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Sunday, August 24, 2025

Acid reflux in babies


Introduction

  • Reflux in infants is the backward flow of stomach contents into the esophagus.

  • It is extremely common: affects up to 40–50% of babies under 3 months.

  • Usually peaks at 4 months and resolves by 12–18 months.

  • Most cases are benign and self-limiting, but some progress to GERD, requiring treatment.

Mechanism

  • In infants, the lower esophageal sphincter (LES) is immature.

  • The esophagus is shorter and babies spend much of their time lying flat.

  • Frequent liquid feedings + small stomach capacity = increased reflux episodes.

Causes and Risk Factors

1. Physiological (Normal)

  • Immature LES function.

  • Overfeeding.

  • Swallowing air during feeding.

  • Supine position after feeding.

2. Pathological (GERD)

  • Prematurity.

  • Neurological impairment (cerebral palsy).

  • Congenital anomalies (esophageal atresia repair, hiatal hernia).

  • Food intolerance (cow’s milk protein allergy).

  • Family history of reflux disease.

Clinical Features

Benign (Physiological Reflux)

  • Spitting up or mild regurgitation after feeds.

  • No distress, normal weight gain, thriving.

Concerning (Suggestive of GERD)

  • Frequent vomiting with distress/crying.

  • Poor weight gain or weight loss.

  • Feeding refusal, arching back during feeds.

  • Coughing, choking, wheezing, recurrent chest infections.

  • Blood in vomit or stool.

  • Severe irritability, disturbed sleep.

Diagnostic Approach

1. History and Examination

  • Feeding pattern, type of milk, amount and frequency.

  • Growth chart review.

  • Associated symptoms (respiratory issues, apnea, feeding refusal).

2. Investigations (only if atypical or severe)

  • Upper GI contrast study: excludes obstruction, malrotation.

  • 24-hour pH probe / impedance study: measures acid reflux episodes.

  • Endoscopy with biopsy: esophagitis, eosinophilic esophagitis.

  • Allergy testing: if cow’s milk protein allergy suspected.

Most infants do not need extensive investigations.

Management and Treatment

Treatment depends on whether reflux is physiological or pathological (GERD).

A. Reassurance and Lifestyle Measures (First-Line for All Babies)

  1. Feeding Adjustments

  • Smaller, more frequent feeds.

  • Burp baby during and after feeds.

  • Avoid overfeeding.

  1. Positioning

  • Keep baby upright for 20–30 minutes after feeds.

  • Avoid seated positions (car seats) immediately after feeding → increases intra-abdominal pressure.

  • Babies should always sleep on their back (supine) to reduce risk of SIDS, even if reflux present.

  1. Thickened Feeds

  • Use commercial thickened formulas or add rice cereal (1 tsp per 30 mL formula).

  • Reduces regurgitation but does not reduce acid exposure.

  1. For Breastfed Babies

  • Continue breastfeeding.

  • If cow’s milk protein allergy suspected → mother eliminates dairy from diet.

B. Pharmacological Treatment (For GERD or Complications)

Used only if conservative measures fail, or if baby has esophagitis, poor weight gain, or respiratory complications.

  1. Proton Pump Inhibitors (PPIs) (first-line in infants with confirmed GERD + esophagitis)

  • Omeprazole 0.7–1 mg/kg orally once daily.

  • Esomeprazole 1 mg/kg orally once daily (for >1 month old).

  1. H2 Receptor Antagonists (alternative if PPI not available)

  • Famotidine 0.5 mg/kg orally twice daily.

  • Less effective than PPIs, tolerance may develop.

** Ranitidine is no longer recommended (removed due to safety concerns).

  1. Prokinetics

  • Domperidone / Metoclopramide sometimes used, but not routinely due to side effects (extrapyramidal symptoms, QT prolongation).

  1. Antacids / Alginates

  • Limited use in infants, only under specialist supervision.

C. Surgical Treatment (Rare, last resort)

  • Nissen fundoplication: wrapping stomach around esophagus to strengthen LES.

  • Considered in severe GERD with complications unresponsive to medical therapy (e.g., aspiration pneumonia, failure to thrive).

Complications of Untreated GERD in Infants

  • Esophagitis (pain, bleeding).

  • Strictures (narrowing of esophagus).

  • Barrett’s esophagus (rare in children).

  • Aspiration pneumonia.

  • Poor growth and developmental delay.

Prognosis

  • Physiological reflux: resolves in 85% by 12 months, almost all by 18–24 months.

  • Pathological GERD: can improve with medical therapy, but requires monitoring.

  • Long-term complications are rare if managed early.

Patient / Parent Education

  • Spitting up is very common and usually harmless.

  • Focus on feeding changes and upright positioning first.

  • Always place baby on back to sleep — reflux is not a reason to change this.

  • Seek medical advice if:

    • Vomiting is forceful (projectile).

    • Blood in vomit or stool.

    • Baby not gaining weight.

    • Associated breathing difficulties (wheezing, apnea).

  • Medications should only be given under medical supervision.




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