Gastroesophageal reflux is the passage of gastric contents upstream of the esophagus, which can appear episodically and physiologically in infants.
What is gastroesophageal reflux?
Gastroesophageal reflux is the passage of gastric contents upstream of the esophagus, which can appear episodically and physiologically in infants. It is more common in younger babies, from 0 to 4 months, decreasing in frequency as the first year of life passes.
These episodes of regurgitation usually appear after ingestion and are often not associated with accompanying symptoms or signs. However, when the reflux is more intense, frequent and aggressive with the esophageal mucosa (lining) and is accompanied by symptoms such as weight loss and other digestive or respiratory, it is referred to as Gastroesophageal Reflux Disease, which is estimated to occur in 8% of infants.
What produces it?
Gastroesophageal reflux occurs at times when there is incompetence of the lower esophageal sphincter, a valve that functions as a non-reversible gateway for food from the esophageal tube into the stomach. When this valve is more immature and there is an abnormal relaxation of the valve, the stomach contents return retrogressively towards the esophagus.
This fact, together with the reduced activity of the normal muscular contractions of the esophagus in babies, which serve to move food towards the stomach and to “clean” the contents of possible episodes of reflux, favours that the acid content of the gastric juices ends up damaging the esophageal mucosa (not the esophagus).
Other associated factors that favour the appearance of gastroesophageal reflux are an increase in intra-abdominal pressure (due to coughing or crying for example), a fatty diet, lying down position (in decubitus), hiatus hernia, etc.
What are the symptoms?
In the case of episodes of functional or physiological gastroesophageal reflux, infants do not have any accompanying symptoms. They can usually present a milk regurgitation after the feedings, without showing discomfort, crying or irritability.
Conversely, when there is gastroesophageal reflux disease, infants may have a variety of symptoms. It is common for the child to suffer a developmental alteration of the stature-weight, i.e. weight loss and growth retardation. This is associated with the presence of persistent regurgitation and/or vomiting. Sometimes vomiting may contain blood (hematemesis) and commonly appear after feeding, when the baby is lying down. Pain can also appear in the central region of the thorax that in babies, often manifests as irritability or crying. They may also have a sensation of acidity or “heartburn”, difficulty in swallowing, pharyngeal pain when swallowing (odynophagia), and sometimes, the presence of blood in the stool (black stools for digested blood), or anemia. All of these symptoms can lead to the baby’s rejection of feedings, sometimes showing arching movements of the body backward when suckling or bottle-feeding. This, together with the vomiting, favors the child’s malnutrition.
In addition, symptoms may be manifested by the involvement of this reflux in the respiratory or otolaryngological apparatus. Thus, there are children who present episodes of laryngitis, hoarseness, respiratory stridor, repetitive otitis, sinusitis, persistent cough, obstructive apneas (interruptions of breathing), repetitive pneumonia, bronchospasm, asthma, and so on.
In a small percentage of children who have not undergone adequate treatment or reflux disease has not been properly diagnosed, complications such as peptic stenosis (narrowing of the lower esophagus), Barrett’s esophagus (alteration of the mucosa of the esophagus by persistent damage produced by gastric acids), which can lead to ulcers, stenosis or adenocarcinomas (tumors) in the esophagus, although this degree of complication is rarer in babies.
How’s the diagnosis?
In mild cases, the paediatrician can make the diagnosis by means of an appropriate clinical questioning of the baby’s parents or caregivers, asking them about the child’s symptoms, history, etc., accompanied by an appropriate physical examination.
On other occasions, when there are diagnostic doubts, the manifestations are more serious, or the aim is to objectify the response to an already established treatment, complementary tests are carried out that help to determine the diagnosis and the possible associated complications.
Within the diagnostic tests, one or the other may be performed on each patient, depending on the symptoms presented by the child and the suspicions that the doctors have of the possible associated complications that the child may suffer.
Thus, an esophageal pH-metry can be performed, in which a continuous measurement of the esophageal pH is carried out for 24 hours; an esophagogastrography with barium, a radiological study with a contrast that helps to detect anatomical alterations (hiatal hernia, esophageal stricture, etc); also an upper endoscopy (esophagoscopy), where a flexible tube with a camera at its end is introduced through the mouth, which allows the mucosa of the esophagus to be visualised and possible lesions produced by reflux (esophagitis) to be detected, in addition to being able to obtain a small sample of the damaged tissue, a biopsy, to be studied in the pathological anatomy laboratory. Another test that may be indicated is a multichannel intraluminal impedance measurement, which by placing sensors in the esophagus by means of a catheter, detects the movement of liquid material or gas within the esophagus, facilitating, in this case, the detection of episodes of non-acidic reflux. Other types of tests that are sometimes required to be performed may be gastric gammagraphy, esophageal manometry, ultrasound…
What’s the treatment?
In terms of treatment, there are three types of therapeutic lines that may need to be applied in a single or complementary way.
On the one hand, postural measures are recommended, such as placing the baby in the crib in a lying position on the left side of the body (left lateral decubitus). Although decreased reflux has been shown when the child is lying “on the stomach” (prone), as this position has been shown to be a risk factor for sudden infant death, it is only exceptionally recommended in older infants and in those infants with reflux that is difficult to control, under strict supervision. There is controversy about the real benefit of raising the headboard in these cases.
Together with these measures, the modification of the feeding can improve the baby’s symptomatology. In this sense, the use of artificial anti-reflux formulas (thickening formulas) is indicated, or in the case of children with allergy to cow’s milk protein, the use of hydrolysed formulas improves gastroesophageal reflux.
In terms of pharmacological treatment, when there is gastroesophageal reflux disease in babies, paediatricians may indicate the use of anti-secretory drugs such as omeprazole, ranitidine or cimetidine; antacid drugs used in short periods of time, such as aluminum or magnesium hydroxide; prokinetic drugs such as cisapride may also be used in certain cases.
On children suffering from severe gastroesophageal reflux disease and who do not respond to pharmacological treatments, presenting important complications, surgery (such as Nissen fundoplication or percutaneous endoscopic gastrostomy) may be indicated.