Gastroesophageal Reflux

What is reflux (infant regurgitation) ?

Gastroesophageal reflux means the backward movement of stomach contents up the oesophagus (the "swallowing tube"). This can take place only in the lower part of the oesophagus or reach up to the mouth or even the nose. Reflux often includes the release of the material from the mouth, as in infants who "spit up."

Reflux is a normal phenomenon, occurs when the muscle between the oesophagus and stomach relaxes (as it does during burping), allowing stomach content to leak up the oesophagus.

When regurgitated stomach material comes out of the mouth, it is often mistaken for vomiting, but technically, and medically speaking, vomiting is a complex mechanism that includes nausea, retching, and gagging prior to the actual vomit.

Is gastric reflux normal?

Reflux is normal and very common. Up to 70% of healthy babies spills regularly with a peak around the age of 4 months. This happens because infant's gastroesophageal sphincter is not fully developed, and their meals are mostly liquid. It is very common for infants to spill the reflux, sometimes even forcefully. That is because of the very small volume that the infant oesophagus can hold and because of the amount of time they spend lying down.
Infants who spill, even multiple times, but otherwise are healthy, considered to have physiologic reflux (Happy spillers). This is not a disease or condition that need to be treated.

Should I worry if my infant spills?

The evidence is that no matter what you do, physiologic reflux gets better by itself by the end of the first year in nearly all of those who have it.
It makes no difference whether the spill comes out the mouth, the nose, or both. Also, the apparent forcefulness of the material cannot, by itself, set apart physiologic from non-physiologic condition.
Projectile (or forceful) vomiting occurs in some serious conditions. But projectile regurgitation that looks like vomiting is also commonly seen in functional infant regurgitation.
Signs that something more serious may be going on would include your baby having problems gaining weight, crying excessively, problems feeding, problems breathing or throwing up blood or bile (green colour).

Gastroesophageal Reflux Disease (GORD) refers to a condition where tissue damage or harmful symptoms happen because of the reflux. GORD is not common in otherwise healthy infants. GORD is more common in preterm birth and in infants with otherwise chronic diseases.

Common problems due to GORD include:

Recurrent aspiration (inhaling) of refluxed material into the lungs
Inflammation in the oesophagus, causing pain and feeding difficulties.
Failure to gain weight appropriately

Should I change my diet / formulas?

The idea of changing formulas is usually because of suspicion of food allergy, most commonly to cow's milk protein. As food allergy can present itself only with reflux symptoms, if symptoms are severe, a trial of dairy-free diet may be worth trying. If you are formula feeding, a prescribed hydrolyzed protein (hypoallergenic) formula may help. If you are breastfeeding, a dairy-free diet for you for two weeks is indicated. Sometimes more foods may cause an allergic reaction such as soy protein. If no improvement with symptoms and allergy is still suspected, your doctor may prescribe an amino-acid based formula which is considered as the most hypoallergenic option.

What about lactose intolerance?
Lactose is the milk sugar. It is found also in human breast milk, so babies are born with the ability to digest lactose. Inborn Lactose intolerance is extremely rare. In older children, it may occur secondary to an infection of the small intestine and usually transient. Lactose intolerance does not present as infant regurgitation.

Diagnosis

Diagnosis is mainly clinical, meaning based on history and symptoms and not on specific tests. The aim of the diagnosis is to determine if the baby has complications from the reflux causing it to be a disease (GORD) rather than a normal physiologic condition. Diagnosis of gastroesophageal reflux disease is made by taking a medical history and physical exam. Testing is not usually needed. Some of the following tests may be done if your child doesn’t respond to treatment or if your doctor is concerned that something else may be going on.

Upper GI series (Barium swallow)- During an upper GI, the baby swallows barium from a bottle. The barium coats the oesophagus and stomach and makes it show up on the x-ray. It is a good way to make sure that there is no blockage or an anatomical abnormality.
pH study- A pH probe is used to quantify gastroesophageal reflux. A small tube is placed through the baby’s nose and down into the oesophagus. A small sensor on the end of the probe detects acid when the child refluxes. The parents can push a button for markers when the baby is having symptoms so the doctor can see if they correlate with reflux. The pH probe lasts for 18-24 hours. As reflux in babies is not always acidic, this test is not used very often with infant reflux.
Gastroscopy- Although usually not required, it is a good tool to assess inflammation(oesophagitis) and exclude other diagnosis. It is usually recommended when there is a concern of other causes for feeding difficulties such as inflammation of the oesophagus.

Treatment

Most babies with gastroesophageal reflux do not require treatment and will outgrow the reflux. improving feeding techniques and avoid overfeeding is very important. It also helps to hold your baby upright for 30 to 60 minutes after they eat.

Thickening the formula can often treat mild reflux, although sometimes may cause constipation, and if the reflux does not seem to bother the baby it may be better not to treat.

Sometimes reflux symptoms are caused due to allergy and change of the mum's diet in breastfed babies, or changing formula is required.

Although baby's reflux is not always acidic, anti-acid agents such as Famotidine or Omeprazole are given to reduce the amount of acid produced by the stomach. Other Medications such as Domperidone which facilitated rapid emptying of the stomach can be used.