Patient education: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)

GASTROESOPHAGEAL REFLUX OVERVIEW — Gastroesophageal reflux (GER) is the medical term for spitting up. It occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Because the stomach naturally produces acid, reflux is sometimes called acid reflux; other terms include regurgitation and spilling.

Gastroesophageal reflux is a normal process that occurs in healthy infants, children, and adults. Most infants have brief episodes, during which they spit up milk or formula through the mouth or nose. Uncomplicated reflux does not usually bother the infant, has a low risk of long-term complications, and does not usually require treatment.

In contrast, in a few infants, the gastroesophageal reflux causes complications, such as slow weight gain, recurrent pneumonia, or spitting up blood. In this case, the infant is considered to have gastroesophageal reflux disease, or "GERD." Infants with these signs and symptoms usually require further testing and may require treatment. Infants who have colic or who are unusually irritable should have a basic evaluation by a health care provider, but, in most cases, they do not have GERD. Although GERD typically improves as the infant grows, the symptoms occasionally continue into childhood.

This topic review discusses the symptoms, causes, diagnosis, and treatment of infants with gastroesophageal reflux and gastroesophageal reflux disease. Gastroesophageal reflux disease in older children and adolescents is discussed separately. (See "Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)".)

WHAT IS GASTROESOPHAGEAL REFLUX? — When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure (figure 1). The esophagus is made of lining and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.

At the lower end of the esophagus where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter. When food enters the top of the esophagus, the lower esophageal sphincter relaxes to allow food to enter the stomach and then closes to prevent food and acid from flowing backwards into the esophagus.

Occasionally, the ring of muscle does not close completely or relaxes at the wrong time, allowing the liquids in the stomach to wash back into the esophagus. This occurs in all individuals but is common in infants. Most of these episodes go unnoticed because the reflux stays in the lower esophagus. Infants have the most episodes of daily reflux between three and six months of age. When they start to sit up (around six months of age), the frequency of reflux often decreases.

As the infant grows, the esophagus becomes longer and the angle between the stomach and esophagus changes. These changes naturally decrease the frequency of reflux episodes. Spitting up disappears in more than 50 percent of infants by 10 months of age, 80 percent by 18 months, and 98 percent by two years of age [1]. Infants who spit up frequently for more than three months are somewhat more likely to have gastrointestinal symptoms later in childhood [2].

Uncomplicated gastroesophageal reflux — Gastroesophageal reflux is common in infants during the first few months of life. Approximately 50 percent of infants younger than three months of age have at least one episode of spitting up per day.

Infants who spit up frequently but who feed well, gain weight normally, and are not unusually irritable are usually considered to have "uncomplicated" reflux. These infants are sometimes referred to as "happy spitters." In this group, spitting up is a natural consequence of the infant's anatomy. You can help reduce the frequency and amount of spitting up by burping the infants frequently during feeding and trying to keep them calm and upright for 20 to 30 minutes after feeding. (See 'Positioning' below.)

Testing is not usually necessary for infants with uncomplicated reflux. If the symptoms become worse, appear for the first time after six months of age, or do not improve by the time they are 18 to 24 months of age, they should be evaluated; a consult with a pediatric gastroenterologist may be recommended.

Gastroesophageal reflux disease — Reflux becomes gastroesophageal reflux disease (GERD) when acid in the reflux causes one or more problems such as asthma, failure to grow, or irritation/injury to the esophagus. This only occurs in a small percentage of infants who spit up frequently. The amount of reflux required to cause injury varies. In general, damage to the esophagus is more likely to occur when acid refluxes frequently, there is a large amount of reflux, or the esophagus is unable to clear away the acid quickly. GERD occasionally develops in infants who are otherwise completely healthy, but it is more likely in those with underlying medical conditions such as Down syndrome or neurologic problems. The treatments for GERD are designed to prevent one or more of these complications from occurring. (See "Gastroesophageal reflux in infants".)

Some of the signs or symptoms that may indicate GERD include refusing to eat, frequently crying or arching the neck and back as if in pain, choking while spitting up, forceful or projectile vomiting, spitting up blood, frequent coughing, or not gaining weight. These behaviors are not normal, and further testing is recommended to determine if GERD (or another condition) is the cause. (See "Patient education: Poor weight gain in infants and children (Beyond the Basics)".)

It is often difficult to know if an infant is in pain. In general, we are not concerned when a crying infant can be consoled by comforting, distraction, or attending to the child's needs (hunger, sleep, or a diaper change); parents who are concerned about their infant's crying should discuss the symptoms and possible management strategies with a health care provider. (See "Patient education: Colic (excessive crying) in infants (Beyond the Basics)".)

Irritability and reflux — Many parents worry that reflux is the cause of their infant's irritability or difficulty sleeping. However, studies have shown that reflux does not usually cause pain and that medications to reduce stomach acid do not improve irritability [3,4].

Irritability and difficulty sleeping are problems that can be related to a number of conditions. Infants who are irritable and not easily consoled or who regurgitate frequently should be evaluated by a health care provider. If there are no other problems, a brief (eg, two-week) trial of a milk-free diet and thickened feeds may be recommended. Extreme irritability (when the infant cannot be comforted) should be evaluated by the infant's health care provider. If the problem persists, neurologic causes of irritability should be considered. (See 'Reflux treatment' below.)

REFLUX DIAGNOSIS — If the health care provider suspects that the infant might have gastroesophageal reflux disease, the first step in the evaluation is a complete medical history and physical examination. The need for further testing depends upon what is found and may include one or more of the following:

●Laboratory testing (blood and/or urine tests)

●An X-ray study to evaluate how well the infant swallows and to evaluate the anatomy of the stomach

●A procedure called upper endoscopy to view the lining of the esophagus

REFLUX TREATMENT — Infants with uncomplicated reflux ("happy spitters") do not require treatment. For those who seem bothered by their symptoms, the first step is to try these lifestyle changes:

●Avoid exposure to tobacco smoke

●Avoid overfeeding

●Keep the infant in an upright position after feeding

●Trials of a cow's milk-free diet and/or thickened feeds

For many infants, the reflux will improve with these lifestyle and dietary measures alone. In one study, over 80 percent of infants partially or completely improved with thickened feeds, avoidance of tobacco smoke, and a trial of a cow's milk-free diet.

Positioning — Infants tend to have fewer episodes of acid reflux if they can be kept upright and calm for 20 to 30 minutes after a feed (ie, carried on an adult's shoulder but not placed in an infant seat). Parents should avoid overfeeding and allow the infant to stop feeding as soon as they seem satisfied or seem to lose interest.

All infants should be positioned on their back to sleep, and this includes infants with reflux. Infants should never be placed on their stomach or side to sleep, because this increases the risk of sudden infant death syndrome (SIDS). Raising the head of the crib occasionally helps a few infants with reflux. Placing the infant to sleep in a car seat is not recommended, except when using the seat for car travel. (See "Patient education: Sudden infant death syndrome (SIDS) (Beyond the Basics)".)

Milk-free diet — In up to 40 percent of infants with problematic gastroesophageal reflux who seem otherwise healthy, the symptoms are triggered by cow's milk [5-7]. The most common cause is cow's milk protein intolerance (CMPI; sometimes called food protein-induced allergic proctocolitis or cow's milk allergy, although this is not a true allergy) or, more rarely, eosinophilic esophagitis. The symptoms and severity of CMPI vary but typically include some combination of vomiting and/or loose or bloody stools and, sometimes, eczema. Most infants are diagnosed with CMPI based upon their symptoms and how they respond to changes in diet; laboratory testing is not usually necessary.

The majority of infants with CMPI are sensitive only to cow's milk protein, although some are also sensitive to soy protein and a few may be sensitive to other proteins.

A milk-free diet for infants involves:

●Breastfed infants – If the infant is breastfed, the mother needs to eliminate all cow's milk and soy products from her own diet for a two- or three-week trial.

•If the symptoms do not improve, the mother may resume her normal diet or discuss the possibility of restricting other foods with her health care provider. In rare cases, the mother may need to eliminate other proteins, although this should only be done with the advice of a health care provider.

•If the infant's reflux symptoms improve during the trial, the mother should continue the restricted diet for another month or two, then she can try reintroducing cow's milk to her diet every few months to see if the infant has outgrown the reflux problem. Most infants outgrow a cow's milk intolerance by one year of age.

●Formula-fed infants – If the infant is formula fed, they can be given a hypoallergenic formula that does not contain intact cow's milk or soy proteins, because these are the most likely culprits (table 1). This is usually continued for one to two weeks to determine if the infant's reflux improves. If this does not work, trying a corn-free formula (eg, the ready-to-feed version of Similac Alimentum) may be beneficial because a few infants are sensitive to corn protein. If symptoms do not improve, the original formula may be restarted.

Almost all infants with CMPI outgrow the problem by one year of age.

Thickened feeds — Thickening formula or expressed breast milk may help to reduce the frequency of acid reflux and is a reasonable approach to reducing symptoms in a healthy infant who is gaining weight normally. For infants under three months of age or those with allergies, we suggest consulting with the health care provider before thickening feeds or changing formulas. Also, thickened feeds should not be routinely used for infants who were born preterm. For the rare infant with an inflamed esophagus (esophagitis) due to acid reflux, thickened feeds are not recommended as the sole treatment.

In the United States, infant cereal is usually used as the thickening agent; in other countries, rice starch, carob flour, or locust bean gum may be used. Oat infant cereal is a good choice for most infants. Be sure to check the ingredients in the infant cereal as some brands contain soy protein to which the infant may be intolerant. To thicken the feed, 1 ounce (30 mL) of formula or expressed breast milk is usually combined with up to 1 tablespoon (15 mL) of infant cereal. Nipples that allow for adjusted flow are available. For formula-fed infants, premixed "antireflux" or "spit-up" formulas also are available, which contain rice starch to thicken the formula.

Women who breastfeed are encouraged to continue doing so; an infant should not be switched to formula for the purpose of thickening the feeds. In fact, breastfeeding may reduce the risk of reflux in infants. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)

Medicines — If an infant's symptoms do not improve after a trial of the lifestyle and dietary treatments discussed above, the health care provider may recommend a trial of an acid-suppressing medicine.

Before deciding whether to use an acid-suppressing medicine, it is important to know:

●Infants with uncomplicated gastroesophageal reflux ("happy spitters") do not benefit from medicines that reduce stomach acid or speed emptying of the stomach.

●Even when the reflux seems to cause pain, acidic reflux is no more painful than non-acid reflux, suggesting that acid-suppressing medications probably will not help [8].

●Infants with suspected gastroesophageal reflux disease might benefit from an acid-suppressing medicine. Omeprazole (Prilosec) and lansoprazole (Prevacid) have been best studied in infants. If the symptoms do not improve significantly within a few weeks, the medicine usually should be stopped.

●Antacids (eg, Maalox) and other medicines (eg, famotidine [Pepcid]) are not as effective as omeprazole and lansoprazole in blocking acid but may help to control symptoms. These medicines can be used occasionally but not frequently, because they can cause side effects in infants.

All of these medicines, even antacids, can cause side effects and are not recommended for infants unless you talk to your child's health care provider.

OUTCOMES FOR CHILDREN WITH REFLUX — For most infants with reflux, symptoms go away by one year of age and do not recur later in life. Infants with symptoms that last for more than three months are more likely to have heartburn later in childhood, but the relevance of these symptoms is not known [2]. Infants with acid reflux should be monitored carefully for both decreased and increased weight gain.

WHEN TO SEEK HELP — Infants with acid reflux who also have the following signs or symptoms should be evaluated by a health care provider:

●Recurrent vomiting or vomiting blood

●Severe diarrhea, bloody stools

●Pneumonia

●Slow weight gain

●Crying for longer than two hours

●Refusing to eat or drink anything for a prolonged period

●Forceful vomiting after each feed with continued hunger

●Behavior changes, including lethargy or decreased responsiveness

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Spitting up and gastroesophageal reflux disease in babies (The Basics)
Patient education: Acid reflux and gastroesophageal reflux disease in children and adolescents (The Basics)
Patient education: Acid reflux and gastroesophageal reflux disease in adults (The Basics)
Patient education: Esophagitis (The Basics)
Patient education: Colic (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)
Patient education: Poor weight gain in infants and children (Beyond the Basics)
Patient education: Colic (excessive crying) in infants (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Sudden infant death syndrome (SIDS) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents
Gastroesophageal reflux in infants
Gastroesophageal reflux in premature infants
Management of gastroesophageal reflux disease in children and adolescents
Food protein-induced allergic proctocolitis of infancy

The following organizations also provide reliable health information:

●National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-infants)

●GI Kids (Children's Digestive Health Information for Kids and Parents)

(www.gikids.org), available in English and Spanish

●La Leche League International

(www.llli.org/breastfeeding-info/)

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

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