Gastroesophageal Reflux (GER)

What is gastroesophageal reflux (GER)?

Gastroesophageal reflux (GER) is a digestive disorder that is caused by the abnormal flow of gastric acid from the stomach into the esophagus.

Gastroesophageal refers to the stomach and esophagus, and reflux means to flow back or return. Gastroesophageal reflux is the return of acidic stomach juices, or food and fluids, back up into the esophagus.

Gastroesophageal reflux is common in babies, although it can occur at any age. It is the most common cause of vomiting during infancy. It may be a temporary condition, or may become a long-term physical problem, often called gastroesophageal reflux disease (GERD).

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What causes gastroesophageal reflux (GER)?

Gastroesophageal reflux is often the result of conditions that affect the lower esophageal sphincter (LES). The LES, a muscle located at the bottom of the esophagus, opens to let food into the stomach and closes to keep food in the stomach. When this muscle relaxes too often or for too long, acid refluxes back into the esophagus, causing nausea, vomiting, or heartburn.

As infants digest their feedings, the LES may open and allows the stomach contents to go back up into the esophagus. Sometimes, the stomach contents go all the way up the esophagus and the baby vomits. Other times, the stomach contents only go part of the way up the esophagus, causing heartburn, breathing problems, or, possibly, no symptoms at all.

Why is gastroesophageal reflux (GER) a concern?

Some babies who have GER may not vomit, but may still have stomach contents move up the esophagus and spill over into the windpipe (the trachea). This can cause asthma, pneumonia, and possibly even SIDS (sudden infant death syndrome).

Babies with GER who vomit frequently may not gain weight and grow normally. Inflammation (esophagitis) or ulcers (sores) can form in the esophagus due to contact with stomach acid. These ulcers can become painful and also may bleed, leading to anemia (too few red blood cells in the bloodstream). Esophageal narrowing (stricture) and Barrett's esophagus (abnormal cells in the esophageal lining) are long-term complications from inflammation that typically occur in adults.

What are the symptoms of gastroesophageal reflux (GER)?

The following are other common symptoms of GER. However, each baby may experience symptoms differently. Symptoms may include:

• Belching

• Refusal to eat

• Stomach ache

• Fussiness around mealtimes

• Hiccups

• Gagging

• Choking

• Frequent cough

• Coughing fits at night

• Wheezing

• Frequent upper respiratory infections (colds)

• Frequent ear infections

• Rattling in the chest

• Frequent sore throats in morning

• Sour taste in the mouth

The symptoms of GER may resemble other conditions or medical problems. Always consult your baby's doctor for a diagnosis.

How is gastroesophageal reflux (GER) diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures that may be performed to help evaluate gastroesophageal reflux include:

• Chest X-ray--a diagnostic test to look for evidence of aspiration--a condition in which stomach contents spill into the lungs leading to breathing problems and lung infections. 

• Upper GI (gastrointestinal) series--a diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an x-ray) is swallowed. X-rays are then taken to evaluate the digestive organs.

• Endoscopy--a test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Tissue samples from inside the digestive tract may also be taken for examination and testing.

• pH testing--a measurement of the level of acidity in the esophagus. 

• Gastric emptying studies--a test designed to determine whether or not the stomach contents empty into the small intestine properly. Delayed gastric emptying can contribute to GERD, allowing stomach contents to back up into the esophagus. 

Treatment for gastroesophageal reflux (GER)

Specific treatment for gastroesophageal reflux will be determined by your baby's doctor based on:

• Your baby's gestational age, overall health, and medical history

• The extent of the disease

• Your baby's tolerance for specific medications, procedures, or therapies

• The expectations for the course of the disease

• Your opinion or preference

In many cases, GER can be relieved through feeding changes, under the direction of your baby's doctor. Some ways to better manage GER symptoms include the following:

• After feedings, hold your baby in an upright position for 30 minutes. Because stomach sleeping has been associated with an increased risk for Sudden Infant Death Syndrome (SIDS), check with your baby's doctor about how to position your baby for sleeping.

• If bottle-feeding, keep the nipple filled with milk so your infant does not swallow too much air while eating. Try different nipples to find one that allows your baby's mouth to make a good seal with the nipple during feeding.

• Adding rice cereal to feeding may be beneficial for some older babies.

• Burp your baby several times during bottle-feeding or breastfeeding. Your baby may reflux more often when burping with a full stomach.

• Make sure your baby's diaper is not too tight since this can exacerbate reflux.

Treatment may include:

• Medications If needed, your baby's doctor may prescribe medications to help with reflux. There are medications which help decrease the amount of acid the stomach makes, which, in turn, will cut down on the heartburn associated with reflux.

  Another type of medication your baby's doctor may prescribe will help to empty the stomach faster. If food does not remain in the stomach as long as usual, there may be less chance of reflux occurring. A medicine in this category that can be prescribed is metoclopramide (Reglan®).  This medicine is usually taken three to four times a day, before meals or feedings and at bedtime.

• Calorie supplements Some babies with reflux will not be able to gain weight due to frequent vomiting. Your baby's doctor may recommend the following:

  • Adding rice cereal to baby formula

  • Providing your infant with more calories by adding a prescribed supplement to formula or breast milk to make the milk higher in calories than normal

  • Change formula to milk-free or soy-free formula if allergy suspected

• Tube feedings Some babies with reflux have other conditions that make them tired, such as congenital heart disease or prematurity. In addition to having reflux, these babies may not be able to drink very much without becoming sleepy. Other babies are not able to tolerate a normal amount of formula in the stomach without vomiting, and would do better if a small amount of milk was given continuously. In both of these cases, tube feedings may be recommended. Formula or breast milk is given through a tube that is placed in the nose, guided through the esophagus, and into the stomach (nasogastric tube). Nasogastric tube feedings can be given in addition to, or instead of, what a baby takes from a bottle. Nasoduodenal tubes can also be used to bypass stomach.

Many babies with GER will "outgrow it" by the time they are about a year old, as the lower esophageal sphincter becomes stronger. But always remember to check with your baby's doctor before elevating the head of the crib if your child has been diagnosed with GER. This is for safety reasons and to reduce the risk for SIDS and other sleep-related infant deaths. 

For others, medications, lifestyle, and diet changes can minimize reflux, vomiting, and heartburn. Surgery to reinforce the lower esophageal sphincter and mechanically discourage reflux may be required in severe cases.