University of Virginia Health System

Gastroesophageal Reflux in Infants

What are some of the symptoms of gastroesophageal reflux?

Remember, we all have some gastroesophageal reflux. We only consider reflux abnormal when there is too much of it or there are unusual symptoms associated with it. Most of the time, we don't feel much when we reflux, however sometimes when adults have gastroesophageal reflux, they complain of:

• heartburn
• indigestion
• a feeling of food getting stuck in their throat (the medical term for this is dysphagia)
• recurrent or persistent hiccoughs

While we assume that young infants may have the same symptoms, we don't know for sure. The most common symptoms that young infants seem to experience with gastroesophageal reflux are:

• frequent or recurrent vomiting
• heartburn, gas, or abdominal pain

Many other symptoms are sometimes blamed on gastroesophageal reflux, but much of the time, we really aren't sure whether reflux actually causes them. Some less common problems seen in young infants that are may be blamed on gastroesophageal reflux include:

• colic or recurrent abdominal pain
• recurrent episodes of choking or gagging
• feeding problems
• poor growth
• unusual posturing such as wry-neck (torticollis) or arching (opisthotonus)
• apnea
• recurrent episodes of wheezing or pneumonia 

Colic, abdominal pain, and feeding difficulties and gastroesophageal reflux:

Older children and adults with chronic reflux sometimes  complain of frequent heartburn, chest pain, or indigestion. Some adults experience frequent or recurrent hiccups or complain that food "gets stuck" in their throat (dysphagia). Most of these symptoms are thought to develop when the esophageal lining becomes inflamed or irritated by chronic or repeated exposure to gastric acid and gastric digestive juices (esophagitis).

While we often assume young infants experience similar symptoms with reflux, it is very difficult to know whether a baby's irritability, difficulty sleeping, or feeding problems are caused by reflux.  Thirty-six percent of infants experience daily episodes of hiccups, 17% cry for at least an hour each day, and 10% have at least one episode of arching each day so these behaviors are by no means specific for reflux.   Nevertheless, there are reports of infants with feeding failure or feeding refusal, repeated arching (opisthotonus), or other unusual forms of posturing whose symptoms improve or resolve with treatment for reflux.

Very rarely, infants with chronic and/or severe reflux may develop erosive or bleeding esophagitis. This can result in blood being visible when the child vomits or spits up. If the esophagitis is extremely severe or it persists for a prolonged period of time, it is possible for esophageal scarring to develop. This is termed an esophageal stricture. It is very difficult to determine how many children with chronic reflux develop esophageal strictures, but they are clearly very rare.  Among adults with chronic esophagitis, only three in 1000 will develop esophageal strictures over many years of follow-up.

Poor growth and gastroesophageal reflux:

It is extremely unusual for gastroesophageal reflux to impair or limit a child’s growth as long as an adequate number of calories are being provided.  In most cases, poor growth in a child with gastroesophageal reflux occurs when a family unintentionally limits their child’s intake of calories.  To try and lessen the vomiting, they dilute the formula with water or limit milk/formula intake and substituting water or Pedialyte^®.    

Respiratory symptoms and gastroesophageal reflux:

There is a long list of respiratory symptoms that may be associated with gastroesophageal reflux, however, it is often difficult to know whether the reflux causes the lung problems or the other way around.  Since the windpipe (trachea) and the esophagus are very close together, many people have assumed that aspiration of refluxed stomach contents leads to respiratory symptoms.

Reflux of stomach contents up into the upper esophagus has been demonstrated in some patients with recurrent respiratory symptoms, however this appears to be very uncommon and is probably extemely rare among children who are neurologically normal.

While children with neurological abnormalities may aspirate refluxed stomach contents, more often, these children aspirate while they are eating.  This is called laryngeal penetration and it occurs when swallow-breathe patterns are not well coordinated. Normally, with the initiation of a swallow, there is a pause in breathing and the larynx closes to protect the airway. In children who show no swallowing difficulties, it is reasonable to assume that these protective reflexes will function during an episode of gastroesophageal reflux.

There are reports describing children who suffer from  chronic congestion and chronic hoarseness having gastroesophageal reflux.  It is thought that aspiration of refluxed stomach contents causes inflammation and swelling of the upper airways and results in noisy breathing (stridor) or spasms of the vocal cords (laryngospasm).  If evaluation of the upper airway demonstrates chronic inflammation, it is reasonable to consider GER as a potential source of the symptoms.

The role of GER in apnea (stopping breathing) and bradycardia (slowing of the heart rate) has been of great interest because of the potentially life-threatening nature of these symptoms. Although many studies have demonstrated that infants with apnea may have gastroesophageal reflux, there is usually little or no correlation between apneic episodes and reflux episodes.  Instances in which apnea and GER have been directly associated in a cause-and-effect manner are extremely uncommon.

Both children and adults with chronic asthma have an increased incidence of gastroesophageal reflux. However, it is extremely difficult to know whether reflux causes asthma or asthma causes reflux. Chronic asthma may precipitate reflux since chronic coughing and increased respiratory efforts increase abdominal pressure which tends to force stomach contents upwards. Among children with chronic asthma, the overall incidence of gastroesophageal reflux has been reported to range between 46 and 75%. In one study, 82% of adult asthmatics had evidence of reflux!. Relatively few children with chronic asthma experience significant improvement in their asthma when they are treated for reflux so while reflux should be considered as a possible cause of uncontrolled chronic respiratory symptoms in children, it is important to remember that many of the trigger factors for wheezing also trigger gastroesophageal reflux.