What is Gastroesophageal Reflux (GER)?
Some infants with an omphalocele experience GER or reflux. Gastroesophageal reflux (GER) occurs when the stomach contents reflux or go into the esophagus (the tube that connects the mouth to the stomach), during or after a meal. Most infants with Gastroesophageal reflux are happy and healthy even though they spit up or vomit. An infant with gastroesophageal reflux may experience:
- Poor feeding
- Discomfort with feeding
How common is reflux?
Gastroesophageal reflux occurs often in normal infants. More than half of all babies experience reflux in the first 3 months of life. Only a small number of infants have problems due to gastroesophageal reflux. Most infants stop spitting up between the ages of 12 to 18 months.
Why does reflux happen?
There is a ring of muscle at the bottom of the esophagus, which opens and closes, allowing food to enter the stomach. This ring of muscle is called the lower esophageal sphincter (LES).
In infants, this sphincter is not as strong as that in older children and adults. The sphincter easily opens and the stomach contents often go up the esophagus and out the mouth (spitting up or vomiting).
Gastroesophageal reflux can also occur when babies cough, cry or strain as the pressure in their stomachs increases at these times.
What are the worrisome symptoms of gastroesophageal reflux?
In a small number of babies, gastroesophageal reflux may result in symptoms that are concerning. These include problems such as:
- Poor growth due to an inability to hold down enough food
- Irritability or feeding refusal due to pain
- Blood loss from acid burning the esophagus
- Breathing problems
Each of these problems can be caused by disorders other than gastroesophageal reflux. Your healthcare provider needs to determine if gastroesophageal reflux is causing your child’s symptoms.
How does your healthcare provider know your child has reflux?
An infant that spits or vomits may have gastroesophageal reflux. The doctor or nurse will talk with you about your child’s symptoms and perform a physical examination.
Sometimes, tests may be ordered to help the doctor or nurse determine whether your child’s symptoms are related to gastroesophageal reflux. Often, treatment is started without the need for any tests.
If your infant or child has any of the previously discussed symptoms and you are concerned that she may have reflux, talk with your pediatrician about having her evaluated. GER may be diagnosed by a single office visit, or a referral may be needed to a pediatric gastroenterologist for further evaluation. Your doctor or specialist will review your child’s symptoms, determine if her weight gain is appropriate, and possibly order special tests. These tests may include an upper gastro-intestinal X-ray (UGI), a milk scan, a 24-hour pH probe, or an endoscopy.
An UGI is an X-ray of the stomach and esophagus after your child swallows a liquid drink called barium. If your child is unable to swallow the barium it will be given through a small feeding tube placed through the nose or mouth down the esophagus and into the stomach. On the X-ray the barium shows any anatomical abnormalities (such as narrowing of the esophagus or blockages) and any refluxing of the barium from the stomach that might occur. A UGI is only 50% accurate because the refluxing might not occur at the time of the X-rays. Another test called a milk scan is very similar to a UGI. Your child drinks a liquid called technetium, which shows any refluxing or anatomical problems on a special scanning device. Parents are often concerned about the dangers of X-rays and consuming an unnatural liquid. The radiation from the X-rays is minimal (your child’s thyroid and genital area is covered by a special apron during the X-ray), and the barium and technetium are not harmful to your child’s health. The barium can cause constipation, but there are no other side effects.
A 24-hour pH probe is a fairly accurate test that shows any increased levels of stomach acid in the esophagus. A long, thin tube that is attached to a machine is placed in your child’s esophagus (via her nose or mouth) by a doctor or nurse. The end of the tube reads the acid level and records it on the machine after each feeding. After 24 hours the doctor will determine if the amount of acid in the esophagus is too high indicating GER. This test can be performed at home, however, some doctors prefer to hospitalize the infant during the test so a nurse can replace the probe immediately if it accidentally comes out.
The last, but most invasive test is called an endoscopy. In the doctor’s office or in the hospital, a flexible tube is placed through the child’s mouth and down into the esophagus. This tube has a microscope built into the tip, enabling the doctor is to examine the tissue in the esophagus and look for any reddened or damaged areas. Because this test is uncomfortable for the child, it requires sedation or general anesthesia and is generally not performed unless all other tests are inconclusive and the suspicion of GER still exists.
How is reflux treated?
The treatment of reflux depends upon the infant’s symptoms and age. Some babies may not need any treatment, as gastroesophageal reflux will resolve in many cases without treatment. Healthy, happy babies may only need the feedings thickened with cereal and to be kept upright after they are fed.
Overfeeding can aggravate reflux, and your health care provider may suggest a different feeding schedule. For example, smaller volume with more frequent feedings can help decrease the chances of reflux.
If a food allergy is suspected your health care provider may ask you to change the baby’s formula (or modify the mother’s diet if the baby is breastfed). If a child is not growing well, feedings with higher calorie content or tube feedings may be recommended.
If your child is uncomfortable, or has difficulty sleeping, eating or growing, the doctor may suggest a medication. Different types of medicine can be used to treat reflux by decreasing the acid in the stomach.
Although these medications will help protect your child’s esophagus from damage due to reflux, the medicines are unlikely to completely cure the spitting up.
Very rarely do infants have severe gastroesophageal reflux that prevents them from growing or that causes breathing problems. It is rare for infants to require surgery for gastroesophageal reflux. If surgery is necessary, your baby’s doctor or nurse can discuss treatment options with you. Source: Cincinnati Children’s Hospital Medical Center
Treatment of GER varies from simply thickening formula, to medication, to surgery. Your doctor may begin with thickening the formula and suggesting that your baby be in an upright position most of the day, especially after eating. Try to hold your baby without putting pressure on her abdomen. Burp your baby frequently (every 1/2 to 1 ounce) and encourage her to suck on a pacifier between feedings. This helps to keep the esophagus in motion, pushing anything in the esophagus back into the stomach.
If an infant is in pain, has slowed or stopped eating, or has apnea or bradycardia that is caused from reflux, more aggressive management needs to be done. Medications such as Zantac or Tagamet that decrease or block the production of acid, and/or medications such as Propulsid or Reglan that improve digestion, may be prescribed. These medications are often used in combination with one another; however, they should not be given in conjunction with some types of antibiotics because of the risk of serious side effects. In any case, check with your physician or pharmacist before giving your baby any medications for reflux.
Most children will out grow GER by one year of age. As children grow, their esophagus becomes longer and the stomach naturally begins to wrap around the muscle at the top of the stomach. It will also help when your child spends more time in an upright position as she develops.
Here is another resource for more information on reflux in infants. Click here: http://infantrefluxdisease.com/infant_acid_reflux/
At any age, if the symptoms are significant and medical intervention does not control the reflux, surgery may be needed. The surgical technique can vary (i.e fundoplication), but the general purpose is to create an artificial sphincter at the top of the stomach by wrapping a small part of the stomach around the esophagus. Traditionally, surgery is done by using a two- to three-inch incision in the middle of the abdomen. Some surgeons perform the surgery laproscopically using four 1/2 inch incisions on the abdomen. Choosing to have surgery is not an easy decision. Discuss all your options with your pediatrician, GI specialist, and surgeon. If possible, talk with other parents whose child has had surgery for reflux. Evaluate whether the surgery will help your child’s pain and growth, and if the benefits from the surgery will out weigh any possible complications. Complications can include gagging and retching after eating, a slight decrease in the stomach volume, scarring and/or infection at the surgery site.
Having a child with reflux can trigger many emotions. It is normal to feel anger, frustration, and sadness. Sometimes it helps to talk with those who can empathize with you and understand your feelings and concerns, such as other parents of children with reflux. You’ll need support to make it through these difficult days. A national parent support group called PAGER (Pediatric Adolescent Gastroesophageal Reflux Association, Inc.) www.reflux.org can help you find any further assistance you might need.
More information on reflux can be found at: http://www.infantreflux.org/