Every baby is a gift. When the gift keeps on giving, however, sometimes that’s a problem. What we’re talking about here in the way of “present” is the breast milk or formula that comes back up after a feed. That outflow of what’s just gone in is a source of much concern for caregivers. They want to know if the baby’s getting enough, if there’s anything wrong, and if the baby is uncomfortable. And they want that often hard-won feed to stay down!
While infants spit and/or vomit for all sorts of reasons, from the benign to the serious, here we’re going to focus on the problems known as gastroesophageal reflux (GER) and its more severe cousin, gastroesophageal reflux disease (GERD). The nomenclature is confusing, to say the least, and at times I find myself wishing the two conditions were called, for example, “John” and “George.” Since the difference in the two does affect treatment decisions, let’s look a little more at them.
The Name Game
Both GER and GERD stem from the same fundamental cause. What happens is that whatever’s in the stomach (read: that recent feeding, along with whatever contents, such as stomach acid, were there naturally to begin with) backtracks into the esophagus (“feeding tube”). GER occurs in greater than two-thirds of otherwise healthy infants and almost all premature babies. It may cause no symptoms at all, or there may be spitting up, but the infant is generally happy and healthy appearing.
With GERD, on the other hand, the symptoms are more severe. The baby may be fussy due to pain, grow poorly, and, if the feeding gets into the lungs, have respiratory symptoms such as cough and wheezing. Ultimately it may lead to dental problems and ear infections. The esophagus itself may actually change and have problems later on in life.
The point at which GER ends and GERD begins in an infant is the appearance of these more concerning symptoms. When the diagnosis is in doubt, testing can be done. One common test measures the amount of acid in the lower esophagus; another measures the pressure exerted by the muscles of the lower esophagus. These tests are rarely necessary, however, and physicians usually can get it right based on the baby’s symptoms.
Before we talk about treatment, let’s discuss the importance of ruling out other illness. A full discussion of what else could be wrong with a vomiting infant is beyond the scope of this blog; safe to say, if a baby looks ill or there is green in the stuff that comes up, it’s worth an immediate call to your pediatric provider. “Happy spitters,” as pediatricians often call those with GER, are less likely to have a concerning issue. One exception that’s not particularly rare is something called pyloric stenosis, a narrowing at the point where the stomach contents flow to the intestine. Vomiting in this case may be a little more severe (although, quite frankly, it’s very tough to make a diagnosis by estimating vomiting severity alone), but early on, the infant is quite healthy and happy looking, as with GER. Pyloric stenosis is easily diagnosed by ultrasound by an experienced radiology department and easily treated by surgery.
If it’s true GER without GERD, little treatment may be required. We often say that it’s more of a laundry problem than a baby problem. That said, spitting may be reduced by feeding upright, more frequent burping, and more frequent small feedings. Some little ones may benefit from feeds thickened with cereal or a change of formula; both these should be discussed with your provider before proceeding. (In my experience, I’ve found that a formula change doesn’t help very often.)
GERD, on the other hand, is generally treated more aggressively. Any or all of the above measures would be tried for starters. Providers might also try certain acid blocking medications or medicines that make the muscles in the esophagus and/or stomach contract, propelling the feeding in the right direction and/or providing a roadblock for the wrong direction. (Some of these medicines have historically also been used for GER; this is generally no longer recommended due to potential side effects and lack of good effect.) In rare cases, surgery may be used to increase the lower esophageal barrier to upward movement of the feeding.
To sum it all up, GER isn’t really a big deal and doesn’t require a lot of treatment. The more severe GERD does, as do many other causes of vomiting that can resemble GER, especially early on. These diseases are in the wheelhouse of pediatricians, who are ready to evaluate your little one and discuss the findings. When necessary, they can involve a specialist in pediatric gastroenterology and/or do some additional testing. Fortunately, most babies do outgrow GER, and you can look forward to fewer washday dilemmas!