Infant Acid Reflux Disease

Infant acid reflux occurs when acids and other materials in the stomach flow back into the esophagus. The esophagus is a muscular tube that connects the throat with the stomach. Normally, the esophagus contracts to move food from the throat into the stomach. A tough rim of muscle, called the esophageal sphincter, opens to allow food out of the esophagus, and then contracts tightly to prevent it from re-entering the esophagus. In infant acid reflux, the esophageal sphincter does not work properly, and the acid flows backwards into the esophagus, causing the infant discomfort. Acid reflux is not at all uncommon in infants--up to have of all babies may experience it occasionally.

Most of these babies are healthy and require no special medical intervention. Symptoms of occasional infant acid reflux may include spitting or vomiting, coughing, occasional fussiness or crying after eating (acid reflux can cause an unpleasant burning sensation in the chest and throat), and reluctance to feed due to discomfort.

What Are the Symptoms of Acid Reflux in Infants and Children?

The most common symptoms are:

• Frequent or recurrent vomiting
• Heartburn, gas, abdominal pain, or colicky behavior (frequent crying and fussiness)
• Regurgitation and re-swallowing
• Spitting up or gulping with a painful look on the face, as if heartburn
• Irritability during or after feedings
• Projectile vomit, sometimes out the nose
• Sour breath
• Persistent hiccups or cough
• Excessive fussiness, crying or colic
• Sudden bursts of painful crying
• Poor day and/or nighttime sleep habits
• Constantly wants to nurse or refuses to nurse
• Poor feeding habits - arches back, pulls up legs, stiffens or screams while feeding or refuses to eat while still hungry
• Prefers upright or inclined positions
• Always wants to be held

In young infants and children, some problems may be associated with GERD and include:

• Colic (frequent crying and fussiness)
• Feeding problems
• Recurrent choking or gagging
• Poor growth
• Breathing problems
• Recurrent wheezing
• Recurrent pneumonia
  

When to see a doctor?

Normal infant acid reflux doesn't interfere with a baby's growth or well-being. Contact your baby's doctor if your baby:

• Isn't gaining weight
• Spits up forcefully, causing stomach contents to shoot out of his or her mouth
• Spits up more than a tablespoon or two at a time
• Spits up green or brown fluid
• Resists feedings
• Is irritable after feedings but improves when held upright
• Has fewer wet diapers than normal or appears lethargic
• Has other signs of illness, such as fever, diarrhea or difficulty breathing
  

Some of these signs may indicate more serious conditions, such as gastroesophageal reflux disease (GERD) or pyloric stenosis. GERD is a severe version of reflux that can cause pain, vomiting and poor weight gain. Pyloric stenosis is a rare condition in which a narrowed valve between the stomach and the small intestine prevents stomach contents from emptying into the small intestine.

What causes Acid Reflux in infants ?

Reflux in infants is due to a poorly coordinated gastrointestinal tract. Many infants with the condition are otherwise healthy; however, some infants can have problems affecting their nerves, brain or muscles.

Normally, the ring of muscle between the esophagus and the stomach (lower esophageal sphincter) relaxes and opens only when you swallow. Otherwise, it's tightly closed — keeping stomach contents where they belong. Until this muscle matures, stomach contents may occasionally flow up the esophagus and out of your baby's mouth. Sometimes air bubbles in the esophagus may push liquid out of your baby's mouth. In other cases, your baby may simply drink too much, too fast.

Tests and Diagnosis

Diagnosis of infant acid reflux is typically based on your baby's symptoms and a physical exam. If your baby is healthy, content and growing well, tests and treatment aren't usually needed.

If your baby's doctor suspects a more serious condition, such as GERD, diagnostic tests may include:

1. Lab tests. Your baby's doctor may do various blood and urine tests to identify or rule out possible causes of recurring vomiting and poor weight gain.
2. Esophageal pH monitoring. To determine if irritability, sleep disturbances or other symptoms are associated with reflux, it may be helpful to measure the acidity in your baby's esophagus. The doctor will insert a thin tube through your baby's nose or mouth into the esophagus. The tube is attached to a device that monitors acidity. Your baby may need to remain in the hospital for the monitoring, which often lasts 24 hours.
3. Barium swallow or Upper GI series. If the doctor suspects a gastrointestinal obstruction, he or she may recommend a series of X-rays known as an upper gastrointestinal (GI) series. Before the X-rays, your baby may drink a white, chalky liquid (barium). The barium coats the stomach, which helps any abnormalities show up more clearly on the X-rays.
4. Upper GI Endoscopy. Your baby's doctor may use this procedure to identify or rule out problems in the esophagus, such as narrowing (stricture) or inflammation (esophagitis). The doctor will insert a special tube equipped with a camera lens and light through your baby's mouth into the esophagus, stomach and first part of the small intestine. Samples of any suspicious areas may be taken for analysis. For infants and children, endoscopy is usually done under general anesthesia.
   
5. Gastric emptying study. During this test, the child drinks milk or eats food mixed with a safe radioactive chemical. This chemical is followed through the gastrointestinal tract using a special camera.
   

Treatments and drugs for Infant Acid Reflux

Most cases of infant acid reflux clear up on their own. Treatment is typically limited to simple changes in feeding technique — such as smaller, more frequent feedings, interrupting feedings to burp or holding your baby upright during feedings. If you're breast-feeding, your baby's doctor may suggest that you avoid cow's milk or certain other foods. If you feed your baby formula, sometimes switching brands helps.

For babies who have severe infant acid reflux or GERD, more aggressive treatment may be recommended.

1. Medication. If your baby is uncomfortable, the doctor may prescribe infant doses of medications commonly used to treat heartburn in adults. The two major pharmacotherapies are H2-blockers and proton pump inhibitors (PPIs), both of which are effective in decreasing acid secretion and have been used safely in children. H2-blockers include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) and nizatidine (Axid). PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix) or rabeprazole (Aciphex). Another group of drugs, prokinetics, can be prescribed to increase motility. These are usually given with medications that inhibit the acid. Examples are metaclopramide (Reglan) and cisapride (Propulsid). Antacids may be tried first in children with mild symptoms.
2. Alternative feeding methods. If your baby isn't growing well, higher calorie feedings or a feeding tube may be recommended.
3. Surgery. Rarely, the muscle that relaxes to let food into the stomach (the lower esophageal sphincter) must be surgically tightened so that less acid is likely to flow back into the esophagus. The procedure, known as fundoplication, is usually reserved for the few babies who have reflux severe enough to interfere with breathing or prevent growth. Although surgery can reduce GERD symptoms, the complications are potentially serious — including persistent gagging during feedings.
   

Resource:
- By Mayo Clinic staff
- Medicinenet.