reflux and no other symptoms, you can consider thickening the feeds as well as lifestyle changes (keeping them upright, smaller feeds more frequently, frequent burping, etc) and monitor.  If no additional symptoms then your child can be observed until 18 months. If it has not resolved by 18 months, then a GI specialist may be consulted.

4) For infants with GERD(see above) and who are losing weight, your infant should be examined by his/her doctor. If everything looks ok, then it is important to discuss a formula change or maternal diet change (for breastfed babies) as well as thickened feeds and lifestyle changes.  If these do not work, then medications can be tried.  If no improvement, then a GI specialist may need to be consulted.

5) For Children/Adolescents the mainstay of treatment is going to be lifestyle change and then a trial of a PPI (see above) for 2 weeks.  If there is no change, then GI may be consulted.  If symptoms improve, you can continue the medicine for 8-12 weeks and then be reevaluated.

6) When in doubt, talk with your doctor.  

I hope this helps shed some light on a difficult topic. I look forward to your comments!

Dr. Mac

Note:  All comments are welcome on the blog, but please do not post medical questions. I am, unfortunately, unable to respond to personal medical questions through this website.   Thank you for understanding!

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