How can we treat gastroesophageal reflux?
The most important thing to remember when treating gastroesophageal reflux is that in almost all cases, the problem will get better on its own! With that in mind, most of our treatments are geared towards lessening the symptoms of the reflux, not fixing it. Given enough time, the baby will fix the problem on his or her own.
If you think of gastroesophageal reflux as incoordination of the baby's upper intestinal tract, then, as the baby's overall coordination improves, the reflux will improve too. Most of the time, when the child is able to sit-up well without any assistance, the reflux starts to get better. This is usually around six months of age. Most of the time, when the baby is able to walk proficiently, the reflux tends to disappear. This is usually around twelve months of age.
Treatments for reflux can best by summarized in several broad categories:
Positioning
Theoretically, the best position to but a baby with reflux in after meals is lying on their stomach with their head propped up about 30 degrees. Lying in this position causes the stomach to fall forward, closing the connection between the stomach and the esophagus. Remember, this is only theoretical! Same infants will not lie in this position without crying, and if the baby cries all the time, they fill up their stomach with air, grunt, and strain, which tends to make their reflux worse.
Perhaps more important than using the "best" position, is avoiding "bad" positions. In young infants who don't have much control of their abdominal or chest muscles, when they are placed in an infant seat or swing, they tend to slump down. This increases the pressure in the their stomachs which tends to worsen their reflux. It is much better to lie them down or place them in a seat that reclines a bit than to have them slumped down.
Dietary Treatments
While many parents and families attribute gastroesophageal reflux to sensitivities or allergies to milk or fomula, there is no convincing evidence to support this. While many infants will have less vomiting when they are switched from one type of milk to another, in most cases, this improvement only lasts two or three days. While there are certainly some infants who do better on one type of formula than another, most infants continue to vomit no matter what type of milk they are fed with (including breast milk).
Many parents are instructed to thicken their infants feedings with cereal as a way of lessening reflux. By thickening the feedings with cereal, the milk is physically heavier, and thus less likely to come back up. There are however, some problems with thickening feedings with cereal. It is not possible to thicken feedings if the baby is largely breast fed. Also, many infants with reflux are very vigorous or voracious feeders. When the milk is thickened with cereal, the baby has to suck harder to get the milk through the nipple. This may cause the baby to fill their stomach with air which can actually worsen the symptoms of reflux.
Many parents find that their babies keep solid foods down more effectively than liquids. This may simply be because solid foods are heavier and thus less likely to come back up, but also, solid foods are emptied out the stomach differently than liquids are. In any case, there is no evidence to suggest that feeding young infants solid foods with a spoon or from an infant feeder is harmful. In many cultures around the world, infants have been fed solid foods in the first month of life for centuries without any problems. There is no evidence to suggest that early introduction of solid foods predisposes to allergies later in life.
Changing Feeding Schedules
Parents are sometimes instructed to feed their babies smaller amounts more often with the idea that over-feeding tends to make reflux worse. Unfortunately, many babies with reflux are not satisfied with only one and a half or two ounces of milk, and they will cry for more. Again, when babies cries for extended periods, they fill their stomachs with air, they grunt, and they strain, all of which tend to make reflux worse.
Medications
While many different medications may be used to try and treat reflux, most of the medications fall into three groups:
- medications that break down or lessen intestinal gas
- medications that decrease or neutralize stomach acid
- medications that improve intestinal coordination
Medications that break down or lessen intestinal gas
Medications that decrease or neutralize stomach acid
Antacids
- Mylanta®
- Maalox®
- Carafate® (sucralfate)
Medcines that inhibit stomach acid secretion or production
- Tagamet® (cimetidine)
- Zantac® (ranitidine)
- Pepcid® (famotidine)
- Axid® (nizatidine)
- Prilosec® (omeprazole)
- Prevacid® (lansoprazole)
- Nexium® (esomeprazole)
It is assumed that decreasing the amount of stomach acid will lessen the symptoms of reflux. While this has clearly been shown in adults, very few studies have been published examining the effectiveness of these medicines in young children. In theory, these types of medications should be helpful to those babies who are having "heartburn" and nearly three fourths of parents report that their babies spit up or throw up less and seem to have less "heartburn" when they take Gaviscon®.
For the most part, medicines that decrease intestinal gas or neutralize stomach acid (antacids) are very safe. At high doses, Mylicon®, Gaviscon®, Maalox®, and Mylanta® may function as laxatives and cause some diarrhea. Chronic use of very high doses of Maalox® or Mylanta® may be associated with an increased risk of rickets (thinning of the bones).
Side effects from medications that inhibit the production of stomach acid are quite uncommon. A small number of children may develop some sleepiness when they take Zantac®, Pepcid®, Axid®, or Tagamet®. Tagamet® may can increase blood levels of certain other medicines including the blood thinner coumadin and the anti-seizure medicine Dilantin®.
Medications the improve intestinal coordination
- Reglan® (metoclopramide)
- Propulcid® (cisapride)
- erythromycin
While Reglan® increases the pressure of the lower esophageal sphincter (LES) and helps that stomach to empty more quickly, in most infants, this medicine does not improve the symptoms of reflux. Rarely, Reglan® can cause frightening side effects. Young infants may develop dystonia (tenseness or stiffness of the muscles) and children with epilepsy appear to be at increased risk of having seizures when taking Reglan®.
Propulcid® was withdrawn from the U.S. market during the spring of 2000 however it is still available in Canada and Europe. Like Reglan®, Propulcid® increases the pressure of the lower esophageal sphincter (LES). Propulcid® increases emptying of the stomach as well as the rate which food moves through the lower intestines. Nearly three fourths of parents report that their babies spit up or throw up less and seem to have less "heartburn" when they take Propulcid®. Serious side effects from Propulcid® are uncommon. Some children will experience some cramping or diarrhea, particularly at higher doses. There have been some reports of children taking Propulcid® developing abnormal heart rhythms. This side-effect seems to be more likely if the Propulcid® is taken with certain other medicines including the antibitiotics erythromycin and clarithromycin and the anti-fungal medicines Nizoral® (ketoconazole) and Diflucan® (fluconazole).
Erythromycin is an antibiotic that is frequently used to treat a variety of common infections. One fairly common side effect of erythromycin is abdominal cramps due to vigorous stomach contractions. In some infants and children with gastroesophageal reflux this side effect can be used to our advantage, causing the food to be emptied out of the stomach more quickly than usual, and therefore lessening the symptoms of the reflux.
Surgery
Fortunately, it is extremely rare for children suffering from gastroesophageal reflux to require surgery. In those very few children who do require surgery, the most commonly performed operation is called Nissen fundoplication. With this operation, the top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts preventing reflux.
This operation is very effective at eliminating gastroesophageal reflux with long-term success rates approaching 90%, however, some children may develop very disturbing and debilitating symptoms following fundoplication. The risks and benefits of surgery must therefore be weighed very carefully.
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