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Monday, August 18, 2025

Reflux in babies


Introduction

Reflux in babies, medically known as infant gastroesophageal reflux (GER), refers to the backward flow of stomach contents, including milk or food, into the esophagus. This is a common condition in infants under one year old because their digestive system is still developing. Reflux often manifests as frequent spitting up or regurgitation and, in most cases, is harmless and self-limiting. However, when it leads to significant discomfort, feeding problems, or poor growth, it is referred to as gastroesophageal reflux disease (GERD).

Causes of Reflux in Babies

The main cause of reflux in babies is the immaturity of the lower esophageal sphincter (LES), the muscle that acts as a valve between the esophagus and stomach. Factors contributing to reflux include:

  • Immature digestive system: The LES is weak in newborns, allowing stomach contents to flow back.

  • Liquid diet: Babies consume mostly milk, which is more likely to regurgitate.

  • Frequent lying down: Babies spend most of their time on their back, which facilitates reflux.

  • Overfeeding: Large volumes of milk can exceed stomach capacity and increase reflux risk.

  • Premature birth: Premature babies are more prone due to underdeveloped gastrointestinal systems.

Symptoms of Reflux in Babies

Common signs of reflux include:

  • Frequent spitting up or regurgitation after feeding

  • Coughing, hiccupping, or gagging during or after feeds

  • Irritability, especially when lying down

  • Poor feeding or refusal to feed

  • Slow weight gain or failure to thrive (in severe GERD)

  • Arching of the back during or after feeds (Sandifer syndrome)

  • Disturbed sleep patterns

  • Bad breath due to acid exposure

In mild cases, babies may spit up but remain happy and continue to gain weight normally. These are often referred to as "happy spitters."

Diagnosis

Diagnosis is typically clinical and based on history and observation. However, when GERD is suspected, further investigations may include:

  • pH probe monitoring: Measures acidity in the esophagus.

  • Upper GI series: X-rays after drinking contrast liquid to detect anatomical abnormalities.

  • Endoscopy: Rarely used, to examine esophageal lining for inflammation.

  • Esophageal impedance study: Detects non-acid reflux episodes.

Complications of Untreated GERD

If reflux is severe and untreated, complications may include:

  • Esophagitis (inflammation of the esophagus)

  • Breathing issues (chronic cough, wheezing, aspiration pneumonia)

  • Feeding difficulties leading to poor growth

  • Anemia from esophageal bleeding

Management of Reflux in Babies

1. Lifestyle and Feeding Modifications (First-line)

Most infants improve with conservative measures:

  • Smaller, frequent feeds: Prevents stomach overfilling.

  • Thickened feeds: Using rice cereal or commercially available thickening agents to reduce regurgitation.

  • Burping frequently: Burp the baby during and after feeds to release trapped air.

  • Upright positioning: Hold the baby upright for 20–30 minutes after feeding.

  • Sleep positioning: Babies should always be placed on their back to sleep to reduce risk of sudden infant death syndrome (SIDS), even if reflux occurs.

  • Formula changes: Hypoallergenic formulas may be tried if cow’s milk protein allergy is suspected.

2. Medical Treatment (For confirmed GERD or complications)

When lifestyle measures fail and the baby shows significant distress, poor weight gain, or complications, medications may be prescribed:

  • Proton Pump Inhibitors (PPIs): Reduce stomach acid production, improving symptoms of esophagitis.

    • Generic names and doses:

      • Omeprazole: 0.7–3.3 mg/kg once daily (oral suspension or capsule).

      • Lansoprazole: 0.7–3 mg/kg once daily.

  • H2 Receptor Antagonists (H2RAs): Decrease acid secretion, less potent than PPIs but sometimes used.

    • Generic names and doses:

      • Ranitidine (note: withdrawn in many countries due to safety concerns).

      • Famotidine: 0.5 mg/kg twice daily.

  • Prokinetic Agents (less commonly used): Improve gastric emptying and strengthen LES tone.

    • Generic name: Domperidone (use restricted due to cardiac side effects).

    • Metoclopramide* is rarely used due to neurological side effects.

Medications are prescribed cautiously and only in severe cases due to safety concerns in infants.

3. Surgical Treatment (Rare and last resort)

If medical and conservative measures fail, and GERD leads to life-threatening complications (such as aspiration or severe esophagitis), fundoplication surgery may be considered. In this procedure, the top of the stomach is wrapped around the LES to strengthen the valve mechanism.

Prognosis

  • Reflux in babies usually resolves spontaneously by 12–18 months of age as the digestive system matures and babies spend more time upright.

  • Most infants require no medication, only reassurance and lifestyle modifications.

  • Persistent GERD beyond infancy may require long-term follow-up.

Precautions for Parents

  • Do not use sleep wedges or inclined sleepers, as they increase the risk of suffocation.

  • Always put the baby to sleep on their back, regardless of reflux.

  • Avoid overfeeding and monitor growth patterns regularly.

  • Consult a pediatrician if reflux is accompanied by blood in vomit, persistent irritability, choking, or poor growth.

Summary of Treatments with Doses (for GERD in infants)

  • Omeprazole: 0.7–3.3 mg/kg once daily

  • Lansoprazole: 0.7–3 mg/kg once daily

  • Famotidine: 0.5 mg/kg twice daily

  • Domperidone: Rare, only specialist use, restricted due to safety issues




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