The Spit-Up Never Ends: Managing Infantile GER and GERD

Column Author: Emily Bryan, MD | Pediatric Resident Physician

Column Editor: Angela D. Etzenhouser, MD, FAAP | Associate Director, Pediatric Residency Program Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

“The spit-up never ends!” As pediatricians, we commonly hear exclamation like this during our day-to-day workflow, as we are asked to differentiate normal physiology from pathology. Infantile gastroesophageal reflux (GER) is a common phenomenon experienced by 70%-85% of infants within the first two months of life. For most patients, dietary changes and medication are not needed, as over 95% of patients will “grow out” of their GER without complication by 1 year of age. However, those who present with more concerning or persistent findings require prompt management to prevent complications such as inadequate weight gain or mucosal injury.^1,2 Differentiating GER from true gastroesophageal reflux disease (GERD), then, is important.

GER is the retrograde passage of gastric contents into the esophagus with or without visible regurgitation or vomiting. This event is anticipated in infants. As the lower esophageal sphincter matures, the swallow reflex becomes more coordinated, leading to fewer transient lower esophageal sphincter relaxation events.³ Infants with physiologic GER are often affectionately referred to as “happy spitters,” living milk-stained lives without effect on growth or development. While reassurance (and empathy for the many loads of laundry and mid-day outfit changes) is appropriate management for these patients, we, as physicians, should re-evaluate once “happy spitting” is no longer “happy.” Back-arching, crying and irritability associated with feeds may be the first signs of GERD rather than benign reflux. Once these signs occur, patients may experience chronic difficulty with feeds, leading to parental frustration as well as inadequate nutrition, and ultimately poor growth and development.⁴ In order to prevent this outcome, several interventions should occur.

Proper feeding technique should be reviewed at every newborn visit and include positioning recommendations, burping techniques and appropriate feed volume. The American Academy of Pediatrics’ HealthyChildren.org has several helpful resources that are great, user-friendly reminders for parents. One such article, “Amount and Schedule of Baby Feedings,” features age- and weight-based feeding recommendations along with suggested feeding frequencies, video examples of feeding cues, and more.⁵ If GERD remains a concern despite supportive care alone, per recommendations from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), a trial of feed thickener should be considered, keeping in mind relative restrictions and risk of constipation.^4,6 If no improvement is noted,  cow’s milk protein allergy (CMPA) should be ruled out, with at least a four-week trial of removal of all casein and whey from the maternal diet in breastfed infants and exclusive intake of extensively hydrolyzed formula in formula-fed infants, remembering 10%-15% of infants with true CMPA will have cross-reactivity to soy- and rice-based formulas.^4,7

If symptoms do not improve, referral to Gastroenterology for further evaluation and consideration of medical or surgical management becomes necessary. While primary care providers may initiate medical management with acid suppression therapy if prompt evaluation is not possible (first line: proton pump inhibitors, second line: histamine 2 receptor antagonists), referrals should continue to be pursued as infants may require further imaging and evaluation to rule out underlying predisposing conditions leading to persistent GERD.⁴ If at any time during evaluation “red flag” symptoms appear, including those outlined in Table 1 below, patients should be referred earlier and with more urgency.⁴

Despite the 2018 NASPGHAN guidelines, acid suppression medication continues to be initiated without first trialing thickened or hypoallergic feeds.⁸ It is important to balance the risks and benefits of these medications. In a 2023 Cochrane review, neither proton pump inhibitors nor H2 receptor antagonists were associated with symptom improvement or changes in pH indices. However, few studies of infants were included, and the certainty of the evidence was very low.⁹ Applicability of such studies is limited by broad inclusion criteria, including many patients with GER alone. If medication is needed, wean trials should occur by six to 12 months of use to reduce the risk of treatment side effects including increased risk of infections and fractures.^2,3

Infantile GER without disease is common and both the American Academy of Pediatrics and Choosing Wisely Campaign (2014) discourage use of acid suppression in these patients. On the other hand, GERD is far from benign, leading to significant pathologies in both the patient and in their caregivers if not appropriately managed. In affected patients, GERD can lead to failure to thrive, apnea, and, if allowed to progress into childhood and adulthood, metaplasia. Concerning caregivers, one study demonstrated higher rates of both generalized anxiety disorder and depressive disorder in caregivers at time of diagnosis. Interestingly, rates of both significantly reduced eight weeks following their child’s diagnosis despite persistence of GERD symptoms, indicating that simply receiving the diagnosis alleviates some caregiver burden.⁸ Appropriate identification, prompt management, and timely referral allows patients with infantile GERD to thrive during a vital time in their development.

General:

• Weight Loss
• Lethargy
• Fever
• Excessive Irritability/Pain
• Dysuria
• Onset of regurgitation/vomiting >6 months or increasing/persisting >12-18 months of age

Neurological:

• Bulging fontanel/rapidly increasing head circumference
• Seizures
• Macro/microcephaly

Gastrointestinal:

• Persistent forecful vomiting
• Nocturnal vomiting
• Bilious vomiting
• Hematemesis
• Chronic diarrhea
• Rectal Bleeding
• Abdominal Distention

Table 1. “Red Flag” Symptoms and Signs Suggesting Disorders Other Than Gastroesophageal Reflux Disease, adapted from Rosen et al.⁴

References:

1. Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Paediatr Drugs. 2013;15(1):19-27. doi:10.1007/s40272-012-0004-2
2. Wolf ER, Sabo RT, Lavallee M, et al. Overuse of reflux medications in infants. Pediatrics. 2023;151(3):e2022058330. doi:10.1542/peds.2022-058330
3. Stepanovich G, Donn SM. Gastro-esophageal reflux in the newborn: pathologic event or does spit happen? OBM Hepatology and Gastroenterology. 2021;5(3). doi:10.21926/obm.hg.2103060
4. Rosen R, Vandenplas Y, Singendonk M, et al. 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. J Pediatr Gastroenterol Nutr. 2018;66(3):516-554. doi:10.1097/MPG.0000000000001889
5. Amount and schedule of baby formula feedings. American Academy of Pediatrics HealthyChildren.org. Last updated May 16, 2022. https://www.healthychildren.org/English/ages-stages/baby/formula-feeding/Pages/amount-and-schedule-of-formula-feedings.aspx
6. Kipfer S, Goldman RD. Formula choices in infants with cow’s milk allergy. Can Fam Physician. 2021;67(3):180-182. doi:10.46747/cfp.6703180
7. Duncan DR, Larson K, Rosen RL. Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. Curr Gastroenterol Rep. 2019;21(7):30. Published May 16, 2019. doi:10.1007/s11894-019-0697-2
8. Tracy MS, Duncan DR, Rosen RL. Evaluating the adherence to national guidelines for treatment of gastroesophageal reflux in infants. Acta Paediatr. 2022;111(2):440-441. doi:10.1111/apa.16142
9. Tighe MP, Andrews E, Liddicoat I, Afzal NA, Hayen A, Beattie RM. Pharmacological treatment of gastro-oesophageal reflux in children. Cochrane Database Syst Rev. 2023;8(8):CD008550. Published August 22, 2023. doi:10.1002/14651858.CD008550.pub3
10. Aizlewood EG, Jones FW, Whatmough RM. Paediatric gastroesophageal reflux disease and parental mental health: prevalence and predictors. Clin Child Psychol Psychiatry. 2023;28(3):1024-1037. doi:10.1177/13591045231164866