WHAT IS GASTROESOPHAGEAL REFLUX?

There are just a few photographs of my second daughter, Marta, in her early months of life. In one of them, taken during the Christmas holidays, when she was just three months old, her tiny face is pale and sad, and a little stream of regurgitated milk comes out of her mouth. It was her trade mark. Curdled milk everywhere: on the bibs, on our shoulders, on the carpet. And the sour cheese smell, for which we had nicknamed her “formaggino (little cheese)”. We were amazed at her ability to burp loudly even hours after feeding. Noises that had earned her another nickname, “the dockworker”.  Hiccups tormented her after almost every feeding. I remember that we had noticed them when she was still in her mother’s womb, by the rhythmic jerking of her little body.  

Then the colic, the crying, the agitation. Sometimes she seemed to experience excruciating  pains. She often had a dejected expression on her face, as if she were resigned to her suffering, while her pediatrician insisted stating that she had “colic”. 

But her “colic”, which should have ended at three months, went on well beyond six months. Even though the more obvious signs of her trouble, like the continual regurgitation, gradually subsided, she kept having here and there bouts of vomiting. Also her tendency to burp long after meals stayed with her. The hiccups were less frequent, but her nervousness and her inability to rest remained unchanged. Rest? A real luxury for us all. Marta didn’t sleep, or rather, during her sleep rolled around constantly, and woke up crying innumerable times, keeping everybody awake. Her preferred position was face down,  kneeling, with her bottom in the air, position that  she held until she was at least three years old. 

She started walking very early, at ten months of age, and I can still see her always carrying around a bottle of apple juice.   She insisted on having that bottle with her also during the night and drunk continuously from it, as if she had an unquenchable thirst. At night we were going back and forth to her room to pick her up, console her, replace the  pacifier in her mouth, and wait until she went back to sleep. A torment for her and for us, who, as it always happens to parents in this situation, were utterly exhausted and exasperated. Consider that, at the time, I was in my third year of Pediatric Residency in New York and I could easily resort to the advice of a top pediatric gastroenterologist. This specialist, however, kept on telling me: “Marta is ok, she looks well and grows better. There is nothing to worry about…”

Well, if you are going through the same ordeal I am describing, it is extremely likely that your baby suffers from gastroesophageal reflux.  And at this point let me give you a more systematic account of this disorder ( which from now on I will name “GERD” from the acronym of “Gastro Esophageal Reflux Disease”, or simply “reflux”), what are its causes and mechanisms and how you can recognize it.

A sphincter that doesn’t work

I’ve often wondered why GERD is so common in human beings.  It’s as if at the origins we needed to bring food back up from the stomach, to chew it over like herbivores, and, in spite  of subsequent evolution, this mechanism did not adapt. Actually the very impression you get observing a baby affected by GERD is that he/she is ruminating, so much so that in the past this disorder was called “mericism”, i.e. “rumination”. 

The basic defect is that a valve between the stomach and the esophagus, the Lower Esophageal Sphincter (LES), does not work properly. It stays partially open most of the time, letting acid stomach content go up toward the esophagus. However only a small portion of

what leaks out reaches the mouth and becomes visible as a regurgitation. Most of it is immediately swallowed back. And, as the baby does so, he/she continually swallows bubbles of air, which keeps accumulating in his/her stomach in large quantities.

Here is why babies who suffer from GERD need to burp so frequently, even hours after feedings, giving the impression that their digestion is an endless process. Great portion of the swallowed air ends up in the bowel, so that these babies often have a distended abdomen, suffer from colic, and  pass a lot of gas. 

However, the main consequences of GERD cause much more discomfort and concern.

1. The first one is “reflux esophagitis”, i.e. the inflammation of the esophagus due to continuous contact with stomach acid, which manifests itself mainly with fussiness and crying because of the burning pain it causes. The inflammation triggers also very frequent hiccups, symptom that can interfere with rest and become very disturbing for the baby. When  the inflammation reaches its worst stage it can cause excruciating spasms of the esophagus and desperate crying bouts. To have an idea of how strong the pain can be, consider that in adults these episodes are often mistaken for heart attacks. Sometimes a severe inflammation of the esophagus can strongly stimulate the vagus nerve and cause nausea, vomiting, extreme pallor and episodes of “vaso-vagal reflex”, in which the blood pressure goes down and the child (or adult) appears as if he/she is on the verge of losing consciousness.
2. b. The second main consequence of reflux is that, especially in the horizontal position,  the stomach content can end up in the airways. Usually this triggers just strong coughing and retching, but occasionally the acid can go deep into the lung and cause aspiration pneumonia.  In very rare cases, a massive aspiration can result in a respiratory arrest and brain damage.
3. c. The inflammation makes the lining of the LES become thicker and stiffer, so that the sphincter contraction becomes even less effective, thus feeding a vicious circle: inflammation-more reflux -more inflammation. If left untreated, this situation can go on no stop.

Gastroesophageal reflux is often associated with a “hiatal hernia”, i.e. the sliding of a small portion of the stomach into the chest cavity. The presence of a hiatal hernia weakens the LES and inevitably triggers reflux. However its presence in a baby does not mean that surgery will be necessary, because in the majority of cases it resolves itself.  With time, the esophagus grows longer, the stomach becomes firmly lodged  in the abdomen and usually the LES works better. Therefore, generally, symptoms of GERD gradually disappear within the first year or two of life.

However, in roughly 50% of cases GERD persists until adulthood, although most of the time symptoms become milder, appearing and disappearing intermittently without a specific pattern.

Reflux, liquids, milk and sweets

Liquids, of course, easily spill from an open LES, making GERD much more likely in a newborn, seen that his/her nutrition is exclusively liquid. After six months, in spite of introduction of solid food, the continuation of some milk feedings (whether breast or formula) keeps the condition alive.

Breast feeding versus formula feeding

It’s a common observation, though, that breastfed babies, when regurgitating,  bring up curdles that are much smaller and less smelly than the ones of formula fed babies. This seems to indicate that digestion of mother’s milk requires less acid secretion and this is probably why  breastfed babies  usually develop symptoms of GERD later,  after the first few months. In formula fed babies, instead, regurgitated milk contains bigger curdles and has a stronger smell, probably because its digestion requires definitely more acid. I believe this is why these babies start showing clear signs of GERD right from the beginning. 

Do sweets have an influence on reflux?

In my experience, sweet food of any sort (i.e. homogenized fruits, desserts, jams, etc.) increases gastric acidity and therefore makes reflux worse.

The position is a crucial factor.

As long as you keep an open bottle of water standing, the liquid is not going to spill. But, if you start tilting it, the water soon leaks out.  The stomach of babies with reflux is a bit like a bottle without a top and this is why they prefer being held upright, like in the picture, and rest better on a seat, like an infant car seat, that keeps the upper part of the body in a near vertical position.

When lying down, reflux-babies would very happily choose to be on their stomach, perhaps because pushing it against a firm surface helps the LES to stay closed. Therefore I am often asked by parents of these babies if it’s all right to let them sleep in that position. Unfortunately, I have to advise them not to, as it may contribute to crib death, at least until five, or six months of age, when the baby starts turning around on his/her own.

How does GERD change with age and how long does it last?

At about six months the baby starts eating solid food and, along with rapid body growth, the esophagus becomes longer, while the stomach settles better inside the abdomen. These developments alleviate some of the symptoms of reflux, although in the majority of cases the LES keeps leaking food toward the esophagus. However at this stage the baby swallows back practically everything that comes up, so that regurgitation becomes less overt and the condition becomes similar to the adult one: the problem is there, but symptoms are subtle, therefore making the diagnosis more difficult. All the same esophagitis, if not treated, keeps causing pain and agitation, usually until two years. And even after this age a considerable proportion of  reflux children goes on having significant symptoms of GERD, alternating “active” periods with long phases of  apparent wellbeing. In the USA, 10 million adults, i.e. 3% of the entire population, complain of daily heartburn. A much larger percentage of Americans, 15 – 20 % , complains of the same symptom intermittently. 

What other factors affect reflux?

Several problems can affect directly or indirectly the course of reflux.

1. Among them are the frequent viral respiratory infections, usually accompanied by cough, especially at night. The act of coughing implies a sudden, strong contraction of the diaphragm, that compresses the stomach and can force its content into the esophagus, particularly in reflux prone children. This mechanism can easily start the vicious circle vomiting-esophagitis-more vomiting, which, if not treated, can go on indefinitely. 
2. Gastroenteritis can trigger the same chain of events, because it usually starts with  repeated vomiting. Even a child who has not been showing signs of reflux for months, following one of these episodes can go back to the worst condition he has ever experienced.