Gastroesophageal Reflux in Infants What is Gastroesophageal Reflux (GER)? When food or liquids are swallowed, they enter the esophagus, a tube leading to the stomach. They then pass through the sphincter, a band of muscles at the lower end of the food tube leading into the stomach. This band of muscles acts as a tight one-way valve, letting food and liquids into the stomach without stomach contents backing up into the esophagus. But in babies with GER, the sphincter doesn’t always stay tightly closed when the stomach is full, so food and liquids can flow backwards into the esophagus. Some babies may reflux into the lower or middle part of the esophagus; others reflux all the way up into the mouth or nose. GER may get worse before it gets better. As infants begin to move on their own, the symptoms may increase. But as the infant grows, the esophagus lengthens and the sphincter become stronger. Usually, GER clears at one year of age when infants eat more solid foods, spend most of their time upright and the sphincter and abdominal muscles get stronger. What are the symptoms of GER? GER is common in healthy infants. More than half of all babies experience reflux in the first 3 months of life, but most stop spitting up between the ages of 12 to 24 months. Only a small number of infants have severe symptoms. An infant with GER may experience: spitting up vomiting coughing irritability poor feeding blood in the stools In a small number of cases, GER results in symptoms that cause concern. These symptoms include: poor growth due to an inability to hold down enough food irritability or refusing to feed due to pain blood loss from acid damaging the esophagus breathing problems Digestive system noting the mouth, esophagus, lower esophageal sphincter (LES), stomach, and small intestine. Problems that can be caused by disorders other than GER in infants and children It is crucial to distinguish vomiting due to GER from vomiting caused by other disorders. Diseases affecting a variety of systems can produce vomiting. A detailed history and physical examination can help eliminate many of these disorders. An important warning sign suggestive of nonreflux disease is forceful vomiting, which can be caused by bowel obstruction. Other warning signals include bloody vomit, bloody stool, diarrhea, abdominal tenderness or distention, onset of vomiting after 6 months of age, fever, lethargy, enlargement of the liver and/or spleen, seizures, and abnormal head circumference. How is GER diagnosed? An infant who is consistently spitting up or vomiting may have GER. The doctor or nurse will talk with you about your child’s symptoms and examine your child. Sometimes treatment is started without tests. If the infant is healthy, content, and growing well, often no tests or treatment are needed. Tests may be ordered to help determine whether your child’s symptoms are related to GER. These tests may include: CONTRAST RADIOGRAPHS. An upper gastrointestinal (UGI) series is taken following the ingestion of a positive contrast agent, such as barium (barium swallow). This test can yield both functional and structural information. ESOPHAGEAL PH MONITORING. Esophageal pH monitoring measures the frequency and duration of acid reflux episodes into the esophagus. A microelectrode that continuously senses the presence of acid is placed in the esophagus through the nose. This is a widely used test of esophageal acid exposure and can be useful in determining the presence of an association between acid reflux and frequently occurring symptoms. If apnea is suspected, simultaneous correlation with respiratory efforts and chest wall movement is necessary. An alternative to the traditional esophageal pH monitoring employing a wireless system is being evaluated in older children. ENDOSCOPY. Fiberoptic assessment of the esophagus and stomach allows macroscopic and microscopic evaluation of the esophagus and the UGI tract. The severity of esophagitis can be evaluated, as can the presence of complications. SCINTIGRAPHY. This technology is based on the consumption of a radioactive isotope labeled feeding (milk or formula). A nuclear image scan is performed to detect the isotope in the GI or respiratory tract. The scan allows the measurement of gastric emptying, detects reflux, and may detect aspiration of food into the respiratory tract.