Reflux in babies

Introduction
Reflux in babies, also referred to as gastroesophageal reflux (GER), is a common condition in which stomach contents flow back into the esophagus. It occurs due to the immaturity of the lower esophageal sphincter (LES), a muscular valve that separates the esophagus from the stomach. This condition is particularly frequent in infants under 12 months of age and is often considered a normal developmental process that improves as the child grows.

Physiology and Mechanism
In healthy infants, feeding leads to stomach distension. The LES may relax inappropriately or be underdeveloped, allowing gastric contents (milk or formula mixed with stomach acid) to regurgitate into the esophagus. In most cases, this is not harmful and is part of the natural maturation of the gastrointestinal system. The reflux episodes tend to decrease in frequency and severity as the LES strengthens and the baby spends more time upright.

Types of Reflux in Babies

1. Physiological GER

   • Common and self-limiting.

   • Characterized by frequent “spitting up” without significant discomfort or growth problems.

   • Usually peaks around 4 months of age and resolves by 12–18 months.

2. Gastroesophageal Reflux Disease (GERD)

   • Pathological reflux that causes complications such as poor weight gain, feeding difficulties, irritability, or respiratory symptoms.

   • Requires medical evaluation and possible treatment.

Risk Factors

• Prematurity (immature gastrointestinal function).

• Overfeeding or large volume feeds.

• Lying flat most of the time.

• Immature neurological control of the LES.

• Certain medical conditions such as neurological disorders or congenital anomalies of the gastrointestinal tract.

Clinical Features
Typical symptoms include:

• Frequent regurgitation or spitting up after feeds.

• Mild discomfort or fussiness after feeding.

• Wet burps or hiccups.

• In GERD cases, additional symptoms may include:

  • Persistent irritability or crying during/after feeds.

  • Arching of the back.

  • Poor feeding or refusal to feed.

  • Poor weight gain or weight loss.

  • Chronic cough, wheezing, or recurrent pneumonia.

Possible Complications of GERD in Infants

• Esophagitis (inflammation of the esophagus due to acid exposure).

• Feeding aversion.

• Respiratory complications (aspiration, bronchospasm).

• Failure to thrive.

Diagnosis
In most cases, reflux in babies is diagnosed clinically based on history and physical examination. For uncomplicated GER, investigations are rarely necessary. In suspected GERD or when complications are present, investigations may include:

• Upper gastrointestinal (GI) contrast study (to rule out anatomical abnormalities).

• pH probe monitoring (measuring acid exposure in the esophagus).

• Multichannel intraluminal impedance testing (assesses reflux of both acidic and non-acidic contents).

• Endoscopy (to assess mucosal injury in suspected severe cases).

Management

1. Non-Pharmacological Management (First-Line in Most Cases)

• Feeding Modifications:

  • Offer smaller, more frequent feeds.

  • Avoid overfeeding by following infant hunger cues.

  • In bottle-fed infants, consider using slower-flow nipples to reduce swallowing of air.

• Positional Strategies:

  • Keep the baby upright for 20–30 minutes after feeding.

  • Avoid seated positions (like car seats) immediately after feeding as these can increase intra-abdominal pressure.

  • Always place babies on their backs for sleep, even if reflux is present, to reduce the risk of sudden infant death syndrome (SIDS).

• Thickened Feeds:

  • For some formula-fed infants, thickening feeds with rice cereal or commercial thickeners may reduce regurgitation.

  • Thickened feeds should be used under medical advice, especially in premature infants, due to choking risk.

  • 
    

2. Pharmacological Treatment (For Confirmed GERD or Complications)
Medication is reserved for infants with significant symptoms or complications that do not improve with non-pharmacological measures.

• Acid-Suppressing Medications:

  • Proton Pump Inhibitors (PPIs):

    • Omeprazole (generic name: omeprazole)

    • Lansoprazole (generic name: lansoprazole)

    • Reduce gastric acid secretion and promote healing of esophagitis.

    • Used for a limited duration under medical supervision.

  • Histamine-2 Receptor Antagonists (H2RAs):

    • Ranitidine (generic name: ranitidine) – previously used, now withdrawn in many countries due to safety concerns.

    • Famotidine (generic name: famotidine) – an alternative with acid-suppressing properties.

• Prokinetic Agents (rarely used due to limited efficacy and potential side effects):

  • Domperidone (generic name: domperidone)

  • Metoclopramide (generic name: metoclopramide) – generally avoided in infants due to neurological side effects.

3. Surgical Intervention

• Reserved for severe, refractory GERD causing life-threatening complications or failure to thrive despite optimal medical therapy.

• Nissen fundoplication is the most common surgical procedure, in which the upper part of the stomach is wrapped around the LES to strengthen the barrier.

Prognosis

• Physiological reflux resolves spontaneously in most infants by 12 to 18 months of age as the LES matures and the infant spends more time upright.

• GERD cases often improve over time, but some children may continue to experience reflux symptoms into early childhood.

Prevention and Parental Guidance

• Encourage exclusive breastfeeding when possible, as breast milk is digested more quickly than formula and may reduce reflux episodes.

• Avoid exposure to tobacco smoke, which can exacerbate reflux.

• Educate caregivers about normal infant behavior and the difference between harmless spitting up and signs of GERD.