Treatment of GE Reflux
The most important thing to remember when treating gastroesophageal (GE) reflux is that in almost all cases, the problem will get better on its own! With that in mind, most of our treatments are geared towards lessening the symptoms, not fixing it. Given enough time, the baby will fix the problem on his or her own.
If you think of GE reflux as incoordination of the baby’s upper intestinal tract, then, as the baby’s overall coordination improves, the reflux will improve too. Usually, when the infant can sit-up well without assistance (around age 6 months) the reflux starts to get better, and once the baby walks well (around 12 months) the reflux tends to disappear.
Treatments for reflux can be summarized in categories (we review these below):
- positioning
- dietary treatments
- changing feeding schedules
- medications
- surgery
Theoretically, the best position to but a baby with reflux in after meals is lying on the stomach with the head propped up about 30 degrees. Lying in this position causes the stomach to fall forward, closing the connection between the stomach and the esophagus. Remember, this is only theoretical! Some infants will cry in this position causing the stomach to fill with air, grunting, and straining, which tends to make the reflux worse.
Perhaps more important than using the “best” position is avoiding “bad” positions. Young infants don’t have much control of their abdominal or chest muscles, so when placed in an infant seat or swing, they tend to slump down. This increases pressure in the stomach and tends to worsen reflux. It is much better to lie them down or place them in a seat that reclines a bit than to have them slumped down.
While many parents and families attribute GE reflux to sensitivities or allergies to milk or fomula, there is no convincing evidence of this. Vomiting will often decrease when an infant is switched from one type of milk to another, but improvement usually lasts only 2-3 days. Certainly, some infants do better on one type of formula than another, but most continue to vomit regardless of the type of milk (including breast milk) they are fed.
Parents may be instructed to thicken infant feedings with cereal. This makes the milk physically heavier and less likely to come back up. But there are some problems with this. It is not possible to thicken feedings if the baby is largely breast fed. Also, many infants with reflux are very vigorous feeders. When milk is thickened, the baby has to suck harder to get it through the nipple. This can cause air to fill the stomach and worsen the reflux.
Many parents find that their babies keep solid foods down more effectively than liquids. This may simply be because solids are heavier, but solid foods also empty from the stomach differently than liquids. There is no evidence to suggest that feeding young infants solid foods with a spoon or from an infant feeder is harmful. In many cultures around the world, infants have been fed solid foods in the first month of life for centuries, without any problems. There is also no evidence that early introduction of solid foods predisposes to allergies later in life.
Parents are sometimes instructed to feed their babies smaller amounts more often with the idea that over-feeding tends to make reflux worse. Unfortunately, many babies with reflux are not satisfied with only 1½-2 ounces of milk, and they will cry for more. Again, when babies cry for extended periods, they fill their stomachs with air, they grunt and strain, and this tends to make reflux worse.
Most medications used to treat reflux fall into three groups based on how they work:
- break down or lessen intestinal gas
- decrease or neutralize stomach acid
- improve intestinal coordination
Medications that break down or lessen intestinal gas: Mylicon®, Gaviscon®
Medications that decrease or neutralize stomach acid: Antacids, Mylanta®, Maalox®, Carafate® (sucralfate)
Medicines that inhibit stomach acid secretion or production: Tagamet® (cimetidine), Zantac® (ranitidine), Pepcid® (famotidine), Axid® (nizatidine), Prilosec® (omeprazole), Prevacid® (lansoprazole), Nexium® (esomeprazole)
It is assumed that decreasing the amount of stomach acid will lessen reflux symptoms. This has clearly been shown in adults, but very few studies have examined the effectiveness of these medicines in young children. In theory, these types of medications should be helpful to babies who are having “heartburn”, and nearly three-fourths of parents report that their babies spit up or throw up less and seem to have less “heartburn” when they take Gaviscon®.
For the most part, medicines that decrease intestinal gas or neutralize stomach acid (antacids) are very safe. At high doses, Mylicon, Gaviscon, Maalox, and Mylanta may function as laxatives and cause some diarrhea. Chronic use of very high doses of Maalox or Mylanta may be associated with an increased risk of rickets (thinning of the bones).
Side effects from medications that inhibit the production of stomach acid are uncommon. A small number of children may develop some sleepiness when they take Zantac, Pepcid, Axid, or Tagamet. Tagamet may can increase blood levels of certain other medicines including the blood thinner coumadin and the anti-seizure medicine Dilantin.
Medications that improve intestinal coordination: Reglan® (metoclopramide), Propulcid® (cisapride), erythromycin
Reglan increases the pressure of the lower esophageal sphincter (LES) and helps the stomach empty more quickly. However, in most infants it does not improve reflux symptoms. It may rarely cause frightening side effects: young infants may develop dystonia (tenseness or stiffness of the muscles) and children with epilepsy appear to be at increased risk for seizures when taking Reglan.
Propulcid was withdrawn from the U.S. market in 2000 but is still available in Canada and Europe. Propulcid increases the pressure of the lower esophageal sphincter (LES), emptying of the stomach, and the rate at which food moves through the lower intestines. Nearly three-fourths of parents report that their babies spit up or throw up less and seem to have less “heartburn” when they take Propulcid. Serious side effects are uncommon. Some children will experience some cramping or diarrhea, particularly at higher doses. There have been some reports of children developing abnormal heart rhythms; this seems more likely if Propulcid is taken with certain other medicines including the antibitiotics erythromycin and clarithromycin and the anti-fungal medicines Nizoral (ketoconazole) and Diflucan (fluconazole).
Erythromycin is an antibiotic frequently used to treat a variety of common infections. One fairly common side effect is abdominal cramps due to vigorous stomach contractions. In some infants and children with reflux this side effect can be used to advantage, causing the food to be emptied out of the stomach more quickly than usual and lessening reflux symptoms.
It is extremely rare for children with GE reflux to require surgery. For those very few who do, the most commonly performed operation is the Nissen fundoplication. The top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts too, preventing reflux. This operation is very effective at eliminating GE reflux, with long-term success rates approaching 90%; however, some children may develop very disturbing and debilitating symptoms following fundoplication. The risks and benefits of surgery must be weighed very carefully.