Babies who spit up
Watch for infants who cross the line to GERD
by Richard Haber, MD
Vol.16, No.05, May 2008

Mrs. A.S. brings her 5-week-old son, Ali, to your office with the complaint that he’s constantly “vomiting.” On further questioning, you discover that some gastric contents often gush out effortlessly after feedings and during attempts at burping the baby, who’s not as discomfited as the mother. Gastroesophageal reflux (GER) is seen in 70-80% of infants and is generally benign. The astute clinician must distinguish between simple GER and reflux disease (GERD) requiring treatment.

Key signs to look for

A good history and physical examination are essential. Key points to inquire about are:

  • Is there any blood in the emesis?
  • Is it forceful or projectile, suggesting pyloric stenosis? A word of caution — many mothers describe all regurgitation as projectile; evaluate the true meaning of the word.
  • Is it bilious, indicative of small bowel obstruction?
  • Is the baby uncomfortable or irritable, especially after feedings?
  • At what age did it start? Simple GER begins early (< 4 mo).

The physical examination should be benign in the case of GER. Check the growth curve with several measurements over time to obtain the growth trajectory. Any infant with regurgitation and failure to thrive falls into the diagnostic category of GERD, not GER. Epigastric tenderness with a history of irritability and pain point toward esophagitis, or GERD. Other ominous findings include: macrocephaly (possibility of hydrocephalus), bulging fontanel (increased intracranial pressure), hepatosplenomegaly (perhaps a metabolic disorder), abdominal mass, or a palpated “olive” indicating pyloric stenosis.

Treatment for GERD

An infant with benign reflux who’s thriving requires no investigations and no treatment — the condition is harmless and self-limiting. The child with GERD, though, will require therapy, both non-pharmacologic and with meds. For instance, infants will regurgitate less in the prone position than supine, so a change in positioning may be good. This, of course, conflicts with the advice of putting babies to bed on their back to prevent sudden infant death syndrome (SIDS), so we can’t recommend sleeping on the stomach. Although an upright position may decrease spit-up, placing an infant in a car seat or seated position may actually increase it. For bottle-fed babies, thickening the formula with rice cereal (15 mL dry per 30 mL formula) can be helpful. Finally, an acid suppressant such as cimetidine (5-15 mg/kg/day divided into 2 doses) may be prescribed for extreme fussiness and pain of esophagitis.

One of the common pitfalls is to presume a milk allergy and advise a change to soy-based formula. Occasionally, infants with that diagnosis may present with emesis, but they’d often have diarrhea and blood in the stool. This is not the case with the majority of infants with GERD, nor is there any benefit to discontinuing breastfeeding. A recent study by S.R. Orenstein and J.D. McGowan (J Pediatr 2008;152[3]: 310-4) showed that conservative measures plus tobacco smoke avoidance resulted in a decrease in symptoms in 78% of infants with GERD, after only 2 weeks.

Richard Haber, MD, FAAP, FRCPC is an associate professor of pediatrics at McGill University and the Director of the Pediatric Consultation Centre at the Montreal Children’s Hospital.

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