Gastroesophageal reflux disease

Is my baby ill or just spitting?

The contents of the stomach sometimes flow backward into the swallowing tube. This is called gastroesophageal reflux, or GER. It happens in all healthy babies and episodes are short and harmless. It happens more in babies than adults because babies have a relatively large stomach and a short esophagus. Sometimes the stomach contents rise so much that they leak out of the mouth, causing spitting. It should not be confused with gastroesophageal reflux disease, or GERD. Babies with GERD generally spit or vomit frequently. They may refuse to feed, grow slowly, be very upset most of the time, or have breathing problems. It is more common in babies with underlying health problems and less common in breastfed babies. This diagnosis has become very common in recent years. There is no gold standard test and there are numerous reported treatments. 

A) Describing reflux

Gastro refers to the stomach, the esophagus is the swallowing tube, and reflux is the flow of body fluids in the direction opposite to normal.

This FAQ is about two types of reflux:

  • Gastroesophageal reflux (GER), which is normal in all babies.
  • Gastroesophageal reflux disease (GERD), which means the baby is ill.

B) Gastroesophageal reflux

With GER, the stomach contents flow backward into the swallowing tube. This reduces pressure in the stomach. Reflux episodes are short and don’t cause problems for most of us.

Reflux tends to happen more in babies than adults because babies have a relatively large stomach and a short esophagus. Sometimes the stomach contents rise farther up the esophagus and leak out of the baby’s mouth. This is called spitting.

When a mother has a large milk supply, their babies tend to spit more and many also vomit one to two times each week. This is normal.

C) Gastroesophageal reflux disease

By one month of age, this baby was feeding for short periods, vomiting frequently, and not growing. Before-feed and after-feed weights showed that the baby was only taking in about 250 ml (8 oz) of breast milk each day. The mother could pump an additional 300 ml (10 oz) each day but the baby refused all supplements. The baby only started gaining after undergoing surgery for a twisted bowel at three months. He was temporarily supplemented with breast milk after surgery.

A small number of babies are sick with GERD and should be seen by their health-care providers.

There is no specific behaviour of babies with GERD. This can lead to both over- and under-diagnosis. It can result in missed diagnoses when some babies are assumed to have GERD but are actually sick with another illness.

Spitting is the most frequent sign of a baby who has GERD. Vomiting and frequent crying are also common. They may (Gonzalez Ayerbe 2019):

  • Cry frequently and never settle.
  • Refuse to feed or suddenly feed all the time.
  • Stop gaining or gain very slowly.
  • Have frequent ear infections.
  • Have hoarseness, difficulty breathing in, wheezing, or a chronic dry cough.
  • Have repeated episodes of pneumonia.
  • Have low iron levels (anemia).
  • Have teeth damaged by acid.
  • Have unusual posturing.

GERD is thought to cause distress because of inflammation and stretching of the swallowing tube (Gonzalez Ayerbe 2019).

GERD in babies tends to be most common at around four months of age (Lightdale 2013). It is less common in breastfed babies than in infant formula-fed babies, and if present, settles more quickly in breastfed babies (Leung 2019; Orenstein 2008). GERD is more common in babies who have other health problems such as obesity, abnormalities of the neurologic or digestive system, and lung and heart disease, There may also be a genetic origin.

Normal babies will be upset on occasion and this is not a reason for concern. Those who cry frequently but without regular spitting and vomiting are unlikely to have GERD (Gonzalez Ayerbe 2019). GERD does not cause: 

  • Sleepiness
  • Fever
  • Spitting or vomiting starting after 6 months of age

A health-care provider should be able to decide whether your baby has GERD by speaking with you and examining your baby (Gonzalez Ayerbe 2019). There is no perfect test for GERD. Any tests are generally reserved for complicated cases and to ensure that there is not another problem (Gonzalez Ayerbe 2019). 

D) Treatment of gastroesophageal reflux disease

Mothers rarely need to stop breastfeeding when their babies have GERD (Gonzalez Ayerbe 2019).

Reported treatments include (Gonzalez Ayerbe 2019):

Some parents will raise the head of the bed but this can result in the baby rolling to the foot of the crib.

E) The popularity of the reflux diagnosis

Diagnoses of GERD and acid-related conditions were rare in the United States but suddenly started to increase in the mid-1990s. Around this time, the U.S. relaxed advertising rules and companies began promoting many products to treat acid-related problems (Hassall 2012).

One study found that between 2000 and 2005, diagnoses of GERD and acid-related conditions among U.S. babies aged 12 months or less more than tripled (from 3.4% to 12.3%) (Nelson 2009). Other studies have reported that as many as one-quarter of all babies have GERD symptoms (Singendonk 2019).  

The increased number of children diagnosed with GERD is mirrored by the increased number of babies receiving medication to treat it. The HealthNuts study followed more than 4,000 Australian children and showed that 14% of parents of normal babies saw their doctor for concerns about uncomplicated reflux and about half of these babies received medication (Hua 2014).  

References

Gonzalez Ayerbe JI, Hauser B, Salvatore S, et al. Diagnosis and Management of Gastroesophageal Reflux Disease in Infants and Children: from Guidelines to Clinical Practice. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):107–121
 
Hassall E. Over-prescription of acid-suppressing medications in infants: how it came about, why it's wrong, and what to do about it. J Pediatr. 2012 Feb;160(2):193-8
 
Horvath A, Dziechciarz P, Szajewska H. The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics. 2008 Dec;122(6):e1268-77
 
Hua S, Peters RL, Allen KJ, et al.; HealthNuts Study Investigators. Medical intervention in parent-reported infant gastro-oesophageal reflux: A population-based study. J Paediatr Child Health. 2014 Nov 12

Leung AK, Hon KL. Gastroesophageal reflux in children: an updated review. Drugs Context. 2019 Jun 17;8:212591

Lightdale JR, Gremse DA. Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics 2013; 131(5)
 
Nelson SP, Kothari S, Wu EQ, et al. Pediatric gastroesophageal reflux disease and acid-related conditions: trends in incidence of diagnosis and acid suppression therapy. J Med Econ. 2009;12(4):348-55
 
Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr. 2008;152(3):310–314
 
Singendonk M, Goudswaard E, Langendam M, et al. Prevalence of Gastroesophageal Reflux Disease Symptoms in Infants and Children: A Systematic Review. J Pediatr Gastroenterol Nutr. 2019 Jan 21