Mrs. Chan, a young and first-time mother, comes to your office with her two-month-old child who is fussy and “vomits all the time.” Probing a little deeper, you find that the “vomiting” is effortless, more like spillage than vomiting. The baby cries sometimes after feedings but isn’t unduly uncomfortable before, during or after feeds. There’s never any blood in the “vomit” and on physical examination, the baby is following her growth curves beautifully at the 75% for height, weight and head circumference. Mrs. Chan, however, is extremely worried and upset about the “vomiting” and wants you to do something. What would you do?
Many physicians will prescribe a proton pump inhibitor (PPI). There’s some concern that these drugs are vastly over-prescribed for infants who are merely fussy or even colicky. One paper appearing in the Journal of Pediatric Gastroenterology and Nutrition1 demonstrated, in a retrospective observational study, that prescriptions for PPIs increased 7.5-fold from 1999 to 2004! This study has many limitations but there’s undoubtedly a trend towards increasing use in questionable clinical circumstances.
Growing up, throwing up
In adolescents and adults who can accurately report their symptoms, it’s much easier to diagnose gastroesophageal reflux disease (GERD), which requires treatment. Heartburn and regurgitation are cardinal symptoms in these age groups. On the other hand, infants’ symptoms aren’t provided first hand but from a third party, the mother. This makes symptom-based diagnosis more difficult. We know that up to 70% or more of normal healthy babies regurgitate and this resolves without intervention by the time the infant is upright and walking, usually by the age of 12-14 months.
A recent guideline on GERD, which is well worth reviewing by all physicians dealing with this problem in their daily practices, established criteria for the definition of GERD.2 Several consensus statements from this guideline are pertinent: #1 “GERD in pediatric patients is present when reflux of gastric contents is the cause of troublesome symptoms and/or complications;” #4 “Otherwise healthy newborns (age: 1-30 days) and infants (age: > 30 days to < 1 year) with reflux symptoms that are not troublesome and are without complications should not be diagnosed with GERD;” #9 “Regurgitation is a characteristic symptom of reflux in infants, but is neither necessary nor sufficient for a diagnosis of GERD, because it is not sensitive or specific.”
These are useful guidelines for the busy clinician and I particularly like the word, “troublesome.” While we can quibble about what constitutes a “troublesome” symptom, it does cover the clinical red flags which make us move from the diagnosis of simple reflux to disease-causing reflux, with or without mucosal damage. These symptoms would include significant pain during and after feeding, writhing movements, failure to thrive, blood streaking of the regurgitated food, as well as some extraesophageal symptoms such as Sandifer’s syndrome.
Excessive crying is less helpful because all infants cry and the median duration of crying is 3 hours per day, and in 1/3 of healthy infants crying can exceed 3 hours/day. Diagnosis can be improved when combining regurgitation, excessive crying and a standardized questionnaire such as the Infant Gastroesophageal Reflux Questionaire. More research needs to be done to validate such questionnaires as one study, authored by Susan Orenstein, a gastroenterologist with a special interest in reflux, demonstrated that even though one could separate normal infants from those with GERD using the questionnaire and validating results with the pH probe, there was no difference in control of symptoms comparing the normal infants with infants with GERD treated with a PPI.
The consensus guideline makes one other useful point: that the symptoms of food allergy (i.e. milk or soy protein allergy) and those of GERD are indistinguishable in the infant. One should therefore consider a protein hydrolysate infant formula before prescribing an H2 blocker in infants with symptoms and signs of GERD.
Lay off the strong stuff
Using H2 blockers and especially PPIs to treat reflux shouldn’t be undertaken lightly, and certainly not before one is convinced of the diagnosis. Infants under one year of age should not be treated with PPIs by a generalist. It’s worth remembering too that simple measures are often effective. These include thickening feeds (clearly not feasible for the breastfed infant), feeding the child lesser amounts but more frequently, avoiding too much handling of the infant immediately after feeding and trying to keep the infant upright for 20-30 minutes after feeding where possible. Parents should be encouraged to quit smoking as this is a significant risk factor for GERD in infants.