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.

Previously, I covered the bascis about infant reflux. If you missed that article, please click here. 

I have a few, more specific topics I promised I would go over in my previous post. 

Should We Try a Medication for My Baby’s Reflux?

This is a tough one for me to talk to parents about, because as a doctor, I really want to “fix” things for you.

I used to prescribe medications more frequently than I do now. This is because I have read recent large studies that make me worry about the future effects of these medications (see links below):

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528619/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137535/
• https://jamanetwork.com/journals/jamapediatrics/article-abstract/2676167

If we change the pH of the gut, what are we doing to the trillions of bacteria, the natural gut biome that lives inside?

Part of the job of this gut biome is to help our body learn “friend from foe,” and a large study recently found that children under 6 months who were put on medications like Prevacid, Nexium, and Zantac (there are many meds available) or any antibiotic were found to be more prone to food allergies and asthma later in life.

Is it worth the risk? In some cases, yes. Some babies are in pain daily. Some babies even lose weight because they are fighting meals to avoid the pain. If a baby is not in daily discomfort, however, I’ll often try to talk parents into trying other methods before medicating. And we talk often about weaning it off or stopping it after a few weeks.

What Is Cow Milk Protein Intolerance and How Does It Relate to Reflux?

Cow milk protein intolerance (CMPI, also known as cow milk protein allergy) happens when a child’s immune system reacts abnormally to proteins found in cow’s milk (either in formula or mom’s diet) and soy. It is NOT the same as lactose intolerance, and it leads to injury/inflammation of the stomach and intestines.

Symptoms of CMPI usually involve the GI tract, like vomiting, abdominal pain, blood in the stool, mucousy stool and diarrhea. Prolonged issues in infants could lead to wheezing, irritability and poor growth / failure to thrive and eczema. Frankly, these are sometimes my fussiest little patients, and they often cry more than most babies do.

CMPI and reflux come hand-in-hand in a lot of kids I see. I often find that eliminating dairy and soy in a mom’s diet will help the reflux as well. Sometimes, kids need to be on special hypoallergenic or amino acid formulas.

Do I Elevate My Baby At Night So They Won’t Spit Up?

I remember many a morning looking into my son’s bassinet and seeing him sleeping peacefully in a puddle of old vomit. The guilt would overwhelm me! And it happened a lot. It was hard not to want to do something different.

But no, we don’t want you to elevate your baby when they sleep. We want you to keep them flat on their backs because this is safest.

While it may seem like elevating the head off the crib makes sense, according to the American Academy of Pediatrics, “There is no evidence that healthy babies placed on their backs are more likely to have serious or fatal choking episodes than those placed on their stomachs. But there is strong evidence that babies placed on their stomachs are at higher risk for sudden infant death syndrome (SIDS).”

There is not a need to a wedge under the mattress, or elevate the head of the bed with blankets or pillows. Studies have actually shown this doesn’t actually help reflux symptoms, anyway.

I’m hopeful that the take-home point in this two part article about reflux is clear: reflux, to some extent, is a part of every baby’s life in the first year. And in MOST kids, it completely resolves by age 12 months. Talk with your pediatrician about how you can help your baby if some of the options we’ve talked about here don’t seem to help!

Hope this helps. Remember, if you still have questions about this topic to read my first article. 

Stay safe,

Dr. Diane

Here, I’m going to address infant reflux only – for babies under 12 months of age. Kids older than this can certainly experience reflux, but I’d like to keep this specific to this age group.

I’ve literally printed your questions out, and will use them as my guide!

WHAT IS REFLUX?

Reflux is when the contents of the stomach (milk, food, stomach juices) goes up into the esophagus. Sometimes, it just stays in the esophagus and goes back down. Sometimes it comes all the way up and out the mouth (or nose).

HOW MANY BABIES HAVE REFLUX?

The books say “more than half.”

I say: All of them. All babies. 100%. I watch all babies reflux in my office daily. It’s often subtle. A little dribble of milk out the side of the mouth, hiccups, gulping. Studies show that healthy infants experience reflux “30 or more times daily.” It tends to get started around week 3-4 of life, peaks around 2-4 months, and in most kids resolves by 12-18 months.

WHAT CAUSES REFLUX?

The valve where the esophagus meets the stomach is pretty loose in infants. So stomach contents can easily come up and down. Combine that with the fact that they are laying down a lot, drinking nothing but fluids, sometimes swallow excess air during nursing or bottle-taking, and have lower muscle tone in their bodies and it’s a perfect recipe for spit-up.

WHAT ARE SIGNS OF REFLUX?

Well, spitting up is the most obvious sign. Some healthy normal kids spit up once a day. Some spit up numerous times after each meal (I had one of each – “normal” babies can be very different and there is a wide range of barfing!).

Sometimes it happens right after eating, and sometimes hours later. Sometimes it’s just a dribble out the side of the mouth, and sometimes you’re covered in puke. Sometimes it’s clear. Sometimes it’s chunky. Sometimes it’s straight up milk. Sometimes it’s acidic. Sometimes it’s not.

Other signs of reflux:

• Hiccups
• An acidic smell here and there
• Coughing, especially when laying down
• Congestion/snoring, especially after laying down
• Arching the back
• Fussing during feeds
• Gagging out of nowhere
• Gulping sounds

WHAT SHOULD I DO ABOUT MY BABY’S REFLUX?

Well, that depends on the kiddo. For the vast majority of babies, you don’t have to do anything different. It’s a laundry problem more than a medical problem! Most babies are what we call “happy spitters” – lots of spitting up, lots of mess – but growing well, happy, and thriving. Thankfully, most kids are in this category and you may just need to try:

• Frequent burping
• Being held upright for 15-30 minutes after feeds.
• A change of formula
• A change of bottle type or nipple flow
• Thickening of formula or breastmilk if other options don’t help (ask your pediatrician before you do this and we will walk you through it)

IT ALWAYS SEEMS LIKE SO MUCH MILK COMES UP! HOW IS MY BABY STILL GROWING?

Most of the time, it’s less milk than you think. I always tell parents, “A stain on your shirt the size of a dinner plate is one ounce.” That’s pretty impressive, right? Talk to your pediatrician about whether s/he believes your child is gaining weight adequately at checkups to assure your baby is keeping enough in.

WHEN SHOULD I WORRY?

I worry if an infant is not gaining weight. I worry if the reflux causes consistent and constant refusal to feed, or disruption of feeds. I worry if an infant seems to be in pain MOST days (all babies have a bad day here and there). I also worry if:

• The vomit looks dark green
• The child’s vomiting is getting more consistently large and forceful
• The baby has fever
• The baby develops pneumonia (VERY rarely reflux can cause lung issues like wheezing and pneumonias)
• There's blood in the stools, or very stringy mucus-y stools.
• The child cries most of the day
• The baby isn’t urinating at least every 6-8 hours

If any of these things are going on, please contact your pediatrician!

Sometimes, it takes more than just those simple methods above to help your child with reflux. It may take a medication or a change in a breastfeeding mom’s diet to improve symptoms. We also need to talk about safe sleep for a child with reflux.

All of this is addressed in Part 2!

It can be really hard to determine the cause of a cough just because of the sound. But here are some different types of coughs and the clues that might help you or the doctor know what is going on.

1. Short time period: Most coughs that last a few days are due to infection, most commonly viruses.
2. Long time period: Coughs that last longer bring up other possibilities, including sinus infections, allergies, asthma, or reflux.
3. Wet cough: Wet coughs with congestion can caused by a variety of reasons but are more commonly infections (most of which are viruses) or allergies. The presence of fever points towards infection while itchy or watery eyes suggest allergies.
4. Tight cough: A tight sounding cough can often be a sign of asthma. If your child has a history of wheezing or the cough is associated with exercise or weather change, think asthma.
5. Cough after eating: Yes, reflux can be a cause of chronic cough and it’s actually more common than you might think. Pay attention the timing and if certain foods might be triggers.
6. Barky cough: Think like a dog or seal. Croup is the most common cause of this type of cough. Usually the child will have runny nose and they can have fever as well. Steam is a good way to treat this cough so use a humidifier or the bathroom with the shower going. If severe or difficulty breathing, the doctor can provide steroids and other treatments.
7. Whooping cough: This cough is severe and comes in terrible spells that end in a whooping sound as the child breathes in. It requires a doctor’s visit and treatment so get it checked out soon.
8. Annoying, chronic throat clearing cough: This can be caused by many reasons but an important one to think about is tics. Children can have vocal tics that sound like throat clearing or even a mild cough.

There are lots of reasons why a child might be coughing but hopefully some of these tips will help you determine what you need to do next.

“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.