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Evidence-Based Strategies for Common Clinical Questions

July, 2018

Gastroesophageal reflux in infants: when is it more than “happy-spitting”

Primary Author: Jennifer Halma, MD | Chief Pediatric Resident

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC 

Gastroesophageal reflux, long described as “happy-spitting,” is the passage of contents from the stomach into the esophagus with or without food expulsion. 1,2 It is a physiologic process which occurs in almost two-thirds of otherwise healthy infants. However, the regurgitation or “spitting up” that can be associated with GER can be quite distressing to caregivers. Up to 25 percent of caregivers seek medical attention for infant regurgitation.4GER is related to relaxation of the lower esophageal sphincter, allowing stomach contents to enter the esophagus. It typically self resolves within the first year of life.1,2 

In contrast, a child with gastroesophageal reflux disease, or GERD, has problematic symptoms or complications secondary to the reflux. Symptoms related to reflux are defined as esophageal or extraesophageal. Common esophageal symptoms in infants include feeding refusal, poor weight gain, dysphagia, vomiting and abdominal pain. Extraesophageal symptoms are further divided into definite associations (dental erosions and Sandifer syndrome) and possible associations including asthma, bronchopulmonary dysplasia, chronic cough, hoarseness, sinusitis, serous otitis media and pathologic apnea in infants. Complications related to reflux include esophagitis, as well as less common findings which typically occur in older children such as strictures, Barrett esophagus, and adenocarcinoma. GERD peaks around 4 months of age in infants and then, similar to GER, the incidence decreases to affect less than 10 percent of infants by 1 year of age.2,3 

There is no gold standard test to diagnose GERD. Distinguishing between GER and GERD largely lies in the details of a thorough history and physical exam, with special attention to screen for the above described symptoms and red flag signs which would suggest a diagnosis other than reflux. Possible red flags include weight loss, lethargy, fever, persistent forceful vomiting, bilious vomiting, hematemesis, chronic diarrhea and abdominal distension. Discussion of the differential diagnosis of the associated red flags is outside the scope of this review; however, if present, further diagnostic evaluation should be promptly pursued. In the absence of red flag signs or symptoms, additional testing such as upper GI barium radiography, esophageal pH monitoring, or endoscopy have insufficient evidence and should not routinely be used in the diagnosis of GERD.2 

The management of both GER and GERD focus on lifestyle changes as the first line of therapy. These include positioning after feeds, feeding smaller volumes more often, and possibly thickening feeds for full-term infants. Keeping infants upright after feeds may help decrease the number of reflux episodes, but infants should not be placed prone during sleep as this increases the risk for SIDS. Additionally, infants positioned in carriers or car seats may experience an increased number of reflux episodes, especially after feeds.5 The 2017 clinical practice guideline on GERD from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition also recognizes that thickening feeds may be trialed in the management of GERD. However, thickening feeds likely decreases the number of observed regurgitation episodes, not the number of actual reflux events.4 Additionally, thickening feeds may lead to excessive caloric intake and decreased breastfeeding, if continued long term. 

The joint guidelines also state that distinguishing between infants with milk protein allergy and those with GERD can be diagnostically challenging as both groups may present with very similar symptoms and as such, trialing a maternal elimination diet of restricting milk and egg or an extensively hydrolyzed protein or amino-based formula for two to four weeks may be beneficial.2 

If there is no improvement after lifestyle changes and a trial of cow’s milk elimination, then a referral to pediatric gastroenterologist could be considered as the next step. If a pediatric GI referral is not possible, then a four to eight-week trial of acid suppression is recommended.2 In discussing medication management of GER and GERD with families, it is important to emphasize that “happy-spitters” or those patients who are not bothered by their symptoms, do not need medications to manage the physiologic process of reflux. Acid suppressants are the mainstay of medication management and are divided into two main classes: histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). PPIs are superior to H2RAs in healing erosive esophagitis and, unlike H2RAs, have not been shown to have decreased efficacy with prolonged use.2 The safety profile for long-term PPI use in children is not well understood. However, prescribers should be cognizant of new literature suggesting increased risk of bone fractures, as well as potential increased risk for respiratory and gastrointestinal infections with long-term PPI use.6 

In conclusion, gastroesophageal reflux is a common and benign condition seen in the majority of infants. When infants experience distressing symptoms, it is no longer considered “happy-spitting,” but rather gastroesophageal reflux disease. The treatment of GER and GERD relies largely on lifestyle changes. When these fail, referral to pediatric GI to discuss further testing and possible medication management is a reasonable next step. Lastly, GER(D) can be quite distressing to caregivers, so discussion with the caregiver is instrumental in addressing these concerns. Providers should emphasize the importance of lifestyle changes and reinforce that medication management should be for a trial of four to eight weeks as the long-term adverse events related to acid suppression therapy is not well understood at this time.

References:

1. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenzl TG, North American Society for Pediatric Gastroenterology Hepatology and Nutrition, European Society for Pediatric Gastroenterology Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2009 Oct;49(4):498-547.

2. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. J Pediatr Gastroenterol Nutr. 2018 Mar;66(3):516-554. 

3. Prevalence of Symptoms of Gastroesophageal Reflux During Infancy. A Pediatric Practice-Based Survey. Nelson SP, Chen EH, Syniar GM, Christoffel KK. Arch Pediatr Adolesc Med. 1997;151(6):569–572. 

4. Clinical Report: Gastroesophageal Reflux: Management Guidance for the Pediatrician. Lightdale JR, Gremse DA, and SECTION OF GASTROENTEROLOGY, HEPATOLOGY, and NUTRITION. Pediatrics. 2013; 131;e1684. 

5. The Infant Seat as Treatment for Gastroesophageal Reflux. Orenstein SR, Whitington PF, Orenstein DM. N Engl J Med. 1983 Sep 29;309(13):760-3.

6. Toxicity of Long-term Use of Proton Pump Inhibitors in Children. De Bruyne P, Ito S. Arch Dis Child. 2018 Jan;103(1):78-82.