Recognizing Gastroesophageal Reflux in the Newborn

Parents and other caregivers soon become familiar with the habits and schedules of the newborns in their care. Feeding and sleeping become activities of great significance – for the baby and for the caregiver whose life often seems to revolve around that of the infant.

For experienced caregivers – such as parents with several previous children or day care providers with years of practice – taking care of babies can become almost instinctive. Those who know the infant best “just know” what’s normal or if something is wrong. But what if a baby doesn’t follow the normal patterns, or has a feeding or sleeping problem that just won’t go away? And what if the caregiver is a new parent or babysitter who isn’t able to draw on years of experience to determine what’s “normal”?

Some of the most distressing problems of newborns revolve around their feeding behaviors. Each baby is different, but there are certain norms that allow even inexperienced caregivers to judge if development is proceeding in a way that’s consistent with future good health.

Most babies spit up on occasion; in fact, most infants usually vomit two or more times a day. This facet of infancy is perfectly normal, and healthy babies show little distress when they spit up. But sometimes a newborn baby vomits several times a day, often an hour or more after a meal. He or she shows symptoms such as pain when spitting up, irritability, and inconsolable crying. If your newborn is showing all or some of these symptoms, you might want to speak to your pediatrician about checking for Gastroesophageal Reflux, or GER.

Reflux most commonly occurs when the ring of muscle that joins the stomach to the esophagus does not function properly. This muscle, the lower esophageal sphincter, or LES, usually opens very briefly for swallowing or vomiting, and then closes again. But in reflux cases, the muscle stays relaxed and food and stomach acids can flow back into the esophagus.

Realizing that there was very little information available regarding GER in newborns, Sudarshan Rao Jadcherla, MD, FRCP (I), DCH, Assistant Professor of Pediatrics at the Medical College of Wisconsin’s Division of Neonatal-Perinatal Medicine, has set out to help people understand the complexities of reflux episodes in newborns. Dr. Jadcherla’s goal is to improve the feeding and growth of newborns with GER, while continuing to research methods of diagnosis and treatment.

A baby who spits up without a struggle, has continued good weight gain and has no accompanying cardiac or respiratory symptoms most likely is experiencing simple physical reflux, with no long-term consequences. Dr. Jadcherla refers to these babies as “Happy Spitters,” and says that these patients usually outgrow their reflux problems without any complications. “In the first six months of life, spitting up is common,” says Dr. Jadcherla. “It is a social nuisance for parents, but it is completely normal.”

“Scrawny Screamers,” on the other hand, show symptoms such as irritability, excessive fussiness, swallowing difficulties and poor weight gain. They seem to have painful regurgitation instead of the effortless spitting up that is typical of newborns. Many also exhibit poor feeding and sucking skills. They sometimes have breathing problems as well, stemming from fluids such as milk or acid being sucked into their lungs during reflux episodes. These are the babies that should be tested for GER.

There are other causes for an infant’s frequent regurgitation that first need to be ruled out. A physician will typically begin testing for GER with a Barium Swallow X-ray, or Fluoroscopy. The baby swallows a liquid that is easily visible by X-ray and highlights any obstructions in the esophagus or stomach. Once obstructions are ruled out, further testing for reflux can take place.

Further tests may include:

• 24-hour ph-Probe Study. A thin tube is inserted into the baby’s esophagus, with the tip of the tube just above the stomach. This flexible tube connects to a monitor which shows the amount of acid in the esophagus, as well as how often the acid levels rise. If a baby has high acid levels for most of the 24 hours, he or she might be diagnosed with GER.
• Scintigrahy, or Milk Scan. The baby is fed liquid mixed with a radio-labeled powder, which is then detected by a scanner. Repeated scans show both the normal emptying of the baby’s stomach and reflux episodes. It also shows whether or not food is being aspirated into the baby’s lungs, which can lead to respiratory problems.
• Endoscopy. A flexible endoscope is inserted through the baby’s mouth, allowing for examination of the sphincters and checking for obstructions or ulcers in the area. With an endoscope, the health care provider can also take biopsies of the esophagus, the stomach, and the top of the small intestine if needed. These samples are checked for signs of other digestive problems that would rule out GER. Testing is also done for Barrett’s Esophagus, which is an abnormal cell growth in the lining of the esophagus.
• Manometry. A manometer measures the pressure inside the esophagus by means of a thin tube with tiny openings at locations throughout the tube. The openings sense pressure as the baby swallows and the esophagus contracts; the results are transmitted to a computer and shown on graph paper. This process allows the health care provider to determine whether the esophageal pressure is normal or abnormal.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.