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Gastroesophageal Reflux in Infants |
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Definition
The backwash of stomach contents into the esophagus, commonly called reflux, occurs when the lower esophageal sphincter (LES) is very weak or, more commonly, when it inappropriately relaxes.
The reflux tends to be worse after big meals and when one lies down at night. The refluxed food irritates the esophageal lining.
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Description
The esophagus is the tubelike structure that connects the mouth to the stomach. At the point where the esophagus joins the stomach, the esophagus is kept closed by a specialized muscle called the lower esophageal sphincter (LES). This muscle is important because the pressure of the stomach is normally higher than that in the esophagus. The muscle of the LES relaxes after swallowing to allow passage of food into the stomach, but then it quickly closes again.
The occurrence and severity of reflux depends on LES dysfunction, but are also affected by the type and amount of fluid brought up from the stomach, by the clearing action of the esophagus, by the neutralizing action of saliva, and by other factors.
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Causes and Risk Factors
Although many infants have minor degrees of reflux, about 1 in 300 to 1,000 infants have significant reflux and associated complications.
In some children, reflux may be caused by abnormal anatomy of the esophagus. Reflux may also occur when the stomach is too full and the infant increases abdominal pressure by coughing, crying, or defecating. The small capacity of the infant's esophagus predisposes to vomiting.
Chronic spitting up may have other origins as well. The muscle of the outlet of the stomach (the pylorus) can grow too strong, a condition called pyloric stenosis, which causes the infant to throw up after each feeding. An infant may not tolerate a particular formula, and vomiting may result. Overfeeding an infant can also cause vomiting.
Chronic reflux and vomiting are harmful to the infant. The acid from the stomach will irritate the esophagus, and the infant may cry each time he or she is fed, leading parents to call the problem "colic." This kind of crying happens during or just after feeding.
Patients with cerebral palsy, Down's syndrome, and other causes of developmental delay have an increased incidence of reflux.
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Symptoms
In 85 percent of affected infants, excessive vomiting occurs during the first week of life. An additional 10 percent have symptoms by week 6.
Symptoms go away without treatment in 60 percent of children by the age of 2 years as the child assumes a more upright posture and eats solid foods.
The other 40 percent of children continue to have symptoms until at least age 4 years.
Some patients may aspirate food contents, resulting in pneumonia.
There may be rumination (repetitive gagging, regurgitation, mouthing and reswallowing of food). Growth and weight gain are adversely affected in about two-thirds of patients.
More serious problems can result from chronic reflux including esophageal bleeding, ulcers, or stricture (narrowing).
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Diagnosis
Diagnosis is based on the medical history, physical examination, and sometimes radiological studies such as barium esophagography (an X-ray study) or rarely a pH probe (detects acidity in the esophagus).
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Treatment
A long-term cure may be expected in infants. In older children, symptoms are likely to be chronic, as with adults.
Thickening an infant's formula with cereal will decrease crying and the volume of vomiting. Smaller but more frequent feedings may also be beneficial.
In older infants and children, the head of the bed should be raised a few inches above the level of the feet when sleeping, and the child should be kept upright during the day as tolerated.
Metoclopramide may help reduce reflux but can cause drowsiness or restlessness in some children. Cisapride may also be helpful.
If esophagitis is present, antacids, H2 acid blockers, or omeprazole may be indicated.
If intensive medical therapy does not improve symptoms, then surgical treatment may be necessary.
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Questions to Ask Your Doctor
Do tests need to be done to diagnose reflux?
What is the cause of the reflux?
Will you be prescribing any medications? What are the side effects?
What antacids do you recommend? How often can the antacids be taken?
Are there any complications of reflux?
What changes in feeding do you recommend?
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