Thanksgiving is only a couple of days away: turkey, casseroles, mashed potatoes and more! It’s also GERD Awareness Week to raise awareness of the complications of gastroesophageal reflex and to know the symptoms to look out for as you gather around the table. LaQuatre Rhodes, D.O, Gastroenterologist at Cook Children's Specialty Clinics in Prosper, breaks down what parents need to know or look out for when it comes to this common disorder.

What is GERD?

Gastroesophageal reflux is the passage of gastric/food contents into the esophagus with or without regurgitation or vomiting. It is defined as gastroesophageal reflux disease when reflux leads to troublesome symptoms or complications. A muscular valve is at the end of the esophagus to help prevent backflow of food/gastric contents, but when it doesn’t close well, it results in irritation of the esophagus and reflux symptoms. Symptoms of reflux vary by age.

What are the symptoms?

Infant/Toddler reflux symptoms:

•  Crying
• Fussiness
• Back arching
• Regurgitation
• Vomiting
• Dry cough
• Feeding difficulties
• Poor weight gain
• Breathing difficulties (wheezing, pneumonia, stridor, apnea)
• Recurrent ear infections

Older children reflux symptoms:

• Heartburn
• Abdominal pain
• Regurgitation
• Vomiting
• Acidic or sour taste
• Sore throat
•  Hoarseness
• Dry cough
• Difficulty swallowing
• Choking

Gastroesophageal reflux may be seen more in children with certain medical conditions including neurologic impairments, prematurity, and pulmonary problems (ex. cystic fibrosis, asthma, laryngomalacia).

What are the “red flag” symptoms?

Other conditions which can mimic reflux require further evaluation especially in the setting of red flag symptoms. Some of those conditions include infections, pyloric stenosis, brain tumor, meningitis, hydrocephalus, increased intracranial pressure, metabolic disorders, inflammatory bowel disease, obstruction, anatomical abnormalities, and decreased gut motility.

Red Flag Symptoms suggesting a disorder other than gastroesophageal reflux:

• Weight loss
• Lethargy
• Fever
• Irritable, severe crying, or inconsolable
• Seizures
• Bulging fontanelles in infants
• Increased head circumference in infants
• Small head circumference in infants
• Recurrent forceful or projectile vomiting
• Vomiting blood
• Vomiting bile
• Vomiting overnight
• Rectal bleeding
• Bloody stools
• Abdominal distention
• Breathing problems (difficulty breathing, stops breathing, turns blue, wheezing, frequent choking, recurrent pneumonia episodes)

How do you treat GERD?

Reflux can be concerning as a parent, but in the absence of “red flag symptoms” and if the child is gaining weight well, there's no need to worry. Symptoms should improve with time, lifestyle modifications, diet modifications, and/or acid suppression. If at any point your child develops worrisome or alarming symptoms please have evaluated by primary care physician, gastroenterologist if established care, or local emergency department.

If there are no red flag symptoms present, initial management of GERD is conservative:

Lifestyle modifications

• Staying upright at least 30 minutes after meals
• Burping infants during feeds
• Avoid tobacco smoke exposure
• Avoid tight diapers or elastic waistbands
• Weight loss if child overweight or obese
• Elevate head of bed 30 degrees

Diet modifications

• Thickening feeds with cereal or thickeners
• Formula change to hydrolyzed or amino acid based formula
• Avoid overfeeding
• More frequent smaller meals
• Avoid eating at least 2-3 hours before bedtime in older children
• Avoid large meals before exercise or increased activity
• Avoid acidic foods (ex. pickles, red sauces, citrus) spicy foods, carbonated drinks (ex. sodas, seltzer beverages), high fat foods, chocolate, and caffeine

Trial acid suppression for 4-8 weeks which may be extended longer based on clinical response and/or physician assessment.

• Proton Pump Inhibitors (ex. omeprazole, pantoprazole, lansoprazole, esomeprazole)
• Anti-histamine (ex. Famotadine, Cimetidine, Ranitidine, Nizatidine)

If alarming or worsening symptoms despite initial management, physician may proceed to gastroenterology referral and/or further evaluation including:

• Esophagogastroduodenoscopy (EGD)
• pH probe
• Abdominal ultrasound
• Barium studies (ex.  Upper GI series, esophagram, swallow study)
• Motility studies
• Severe reflux resulting in complications must consider surgery referral for Nissen fundoplication if not responding to medications and no other disorder cause of severe vomiting.

“Is it GERD?”

Or, as I frequently see it spelled, “Is it gurd?”

Every baby spits up ... there is definitely a spectrum from the babies that spit up once in their whole life all the way to the babies that spit up every single time they eat.

It can be hard to understand what a doctor or patient means when they use the terms spitting up, reflux or GERD because people use them in different ways.

I try to keep it simple and only use the terms reflux and GERD when I think that the spitting up might be causing a problem:

So, if every baby spits up, how do I decide what is normal? When is it spitting up vs. reflux vs. gastro-esophageal reflux disease (GERD)?

The answer to this is tricky but I’m hopeful that I can help you decide.

Studies have been done where they watch how many times a baby regurgitates milk and stomach acid by placing a probe down his or her esophagus (this is reflux). The answer ... on average, 30 times per day. Most, but not all, of these episodes were associated with milk at least making it into the mouth.

Why does this happen?

There's a muscle that sits on top of the stomach that is meant to properly relax and squeeze to allow milk into, but not out of the stomach. Unfortunately, in most young infants, this muscle is both weak and dumb. It's not strong enough to override the pressure of the stomach pressing on it and it frequently relaxes when it is supposed to be contracting, letting stomach acid run back up into the esophagus.

So, reflux is, for the most part, a mechanical problem that's based on the pressure of the stomach and the strength of the muscle that sits on top of it. That is why, I think, that the most common cause of spitting up is overfeeding.

Often a family of a 2 month old will come in for their checkup and have questions about why their baby (who eats 6 ounces per feed) is spitting up. The issue is that the stomach is only a few ounces big at this age and everything else that you try to squeeze into it just raises the pressure and causes the baby to spit up.

So, if it’s so common what makes it abnormal?

There’s really only 2 reasons why I will treat babies for reflux: poor weight gain or associated pain/fussiness. So, the most common thing I will do to treat reflux is check the baby’s weight and if weight gain is good, reassure the family that they have a “happy spitter.”

I also see babies who are consistently fussy with their spitting up or that have fussiness predictably during feeds or in the 30 minutes following each feed with or without spitting up. Some people have termed this “silent reflux,” but I don’t really like that term because the screaming associated with it is anything but “silent.” Babies can also arch their backs which is sometimes confused for seizures but is, in fact, reflux.

What do we do about it?

Many babies can be helped by just cutting back on the amount of milk they are ingesting ... most babies need about 2-3 ounces per feed at 2 months and this goes up about 1 ounce per month of age after (6 ounces at 6 months).

I still commonly discuss with families that they can slightly elevate the head of the crib although it looks like review of the literature questions whether this is actually helpful,  so I may have to rethink this.

Studies have shown varying percentages about babies with reflux who have an allergy or sensitivity to cow’s milk protein (some studies show it as high as 40 percent). Thus it might be reasonable to try a short trial of a hypo-allergenic formula (Neutramigen or Alimentum). Many babies who are sensitive to cow’s milk will also be sensitive to soy. Many publications don't recommend a trial of soy, but because of the expense of the hypo-allergenic formulas I will sometimes have families do a trial of soy formula first.

Finally, in those babies who aren't gaining weight well or who are fussy with their GERD or following feeds, a short trial of an antacid medicine can be attempted to help with symptoms. There are two types of medicines that can be used: H2-blockers (ex Zantac) and PPI (ex Prevacid). I try to remind families that neither of these medicines are meant to help keep milk in the stomach. They only change the acidity of the contents that are coming up. So, it's likely that the baby will continue to spit.

Summary

1. Most babies with reflux have a laundry problem and not a medical problem (think happy spitter).

2. Limiting overfeeding is the major non-medical treatment for spit up.

3. Medicines for reflux can be used in babies with poor weight gain or fussiness but should be used sparingly and with appropriate expectations.