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Gastro-esophageal Reflux (GERD) in Infants

What is GERD?

Gastro-esophageal reflux describes the process where stomach contents flow backward up into the esophagus. The majority of infants have some degree of reflux, or spitting up. For most, it doesn't bother them, and they eventually outgrow the spitting up. Gastro-esophageal reflux disease refers to symptoms or complications that occur when stomach contents reflux into the esophagus or mouth.

How do I know if my infant has GERD vs. benign reflux (spitting up)?

Babies with benign reflux are not bothered by their spitting up. They eat vigorously and comfortably, and gain weight appropriately. These babies sometimes spit up A LOT of milk, but they just don't seem bothered by it. It's a big mess and a nuisance, but of no harm to these "happy spitters." On the other hand, babies with GERD often seem uncomfortable with feeds. They often arch their backs during feeds, or pull away from the bottle or breast shortly after beginning a feed. A clue is if your infant is getting older, but taking less formula or breast milk. Some babies with GERD do not actually spit up; some have symptoms just from the food washing back into their esophagus. Some parents report gagging or swallowing sounds even when their infant isn't feeding, or can actually hear the formula or breast milk coming back into the esophagus. These infants often are not gaining weight well.

What symptoms should alert me that something more serious than GERD is occurring?

Symptoms that are not compatible with a diagnosis of GERD that warrant additional medical evaluation include vomiting that is green (bilious), bloody, or consistently forceful/projectile. Blood in the stool or a distended abdomen that does not go down in between feeds is also a cause for concern.

GERD vs. Colic

The million dollar question: why does my baby appear so uncomfortable, and why is he crying so much? If your baby has a certain time of the day when he is fussy, or if his fussiness is seemingly unrelated to feeds, colic is more likely. If the fussiness seems to occur during or shortly after feedings, reflux is more likely. Colic usually begins around two weeks, peaks around 6-8 weeks, and is significantly better by four months. Infant GERD can begin anytime after birth, and can persist throughout the first year. GERD can worsen between 4 and 6 months, a time when colic has generally subsided. Since both of these issues are so common, they often exist together.

What can I do if my infant has GERD?

  • Positioning: Contrary to popular opinion, placing an infant on their back in a semi-reclined position (such as by placing in an infant carrier or elevating the head of the bed) actually worsens reflux symptoms. Alternatively, it is helpful to keep your infant upright or semi-reclined on his stomach after feeds. A good position is to have your infant on your chest in a semi-reclined or upright position after a feed. Babies should always be placed flat on their backs on a firm mattress when unobserved during sleep to decrease the chance of SIDS. If you are going to place an infant on his stomach for sleep, make sure he is on a firm mattress and you are observing him closely. This may be helpful for napping young infants with significant GERD.
  • Over Feeding: Make sure you are not over feeding your infant. If she is gaining weight rapidly, but spitting up a lot, try decreasing the volume of feeds. Also, infants with reflux tend to do better with smaller, more frequent meals. Pace your baby during feedings, and burp her often.
  • Thickening formula: Thickened formula often "stays down" better in infants with GERD. To thicken formula, add 1 teaspoon of rice cereal per ounce of formula or breast milk. We prefer Beechnut rice cereal because it is pure rice. You can add up to 1 tablespoon per ounce of cereal; experiment to see what works best. You may need to go up to a larger nipple size in order for the thickened formula to flow. Alternatively, you can "cross cut" a nipple by cutting a small "x" in the nipple if you are adding larger amounts of rice cereal. There are also pre-thickened formulas available, such as Enfamil AR (anti-reflux). This formula has rice starch already added, and thickens in the stomach in response to acid. Therefore, Enfamil AR doesn't work well if your baby is on acid suppressor therapy. The advantage of Enfamil AR over thickening with rice cereal is that the balance of nutrients is maintained, whereas when adding rice yourself you are adding extra carbohydrate calories. The disadvantage with Enfamil AR is that it can't be used with suppressor therapy and it is more expensive.
  • Medications: If the above conservative measures are inadequate for your baby, call our office to discuss medications. The first medication we usually try for infants with GERD is an acid-blocker, such as Axid or Zantac. These medications are dosed two or three times per day. They should be given 15-20 minutes prior to feeds. This is important because we want the medication in his system BEFORE the food hits the stomach, turning on acid production.

Sometimes, we will recommend a trial of Maalox for your baby before prescribing the above medications. You can give your infant 1 tsp of Maalox 3 times per day for 2-3 days. If it seems to help, there is a good chance that your infant has GERD. Maalox is not a long term solution. Using Maalox chronically in infants can lead to electrolyte imbalances, so don't use it for more than 72 hours without discussing this issue with our office.

Some infants with reflux continue to have problems even after Axid or Zantac is started. If your infant continues to have problems, we may prescribe a stronger acid-suppressor, such as Prevacid, which is given 1-2 times per day, also 15-20 minutes prior to a feeding. You may also have heard of Reglan. Reglan is a medication which helps to move food through the GI tract. It is unclear if this medication actually helps infant GERD and it can have significant side effects. For these reasons, we seldom prescribe Reglan.

When should I stop medication for GERD?

The only way to know if your infant still needs his medication is to stop the medication and observe him. If you think your baby no longer needs the medication, try decreasing the frequency and see if symptoms increase or return. If symptoms don't increase or return, it is safe to stop the medication. Do you ever miss giving doses of medication? Does your baby seem bothered by missed doses? If he does, he probably still needs the medication. If he's not bothered, it's a good time to trial off the medication. Most infants are on these medications for 2-4 months, but some infants need medication throughout the first year, or even longer.

These medications are dosed based on weight, so if you're concerned that the medicine isn't working as effectively, it may be that the dosage needs to be increased. Alternately, her reflux may be worsening and need additional evaluation or medication. Contact our office to discuss these issues.

Should I switch to a different type of formula?

There may be certain infants whose GERD is attributable to a formula or breast milk intolerance. Suspect this if your infant's GERD is unresponsive to medical treatment. Often, these infants have other symptoms of allergy, such as skin rash, chronic nasal congestion, and/or recurrent wheezing. Discuss potential formula changes with our office.

What is the long term outlook for infants with GERD?

Infantile GERD is usually outgrown. Half of affected infants have stopped refluxing by 10 months, 80% by 18 months, and 98% by two years. However, some of these infants may go on to have trouble with GERD as children and even adults. Observe your child for symptoms as he grows and discuss concerns with our office. (See information on GERD in children and adolescents).