For some babies, spitting up too much can be a sign of gastroesophageal reflux
disease (GERD). Here, Children's Hospital Boston gastroenterologist Samuel Nurko, MD, MPH, discusses medicating infants for GERD and what pediatricians should know about other possible treatments.
What's the difference between GER and GERD?
Gastroesophageal reflux (GER) is the backward flow of stomach contents up into the esophagus or the mouth. It happens to everyone. In babies, a small amount of GER is normal and almost
always goes away by the time a child is
18 months old. Gastroesophageal reflux
disease (GERD) occurs when
complications from GER arise, such
as failure to gain weight, bleeding,
respiratory problems or esophagitis.
How is GERD diagnosed?
GERD can usually be diagnosed with the presence of vomiting, pain associated with regurgitation, arching back and feeding refusal. However, in very young infants, it may be difficult to differentiate GERD from normal GER or colic because some of the symptoms are similar—constant
or sudden crying, spitting up or vomiting, hiccups, irritability or pain and refusal
to eat. Infants with GERD can also
have atypical symptoms, including
At times, it may be necessary to
perform tests to confirm the diagnosis of GERD, including endoscopic studies or measuring the amount of reflux with pH-probes or impedance technology. A trial of medications may also be a useful diagnostic tool.
For an infant with typical reflux
symptoms, a trial of antacids or H2-
blockers may provide clues to help
establish a diagnosis. In children less than 3 months, changing formulas may also help when allergy is suspected. It's important to note that if a formula change is considered, the new formula must have different protein content. If the formula change works, it may be possible to
conclude that the crying or spitting up were the result of an allergy. GERD is
suspected when these measures don't resolve the symptoms, or if the child has other associated symptoms, typically lack of weight gain, bleeding or respiratory problems. In those patients, diagnostic procedures or more aggressive therapies may be needed.
What are nonmedical ways to treat it?
Because many infants have an easier time keeping down small meals, it's a good idea to try smaller, more frequent feedings. Thickening the formula also helps. Adding rice cereal makes the liquid less likely to slosh up out of the stomach into the
esophagus. Studies show that even though the total amount of reflux may not change, the symptoms improve after the formulas are thickened. Keeping the baby upright before and after feedings will also decrease the amount of reflux. Pharmacotherapy may be prescribed when conservative
therapy has not resolved the symptoms
and when the diagnosis of GERD is
What types of medication are used?
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.
How are medications used?
Once the diagnosis of GERD has been established there are two main approaches to treatment. Starting patients with a PPI then switching to an H2-blocker
(step-down therapy) is usually more cost effective. A step-up approach (starting with an H2-blocker then going to a PPI if there is no response) is recommended when the symptoms are less severe,
particularly in infants. Due to concerns over side effects, prokinetic drugs should only be used in severe cases under the supervision of a specialist.
Are there risks associated with them?
H2-blockers have been used extensively in infants and are considered very safe, but may produce side effects, including
diarrhea, constipation and abdominal pain. Rarely, effects on blood counts and liver inflammation may be seen. PPIs are newer, but in recent years have been used increasingly in children and infants. They appear to be safe. In fact, Children's has participated in studies that have
established the efficacy and safety of PPIs in children. In patients with severe GERD, treatment with PPI drugs is extremely effective. However, long-term use may produce side effects that should be
monitored by a gastroenterologist. These may include liver problems and
hyperplastic polyps in the stomach. Even though their use seems to be safe, they should be used only when a diagnosis of severe GERD has been established.
When should a child be referred?
In general, children with severe GERD or associated complications should be seen by a specialist. Children in which GERD is suspected and have not responded to a PPI after several weeks should also be referred. Referral is also recommended if a child's symptoms return after effective use and weaning from a PPI.
What services does Children's provide?
We're one of the largest pediatric GI
programs in the world and have
extensive experience diagnosing and treating GERD. We offer state-of-the-art clinical care, testing and treatment. Our specialists also look to exclude possible anatomic and metabolic problems in
addition to diagnosing complications
associated with GERD.
We are also looking at the role that non-acid reflux may play in the disease. Until recently, standard reflux tests that measure acid level in the esophagus haven't been able to diagnose non-acid reflux. A new technique called pH-
impedance was recently introduced as a clinical tool and allows us to determine if a child has non-acid reflux. Children's is one of only a few pediatric centers that has this technology.