Sunday, November 27, 2011

Re-evaluating Reflux

GERD - Gastroesophageal Reflux Disease

Gastroesophageal reflux, abbreviated as GER, or known simply as reflux, describes the process by which the contents of the stomach (stomach acid, formula, or food) moves backwards into the food pipe (esophagus) rather than out the bottom of the stomach into the intestines.

Reflux is extremely common in infants.  Research from the Archives or Pediatric and Adolescent Medicine & Pediatric Review states that up to 70% of infants will have reflux at least 1 time per day by between 4-6 months of age.
·         50% of infants between 0 and 3 months of age will have some degree of reflux. 

Some of the more common symptoms of reflux are vomiting, crying, fussiness, irritability, back arching, or chronic cough. 
  • Spit-ups are normal in infants after feeds and during burping.  Almost all infants will spit-up at least once in a while.  Spit-ups contain a small amount (although it often appears larger) of formula or milk that comes out of the mouth without force. 
    • Vomiting occurs with more force and contains a larger amount of expelled formula or milk.
·         Reflux does not cause bloody or green colored vomit. 
o   An infant or young child who throws up bloody or green colored liquid should be evaluated immediately by a physician.

There are a number of potential treatment modalities for gastroesophageal reflux with some more conclusive and supported than others.

Managing reflux
·         Positioning - following a feeding, infants should be kept upright for 20-30 minutes. 
o   This allows time for the stomach to clear the contents of the feeding which helps to decrease the frequency of reflux. 
o   Avoid laying an infant flat on their back immediately after a feed.
§   If the baby is still awake after a feeding, they can be placed on their belly for "tummy time" which can help reduce episodes of reflux. 
§  Always place infants flat on their back to sleep to reduce the risk for SIDS (sudden infant death syndrome)
o   Avoid placing an infant into a car seat immediately after feeding as the scrunched position in a car seat can actually worsen reflux.
·         During feeds - frequent pauses during feeding to burp the baby helps to lower the pressure in the stomach. 
o   When the pressure is reduced in the stomach there is less force to push the stomach contents back into the esophagus.
·         After feeds - pacifier use has also been associated with improvement in symptoms of reflux. 
o   Consider using a pacifier in between feeds to help your baby's reflux symptoms.
·         Avoid overfeeding - infant’s stomachs do not handle over filling well and this can lead to symptoms of reflux. 
o   Ask your pediatrician how many ounces your infant should be taking to avoid over-feeding.
·         Thickeners - For infants who take formula or expressed breast milk, thickening agents are a popular additive to the bottles. 
o   While formula thickeners do decrease the number of times an infant will vomit in a given day, they do not change the reflux index.
§  The reflux index is the amount of time in which the level of acid (pH) in the esophagus is in the reflux range (pH < 4).
o   Ask your pediatrician if a thickening agent can be added to your infants' formula. 
§  Not all thickening agents are the same and some can actually be an allergen to certain infants.  Ask your pediatrician which thickener they recommend.
·         The AAP (American Academy of Pediatrics) also recommends avoiding clothes with tight elastic waistbands which can also increase the pressure in the baby's belly and can worsen reflux.

Is formula better than breast milk for reflux?
Breast milk is often refluxed less than formula and it is recommended for any breastfeeding mother to continue breastfeeding even if your baby has reflux. 
·         Using the techniques above as well as medications if necessary will usually allow you to continue breastfeeding without interruption.

Should I Change formulas?
Symptoms of reflux can also be a result of an allergy to foods, like milk or soy.  In these cases, a 2-week trial period using a formula that is hypoallergenic (i.e. elemental formula) is sometimes prescribed. 
·         Discuss with your pediatrician the symptoms associated with a true allergy to milk or soy products to determine what tests should be used for diagnosis and if a hypoallergenic formula trial is right for your baby.

Are anti-reflux medications safe and effective?
§  There are several classes of medication which can be used to treat reflux.  These medications are used very frequently, are well tolerated, and often yield excellent results. 
o   Medications can either reduce the amount of acid in the stomach or help the stomach to empty its contents quicker, each of which can significantly reduce the amount of reflux.
§  Ask your pediatrician if an acid reducing medication is right for your baby’s reflux.
o   Infants typically are able to stop taking the medication once they are older and have outgrown their symptoms.

Does my baby need tests?
Often, infants are diagnosed with reflux simply by the history and physical exam.  Tests can be used to confirm the diagnosis of reflux or to rule out other potential diseases which cause symptoms that resemble simple gastroesophageal reflux.  They are also used when typical first line medications and treatments do not work.

The bright side of reflux.
The majority of infants will "grow out" of their reflux.  Less than 10% of babies will continue to have reflux past their first birthday.

Infants who are not gaining weight or who have symptoms which are affecting their ability to breathe, feed properly, or if they appear ill should be evaluated immediately a physician.
Never attempt to start or stop a treatment regimen for your baby without first consulting with your pediatrician.

For more information on gastroesophageal reflux or symptoms affecting your child’s feeding, please consult with your pediatrician.

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