What is Infant Acid Reflux Disease?All babies reflux or spit up food into the esophagus and out of the mouth. Medical literature suggests that almost all babies will do this in the first year of life. However one in three of these babies will develop significant symptoms from the infant acid reflux events. When there are specific other symptoms present this changes the infant acid reflux into infant acid reflux disease (also called Infant GERD; GastroEsophageal Reflux Disease). This is important so that you can speak the same language as your physician. Since it is normal for infants to have some reflux, the physician may suggest that, "they will outgrow it". We can’t tell you how many times we hear this from Moms and we realize how frustrating this can be. Especially when you’re watching your baby suffer and cry non-stop, refuses to eat or worse. It should not be acceptable to allow an infant to suffer in pain as it can affect everything from their development to their ability to gain weight and even the possibility of changes in the esophagus that may lead to the future likelihood of GERD throughout their lives.
What are the symptoms of Infant Acid Reflux Disease?
Some of the most common symptoms include:
1. Spitting up with related crying. The crying is often from the acid in the spit up (refluxate). The spit up can be from small to large amounts of a projectile nature. Sometimes a parent will call this vomiting, however, vomiting involves retching. Certainly, babies can vomit but often times it is projectile reflux.
2. Back arching. This is also typically related to feeding. As the acid comes up the esophagus, the infant arches the back instinctively to try and relieve the pain. They will often arch away from the bottle.
3. Hiccups (wet hiccups or wet burps). Hiccups are due to the effect of acid and/or pressure affecting the nerves near the esophagus affecting the diaphragm. Infants with GERD have recurrent hiccups. Wet hiccups occur when there is refluxate coming up when hiccupping.
4. Irritability during feeding. This occurs when infants start screaming or crying suddenly while feeding. This is usually due to acid causing esophageal irritation and then causing pain.
5. Refusal to eat, difficulty swallowing. This is due to the pain caused by acid coming back into the esophagus
6. Gagging or choking. These symptoms can be related to the acid refluxate coming into the esophagus and moving up into the upper esophagus (proximal). It helps to keep the baby more upright for about ½ hr after feeding. Larger volumes of formula or milk can also create more reflux as the volume exceeds what can be held in the stomach.
7. Difficulty sleeping or nighttime awakening. As the infant is lying down for extended periods during the night, gravity works against them. Acid moves into the esophagus and is painful. In adults this is also common and is called nighttime acid reflux.
8. Not gaining weight. Obviously when the above symptoms are occurring, it can be an expected that the infant won’t want to eat. In fact, an aversion to feeding can be learned as a result of the above symptoms. Once learned, it can be challenging to unlearn. A feeding specialist can be helpful. Moms (and dads) spend most of the day (and night) trying to get enough ounces into their infants including feeding during sleeping (sleep feeding). This is very good for the infant, however, oftentimes it can be normal for a physician to observe that the baby is seemingly gaining weight just fine and will then think that the reflux must not be that bad.
More severe symptoms
1. Purple baby syndrome. This can be frightening and is very serious. Obviously, the infant has trouble breathing such that they stop breathing and the lips and face turn purple or blue. Since the oxygen is not moving throughout the blood, the color change occurs. This can lead to what is known as an Apparent Life Threatening Event (ALTE). This often involves an emergency room visit. Then there can be an extensive work-up searching for a cause (but many times, by the time the infant arrives at the ER, they have begun breathing again).
2. SIDS (sudden infant death syndrome). Consider an ALTE (see directly above #1) in which the infant does not spontaneously start breathing on their own. Then you have SIDS. There are a number of reasons that infant may develop SIDS but certainly acid reflux is one of them.
3. Asthma Like symptoms. If an infant has asthma like symptoms and has infant acid reflux disease, then one of the first things to consider is that acid is the cause. The acid may not even have to reach the lungs (although it certainly can). Even acid vapor can move up from the esophagus and cause sufficient inflammation to lead the apnea and asthma like symptoms.
4. Recurrent ear infections. The acid is refluxed up to the level where the eustachian tube drains into the esophagus. This acid then inflames the tissue and with the resultant swelling the normal flow of secretions from the middle ear can’t occur. Bacteria can then overgrow and cause infection in the middle ear. Treating with antibiotics (without treating the reflux) leads to bacteria that are resistant to antibiotics.
5. Laryngomalacia. Laryngomalacia can be congenital (at birth) and it can develop soon after birth. Either way, acid refluxate plays an important role. Significant control of infant acid reflux can lead to a reduction of inflammations, which can improve symptoms.
6. Coughing without a cold, noisy breathing, wheezing. These symptoms occur when the acid affects the upper esophagus (proximal esophagus) and airways. Often times these symptoms, along with recurrent ear infection and sinusitis are known as Extra Esophageal manifestations of reflux, or ENT-related manifestations, or LPR (LaryngoPharyngeal Reflux). These symptoms can be more difficult to control as very few reflux events are required to keep this symptoms continuing.
7. Sandifer’s Syndrome. While the Sandifer’s syndrome in and of itself is not dangerous, the problem is that it is sometimes mistaken for a seizure or a neurological disease. Therefore, extensive neurological studies may be undertaken and seizure medicine may be unnecessarily started.
There are a large number of other signs and symptoms related to infant acid reflux disease. You can view some of these on this symptoms page.This is why it is important to have a list of symptoms to report to your physician. The Infant Acid Reflux Questionnaire is very useful in this regard. It also allows you to follow the progress of your infant when you make changes to diet, formula, medicine, etc. (A reflux diary of sorts).
What is the treatment for infant acid reflux disease?There is a great deal of controversy related to the treatment of Infant Acid Reflux Disease (Infant GERD). There are several mainstay treatments that have been in use for more than 20 years. These include H2 blockers (histamine type 2 blockers) such as Zantac® (ranitidine), Pepcid® (famotidine) and Axid® (nizatidine). The primary difficulty with the use of H2 blockers is that infants rapidly develop tolerance to the effects (also called tachyphylaxis) and the H2 blocker, which was working, just seems to stop working. Increasing the dose or changing to another H2 blocker is not useful. When an H2 blocker is used and the symptoms return (due to tolerance), some physicians may be puzzled (if they do not already know how common tolerance to H2 blockers occurs) and therefore may have the thought that perhaps acid reflux isn’t the problem. The physician may think to himself or herself that they are giving a medicine, an H2 blocker, that (in their way of thinking) should work, however, it isn’t helping. It is helpful to mention that you have read about tolerance developing to H2 blockers and you wonder if this is happening in your infant.
Proton Pump Inhibitors or (PPIs). PPI medicines are very potent inhibitors of acid secretion. PPI’s are medicines such as omeprazole (Prilosec®), lansoprazole (Prevacid®), esomeprazole (Nexium®). They work by blocking the final pathway for the production of acid. Tolerance cannot develop with PPI medicines. However, it is important to use the correct amount of the PPI medicine. This is the most common shortcoming of using PPI’s. You can read several studies that were performed at the University of Missouri and many studies and papers that explore infant dosing of PPI’s. In general, after approximately 4 weeks of age, the infant’s metabolism of many medicines is at the best it will be in their life. It is well studied and found that infants have a rapid metabolism of many medicines (as we age the metabolism of medicines slows down). So, as we found in our studies, the half-life of PPI medicines (note that the half-life is the time required for the amount of medicine in the body to be reduced by half) was much shorter (up to 3 times faster than adults). Meaning that infants metabolize the PPI medicines 3 times faster than adults.
A: Infants Have Shorter Half Life for PPI’s.
C. PPI Dosing Information for Your Doctor.
It was found in the study above (C.) that, in general, infants/toddlers benefit from two or more doses per day of a PPI. The younger the infant (after 4 weeks) the more likely they will benefit from three doses per day. Studies using single small doses of PPIs per day showed that the single small dose per day were no different than placebo, yet this small dose is often used in infants with Infant Acid Reflux Disease (Infant GERD). If an insufficient dose is used, then symptoms will persist or worsen and can create the long-term symptoms as mentioned previously as well as losing out on those precious times you could be sharing with your little one. When reflux is well controlled, parents will often remark that their infant’s personality is finally shining through.
It takes approximately 10 to 14 days for sufficient healing to occur after starting the correct dose of a PPI medicine but that effective dose is pertinent to getting your baby feeling better and back on track. Infant acid reflux can cause a lot of stress on you and your home life as well. Sure, I know what you're thinking. "I don't want to give my baby medication." It's a hard pill to swallow, literally. The parent may be thinking, my infant has to be medicated so early in life and this can be disheartening. But it may be necessary. Consider this, "Do you provide breathing treatments to a baby that has asthma?" The answer is "Yes, of course!" Then why wouldn't you give a treatment to a baby with reflux disease if it works effectively with a good safety profile? It's not a life style choice. It is a treatment to help that baby overcome a temporary situation and keep them out of pain. It is true that most babies outgrow infant reflux or GERD in the first year of life. But why wait and lose those precious years of life?
Of course, it is crucial to discuss these issues with your physician / health care team. Often times it is not prudent to wait to treat your baby. Don’t wait to enjoy this time with your baby and most importantly, don’t wait to get your baby out of pain! Explain the list of symptoms your baby is suffering from, discuss the many hours a day you try to feed them. It is good to be informed and to be the advocate for your infant or toddler with reflux disease. Finally, you can connect with other Moms on Facebook. This can be helpful in understanding what other parents are facing and to see what they are doing to treat their baby’s reflux successfully. It also provides support. You are not the only one going through this difficult time for you and your infant.