Gastroesophageal reflux (GER) – also called acid reflux, heartburn, and acid indigestion – is a painful medical condition in which the acid-containing stomach contents regurgitate back into the esophagus. Normally during swallowing, the food travels down the long, muscular tube called the esophagus. The muscles in the wall of the esophagus contract from top to bottom pushing the food down into the stomach. Once swallowing is over and all the food has entered the stomach, a circular band of muscle called the lower esophageal sphincter (LES), where the esophagus joins the stomach, contracts and acts like a door that closes to keep stomach contents and stomach acids from regurgitating, or refluxing, back into the esophagus. If, instead of closing, the LES remains open, stomach acids reflux back into the esophagus and irritate, or "burn," the sensitive lining of the esophagus causing pain. The degree of pain the infant has depends upon the severity of the reflux. If the stomach contents reflux just partway up the esophagus, baby may hurt, but not spit-up or vomit. If reflux is severe, the baby may spit-up a little, or a lot. Sometimes the refluxed gastric contents can enter the back of the throat, causing a sore throat, choking, gagging, coughing, erosion of dental enamel, and even be aspirated into the lungs, causing respiratory infections, wheezing, and asthma- like symptoms.

Usually infants associate feeding with comfort, yet the baby with GER may associate feeding with pain and refuse to feed, and show poor weight gain. Or, because breastmilk and formula neutralize the stomach acids, the infant may want to "feed constantly." Because gravity holds the stomach contents down and, therefore, lessens reflux, babies will often seem more comfortable when upright, but shriek in pain when put down to sleep.

Not only does GER hurt babies, it hurts parents, who may be erroneously led to believe that their baby cries a lot because they just have a "fussy baby" or something is wrong with their parenting, which is not true. Undiagnosed and untreated reflux often results in the "hurting family."

In the early months, around two-thirds of all babies have some degree of GER, which accounts for the frequent spitting up that most babies have. The spitting up does not usually bother these babies, dubbed "happy spitters." It is not painful, does not slow weight gain, and is more of a laundry problem than a medical one. GER becomes a problem (called GERD – gastroesophageal reflux disease) when it causes painful irritation or damage to the esophagus, interferes with growth and development, interferes with feeding and sleeping, and/or contributes to respiratory problems.

Symptomatic GER usually starts between two to four weeks of age, peaks around four months of age and begins to subside around seven months of age, when babies begin spending most of their days upright, start solid foods and by the law of gravity, food stays down easier. Most infants will outgrow GER by one year of age – I call this "walking away from GER." Yet, in some children, GER continues throughout childhood, and sometimes into adulthood, where it is manifested more by "heartburn" and "wheezing" episodes.

Clues that your baby suffers from GER enough to need treatment are:

• Frequent spitting up or vomiting (not all babies with GER spit up)
• Baby isn't outgrowing the "colic" and/or spitting up
• Frequent blasts of crying that are painful cries, not just baby cries
• Your gut feeling tells you that your baby "hurts somewhere"
• Bursts of nightwaking "as if in pain"
• Colicky, abdominal pain after eating, even as long as one hour afterwards
• Poor sleep habits, restless
• Writhing as if in pain: drawing up legs, arching back
• Erratic feeding patterns. Refuses to feed or wants to breast or bottlefeed all the time.
• Frequent "wet burps" or "wet hiccups"
• Throaty noises: swallowing noises, choking, gagging
• Frequent, unexplained colds, wheezing, and chest infections
• Stop-breathing episodes
• Excessive drooling
• Spits up like a "volcano"

Other symptoms in toddlers and older children:

• Bodily contortions: head tilt or arching back and body twisting motions after eating
• Swallowing difficulties
• Bad breath
• Dental cavities from eroding enamel
• Eats and/or drinks constantly
• Doesn't want to eat
• Poor weight gain
• Hoarse voice
• Excessive drooling
• Frequent sore throats
• Respiratory problems: wheezing, frequent coughing, asthma
• Frequent ear infections
• Bitter aftertaste in mouth after eating, "sour burps"
• Post-feeding fussiness

The following are clues and tests that your baby has GER and how aggressively it should be treated:

• Parents' observations. Your doctor may suspect GER based upon your observations. Parents need to be keen observers and accurate reporters. Go through the above list of signs and symptoms and write down how many of these your baby has and how often. Impress upon your doctor the severity of these symptoms. Is it simply an occasional spitting up nuisance, or a restless night? Or is it a daily, even hourly, occurrence, enough to interfere with your infant's well being – and yours. To show how much your baby truly is hurting, show your doctor a videotape. Let your doctor know how much of a problem this is for your family. One patient said to me, "I am camping out in your office until you find out what's wrong with my baby." A father in my practice told me that he was so disturbed by his baby's incessant crying that he had a vasectomy. Oftentimes, a doctor will begin treatment based upon a parent's history alone and not wait for the results of the tests. Or, if the diagnosis is in doubt, your doctor may order some of the following tests:

• Barium swallow x-ray (fluoroscopy). Also known as an upper G.I. series, baby swallows some barium that outlines the esophagus, stomach, and upper intestines. The main reason for this upper G.I. study is to exclude other causes of vomiting, such as the anatomical abnormalities of the stomach or intestines that could cause a partial obstruction. An upper G.I. series is not considered diagnostic of GER, since most infants show some degree of reflux that shows up on the x-ray.

• pH probe. A thin, flexible tubing is placed through your baby's mouth or nose into the esophagus just above the entrance to the stomach. The tip of the tube measures stomach acid that is regurgitated up into the esophagus. The pH probe is the most sensitive test for measuring the frequency and degree of acid reflux. The probe is left in for 12 to 24 hours. This can be done either overnight in the hospital or in your own home. A technician skilled in probe placement comes to your home, places the probe into baby's esophagus, and attaches it to the recording machine. The recording is then monitored for 12 to 24 hours.

  Dr. Sears suggests: A useful diagnostic tool I have found is to have parents record the severity, frequency, and timing of their baby's hurting episodes while the ph probe is in and try to correlate them with the probe readings of acid reflux. If they correlate, this suggests acid reflux is indeed the cause of baby's hurting.

• Scintography. Baby is fed a bottle of breastmilk or formula that contains a radioactive substance. A computerized scan of baby's abdomen reveals if it takes a long time for the stomach to empty – called "delayed gastric emptying." Slow gastric emptying contributes to GER. This scanning technique is not considered reliable for showing the presence or degree of GER, but merely gives a clue to delayed gastric emptying contributing to GER. It can also show aspiration of reflux material into the lungs.

• Endoscopy (esophagoscopy). Under light anesthesia as an outpatient, a pediatric gastroenterologist inserts a flexible tube into baby's esophagus, stomach, and upper intestine; the doctor examines these areas for abnormalities and especially looks at the lining of the esophagus for damage – called esophagitis. The presence and degree of reflux esophagitis gives a clue of the severity of the reflux and guides the doctor into how aggressive the treatment regimen should be.

Dr. Sears suggests: I recently saw a nine-month-old infant for fussy- baby counseling whose mother had been advised to "let him cry-it-out." She was told she was anxious and overreacting, and that he was just manipulating her. Mother's gut feeling told her "I know something is wrong with him." After listening to her, I suspected severe GER. The endoscopy showed severe erosion and ulcerations of the lower end of the child's esophagus. The damage from the reflux was so severe that baby needed surgical correction. Mother knows best! Lose points for the let-him-cry-it-out crowd.

How long and how aggressively GER is treated depends upon the severity of the reflux and how much it is interfering with an infant's growth and well-being.

Dr. Sears suggests: any GER treatment regimen is primarily parental, in addition to medical. Babies with reflux require parental intensive care, as you will soon learn.

Treatment for reflux is aimed at keeping baby comfortable and thriving and minimizing possible esophageal damage until the natural intestinal maturity enables baby to outgrow this condition. The basis of GER treatment is:

1. Developing a feeding pattern and choosing foods that keep the stomach emptying rapidly and the food going down instead of up.

2. Positioning your infant – day and night – that allows gravity to help keep the food down.

3. Developing a parenting style that lessens crying, since crying increases intra-abdominal pressure, which worsens the reflux.

1. Practice attachment parenting. This high-touch style of parenting decreases baby's need to cry (remember, crying increases reflux) and increases parents' ability to cope. Less crying and more coping is the basic recipe for living with GER. The painful shrieking cries of GER babies can take its toll on parents, often producing parental anger. There have been cases of child abuse and the shaken baby syndrome when parents have been unable to manage their baby with GER. Attachment parenting (especially the three baby B's of breastfeeding, babywearing, and belief in the signal value of baby's cries) not only comforts the hurting baby, but helps parents more intuitively read their baby's pre-cry, or about-to-reflux body language, and intervene appropriately. Attachment parenting (AP) increases the maternal hormones prolactin and oxytocin, which have a calming and relaxing effect on mother. Above all, shun the "cry-it-out crowd." Babies with GER cry because they hurt. Consider your nurturing response to your baby's cry as baby's best medicine. See Attachment Parenting for detailed information on how this style of parenting helps parents and babies thrive.

   Dr. Sears suggests: Don't take it personally that your baby cries a lot. A baby knows that his parents are there and care, even if they can't always relieve the pain.

2. Keep baby semi-upright, especially during feedings. Gravity helps minimize reflux by helping the food stay down instead of go up. Wear your infant in a baby sling most of the day. See babywearing for instructions. Be cautious in leaving a baby with GER sitting for long periods in carseats or infant seats. Some sitting positions can actually increase reflex in some infants.

   Dr. Sears suggests: Wearing your baby in a sling keeps baby in an upright position and helps gravity keep the food down.

3. Keep baby quiet after feedings. Cuddle with your baby or wear your baby in a sling for at least thirty minutes after a feeding. Above all, don't jostle or vigorously play with baby after feedings. This can cause stomach contents to splash around and increase reflux.

4. Offer smaller feedings more frequently. As a rule of reflux feeding: feed half as much twice as often. Less food in the stomach at one time lessens reflux. Feeding frequently stimulates more saliva production. Saliva contains a healing substance called epidermal growth factor, which helps repair the damaged tissues in the esophagus. It also neutralizes stomach acid and lubricates the irritated lining of the esophagus.

5. Burp baby efficiently. Excess swallowed gastrointestinal air aggravates reflux. If breastfeeding, burp when switching breasts. If bottlefeeding, burp after every few ounces of formula.

6. Breastfeed your baby. GER is much less severe in the breastfed baby, and a breastfed mother is able to cope better, for the following reasons:
   • Breastmilk empties from the stomach twice as fast as formula.
   • Breastmilk is generally more intestine-friendly than formula.
   • Breastfed babies naturally feed more frequently and breastmilk is a natural antacid.
   • Mothers enjoy the relaxing effect of maternal hormones while breastfeeding.

7. Don't bottle-prop and leave baby unsupervised during feedings. Babies with reflux can gag, choke, and have stop-breathing episodes during a feeding.

8. Work out a reflux-friendly sleeping position. While it is always safest to put infants under six months of age to sleep on their backs to reduce the risk of SIDS, babies with severe reflux often sleep more comfortably and safely on their tummies, or on their left side. (When sleeping on the left side, the gastric inlet is higher than the outlet, which helps gravity keep the food down.) Discuss with your doctor whether the reflux is severe enough to warrant tummy sleeping. Otherwise put your baby to sleep on her back. Other reflux-lowering helpers are:
   • Elevate the head of baby's crib thirty degrees.
   • If baby sleeps in your bed, try placing baby on a reflux wedge (available at infant product stores). Try The Tucker Sling™. This sling fits around the upper part of the mattress like a contour sheet. A diaper-shaped part goes between baby's legs and fastens around the waist with velcro. This sling, designed by a mother who's infant, Tucker, suffered from severe GER, keeps baby from sliding down to the foot of the mattress when the mattress is elevated. (For more information about The Tucker Sling and reflux wedges, click on www.tuckerdesigns.com)

   Dr. Sears suggests: Unless advised by your doctor, avoid the frequent use of decongestants. Infants and children with reflux tend to build up congestion during the night, yet decongestants can make the secretions thicker and harder to cough up.

9. Minimize air swallowing and gas. If breastfeeding, be sure baby has a tight seal (See Latch-on Basics). If bottlefeeding, try bottles and nipples which minimize air swallowing. Simethicone (Mylicon) drops are marginally effective. This substance breaks up large stomach bubbles into smaller stomach bubbles, which are easier to pass. Excess air in the stomach and intestines acts as a pneumatic pump, so when the stomach contracts it can cause stomach contents to reflux.

10. Don't smoke around baby. Nicotine stimulates gastric acid production and opens the lower esophageal sphincter.

11. Try pacifiers. While the most effective pacifiers will be your touch and your holding, some infants with GER are helped by the frequent use of pacifiers. Non-nutritive sucking can often ease reflux. This is why breastfeeding mothers often find that their babies with GER want to "nurse constantly." (Yet, some babies with severe GER refuse to feed often because they associate feeding with pain.) Frequent sucking stimulates saliva production, which, as described above, eases the irritation of reflux. Yet, vigorously sucking on pacifiers aggravates GER in some infants by increasing air swallowing. (See Pacifiers to see how to use, but not abuse, them)

12. Thicken feedings. If your baby is bottlefeeding and ready for solids (between four and six months of age), and if recommended by your doctor, thicken baby's feedings with one or two tablespoons of rice cereal in each eight-ounce bottle. Gravity holds heavier food down more easily.

13. Additional reflux treatment for toddlers and older children:
    • Chew-chew-chew. Teach your child how to take small bites and chew the food well. Food chewed into smaller particles empties from the stomach faster.

    • Let your child graze. Small, frequent mini-meals are easier to digest. See Grazing for some helpful tips on offering your child a Nibble Tray.

    • Lessen before bedtime eating. Eat dinner earlier in the evening and serve rapid-transit foods for the evening meal and bedtime snack. Adults with reflux often remember, "Don't dine after nine."

    • Get friendly with your blender. Fruit-and-yogurt smoothies and blended vegetables are liquid enough to pass through the stomach quickly and therefore are less likely to cause reflux. See Smoothies for suggestions.

    • Don't drink fluids with a meal. While the stomach churns the food, it splashes the fluids (and the stomach acids) back up into the esophagus.

    • Keep your child lean. Obesity aggravates reflux.

    • Eat rapid-transit foods. Low fat, mushy foods pass through the stomach more quickly, unlike the following foods that linger in the stomach for a while.

    FOODS THAT MAY AGGRAVATE REFLUX

    • Fatty foods
    • Fried foods
    • Stringy foods: seeds, skins, stringy fruits and vegetables
    • Acidic foods: citrus, tomatoes, peppers, onions
    • Meats with a lot of gristle
    • Alcohol
    • Caffeine: coffee, tea, soft drinks (caffeine increases gastric stomach acid production)
    • Chocolate
    • Carbonated beverages
    • Spices
    • Peppermint
    • Chilies
    • High sorbitol fruit juices (prune, pear, and apple)
14. Sit and stand still and eat. Jostling causes stomach acids to splash up into the esophagus. Encourage your child to sit or stand still for thirty minutes after eating.

15. Medications for GER:
    • Antacids. These neutralize stomach acids (e.g. Mylanta and Maalox). Given three or four times a day with each feeding (dosage to be determined by child's doctor). They start working rapidly but the neutralizing effect lasts only a couple of hours or less. For older children, chewables work better because they stimulate and mix with the saliva to help antacids stick to the lining of the esophagus where it can better neutralize stomach acids. Used to excess can contribute to constipation or diarrhea.

    • Acid blockers. These medicines block stomach acid production: Zantac, Pepcid, Tagamet, Prilosec. They can take anywhere from 30 minutes to a couple of hours to take effect, yet may last for 8 hours. They are usually given twice a day. If GER awakens your child give a dose one hour before bedtime.

    • Motility medicines. Work by increasing muscle tone and therefore tightening the lower esophageal sphincter muscle, or increase the movement of the muscle tone of the stomach and upper intestines, and thereby increase gastric emptying. They are sometimes referred to as prokinetics. The most common ones currently used in order of frequency are:
      • Urecholine (bethanechol). Side effects include cramping and diarrhea. This is the medication we most commonly use in our practice.

      • Reglan (metclopramide). Side effects include restlessness, twitching, and fainting. Because of the frequency of unpleasant side effects, we seldom use this medication in our pediatric practice.

      • Propulsid (cisapride) is a very effective prokinetic agent for increasing gastric emptying. Yet, because of the recently discovered side effects of cardiac arrhythmias, it is not used for reflux management without first performing an electrocardiogram.

    Dr. Sears suggests: Remember, while medications can certainly help ease the discomfort of GER and minimize esophageal damage, they should always be used in addition to, but not instead of most of the above parenting, positioning, and feeding suggestions. Be sure to work closely with your infant's doctor and/or a pediatric gastroenterologist toward working out a GER management regimen that works best and safest for your child.

16. Surgery for GER. Surgical correction of GER is now being performed more frequently for several reasons: the debilitating nature of GER is being more widely appreciated, so that doctors are now becoming more knowledgeable and aggressive about its treatment. Also, surgical procedures have become safer, more refined, and now most are done through laparoscopy, sparing the child from a large abdominal incision and prolonged postoperative recovery. I have assisted at laparoscopy procedures in infants. Basically, this surgery is done through several punctures through the abdominal wall. The surgeon then operates by use of small tubes inserted through these holes with tiny cameras at the end of the tube, while the surgeon observes the infant's insides on a nearby video screen. My first thought when I initially assisted with a laparoscopy procedure was how the current generation of video-game players could grow up to be magnificent laparoscopy surgeons.

    The general aim of GER surgery is fundoplication, which means a band of upper stomach muscle is wrapped totally, or partially, around the lower esophagus, in effect tightening the valve and lessening reflux. In the Nissan procedure, a total 360-degree wrap is performed, whereas in the Thal procedure a partial wrap is performed. Because with the total wrap a child can lose the protective ability to vomit, burp, and retch, the partial wrap is often the preferred choice. In a 1987 study of 7,467 infants and children operated on for GER, there was a 94 percent cure rate. GER surgery is considered particularly beneficial for infants who are neurologically impaired.

    The main criteria that doctors use in deciding when and if to perform fundoplication surgery is how much the GER is bothering the child, is the GER increasing in severity and frequency, and how much esophageal damage is seen on the esophagoscopy, and whether the more conservative treatment regimens are working. Ideally, the fundoplication is performed before severe esophageal damage occurs, which if untreated can lead to life-long debilitating narrowing of the lower esophagus (called esophageal stricture).

17. Keep a diary. Parents are VIPs (very important persons) in the GER management team. You need to be a keen observer and accurate reporter of your child's symptoms, since the doctor will often gauge the aggressiveness of the treatment regimen based upon your reporting. The doctor also relies upon your recording and reporting to modify treatment, such as changing medications or adjusting dosages. Keep a reflux diary listing the main symptoms your child has, the treatment regimen, and the progress (better, worse, no change). A sample of such a diary could be:

    SAMPLE GER DIARY
    GER Symptoms	Treatment	Better	Worse	No change