Which is the most appropriate intervention for a 3 month old infant who has gastroesophageal reflux?

It's common for infants to spit up after a meal. That little spit is called gastroesaphogeal reflux or GER. But frequent vomiting associated with discomfort and difficulty feeding or weight loss may be caused by something more serious known as GERD (gastroesophageal reflux disease). Both GER and GERD can cause the upward movement of stomach content, including acid, into the esophagus and sometimes into or out of the mouth. Oftentimes, that vomiting is repetitive. The differences between the two conditions are marked by the severity and by the lasting effects.

Older children also can have GERD.

What Causes GERD in Babies and Children?

Most of the time, reflux in babies is due to a poorly coordinated gastrointestinal tract. Many infants with GERD are otherwise healthy; however, some infants can have problems affecting their nerves, brain, or muscles. According to the National Digestive Diseases Information Clearinghouse, a child's immature digestive system is usually to blame and most infants grow out of the condition by their first birthday.

In older children, the causes of GERD are often the same as those seen in adults. Also, an older child is at increased risk for GERD if they experienced it as a baby. Anything that causes the muscular valve between the stomach and esophagus (the lower esophageal sphincter, or LES) to relax, or anything that increases the pressure below the LES, can cause GERD.

Certain factors also may contribute to GERD, including obesity, overeating, eating spicy or fried foods, drinking caffeine, carbonation, and specific medications. There also appears to be an inherited component to GERD, as it is more common in some families than in others.

What Are the Symptoms of GERD in Infants and Children?

The most common symptoms of gastroesophageal reflux in infants and children are:

• Frequent or recurrent vomiting
• Frequent or persistent cough or wheezing
• Refusing to eat or difficulty eating (choking or gagging with feeding)
• Heartburn, gas, abdominal pain, or colicky behavior (frequent crying and fussiness) associated with feeding or immediately after
• Regurgitation and re-swallowing
• Complaining of a sour taste in their mouth, especially in the morning

Many other symptoms are sometimes blamed on GERD, but much of the time, we really aren't sure whether reflux actually causes them. Other problems seen in young children and infants that may be blamed on the condition include:

• Colic
• Poor growth
• Breathing problems or wheezing
• Recurrent pneumonia

Do Babies Outgrow GERD?

Yes. Most babies outgrow reflux by age 1, with less than 5% continuing to have symptoms as toddlers. However, GERD can also occur in older children. In either case, the problem is usually manageable.

How Is GERD Diagnosed in Infants and Children?

Usually, the medical history as told by the parent is enough for the doctor to diagnose GERD, especially if the problem occurs regularly and causes discomfort. The growth chart and diet history are also helpful, but occasionally, further tests are recommended. They may include:

• Barium swallow or upper GI series.This is a special X-ray test that uses barium to highlight the esophagus, stomach, and upper part of the small intestine. This test may identify any obstructions or narrowing in these areas.
• pH probe.During the test, your child is asked to swallow a long, thin tube with a probe at the tip that will stay in the esophagus for 24 hours. The tip is positioned, usually at the lower part of the esophagus, and measures levels of stomach acids. It also helps determine if breathing problems are the result of GERD.
• Upper GI endoscopy.This is done using an endoscope (a thin, flexible, lighted tube and camera) that allows the doctor to look directly inside the esophagus, stomach, and upper part of the small intestine.
• Gastric emptying study. Some people with GERD have a slow emptying of the stomach that may be contributing to the reflux of acid. During this test, your child drinks milk or eats food mixed with a radioactive chemical. This chemical is followed through the gastrointestinal tract using a special camera.

What Are the Treatments for Acid Reflux in Infants and Children?

There are a variety of lifestyle measures you can try for acid reflux in babies and older children:

For babies:

• Elevate the head of the baby's crib or bassinet.
• Hold the baby upright for 30 minutes after a feeding.
• Thicken bottle feedings with cereal (do not do this without your doctor's approval).
• Feed your baby smaller amounts of food more often.
• Try solid food (with your doctor's approval).

For older children:

• Elevate the head of the child's bed.
• Keep the child upright for at least two hours after eating.
• Serve several small meals throughout the day, rather than three large meals.
• Make sure your child is not overeating.
• Limit foods and beverages that seem to worsen your child's reflux such as high fat, fried or spicy foods, carbonation, and caffeine.
• Encourage your child to get regular exercise.

If the reflux is severe or doesn't get better, your doctor may recommend medication.

Drugs to Neutralize or Decrease Stomach Acid

Drugs to decrease stomach acid include:

• Antacids such as Mylanta and Maalox
• Histamine-2 (H2) blockers such as cimetidine (Tagamet) or famotidine (Pepcid)
• Proton-pump inhibitors such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), omeprazole-Sodium Bicarbonate (Zegerid), pantoprazole (Protonix), rabeprazole (Aciphex)

Researchers aren't sure whether decreasing stomach acid lessens reflux in infants.

For the most part, drugs that decrease intestinal gas or neutralize stomach acid (antacids) are very safe. At high doses, antacids can cause some side effects, such as diarrhea. Chronic use of very high doses of Maalox or Mylanta may be associated with an increased risk of rickets (thinning of the bones).

Side effects from medications that inhibit the production of stomach acid are uncommon. A small number of children may develop some sleepiness when they take nizatadine, Pepcid, or Tagamet.

Surgery for GERD in Babies and Kids

Surgery isn't often needed to treat acid reflux in babies and kids. When it is necessary, a fundoplication is the most often performed surgery. During this procedure, the top part of the stomach is wrapped around the esophagus forming a cuff that contracts and closes off the esophagus whenever the stomach contracts -- preventing reflux.

The procedure is usually effective, but it is not without risk. Discuss the potential risks and benefits of any operation with your child's doctor.