Gastroesophageal Reflux Disease (GERD) is what happens when simple gastroesophageal reflux becomes problematic. It is often referred to as acid reflux in infants.

Some reflux in babies is normal. It becomes problematic when:

• reflux interferes with growth (mainly weight gain)
• acid is burning the lower end of the esophagus as it refluxes up from the stomach

Why is acid reflux a problem?

Usually if a baby vomits a feed, she vomits milk which will dilute any stomach acid coming up the esophagus, so there is no damage from any acid. However, if there is a lot of acid coming up the esophagus that is not diluted, it can burn the esophagus, particularly at the lower end.

If the acid continues burning the esophagus over a long time, this can cause damage to the cells of the esophagus and in the long-term (in adult life) this could even lead to cancer. We don't want acid reflux in infants or toddlers causing damage to the esophagus.

Can toddlers have acid reflux?

Yes, they can although it is less common than acid reflux in babies. The symptoms would include discomfort after eating and with lying flat. They may also have vomiting.

How is gastroesophageal reflux disease (GERD) diagnosed?

Gastroesophageal Reflux Disease is diagnosed from the story of the vomiting and the associated symptoms of acid reflux - in infants this would include discomfort or distress with vomiting or with lying flat. There are also tests that can show Gastroesophageal Reflux Disease.

• A Barium Swallow is a test where the baby is given Barium (a white chalky liquid) to drink - it shows up on x-ray and so we can see if the barium comes back up the esophagus after it reaches the stomach. The test will also show a hiatus hernia (a condition where part of the stomach is pulled up above the diaphragm). A Barium swallow will not tell us if there is acid coming up that is burning the esophagus, though. It is best used to look at the anatomy of the gut and for any problems with esophageal motility. So it is not good for diagnosing acid reflux in infants or toddlers but does show reflux.
• There is also a test called a pH study - this measures the acid at the base of the esophagus. It should not be very acid at the base of the esophagus for very long (whereas the stomach is acid). If the pH is less than 4 (acid) for more than 4% of the time we are measuring, this is abnormal and would indicate gastro-esophageal reflux disease (GERD) or acid reflux in infants or toddlers. We usually measure the pH for at least a 24 hour period. We ask the mother to indicate when her baby is having symptoms and we can check what the pH was at that time to know if acid is the cause. A pH study is particularly useful if silent reflux is a possible diagnosis.

What is the treatment of Gastroesophageal Reflux Disease?

First, make sure you do all the simple things we advise for gastroesophageal reflux like positioning, thickening the feeds and Gaviscon if necessary.

Specific treatments for acid reflux in infants (GERD) depend on the symptoms that are most worrying.

• When acid reflux in infants is the problem, the treatment is an acid-suppression medication like Zantac (the common brand name for Ranitidine) or Omeprazole. These medications will not necessarily stop vomiting but they will stop the acid and so protect the esophagus.

• If vomiting is a big problem causing poor growth, there are some medications that might help by emptying the stomach quickly (so there is not so much milk to reflux). These medications, like Metoclopramide or the antibiotic Erythromycin, can have side effects so only try them if vomiting is a major problem. In the past a medication called Cisapride was used to empty the stomach in reflux - it was then found to have serious side effects and now it should not be used.

• There is a surgical procedure, called a Nissen's fundoplication, which is sometimes used in severe cases of acid reflux in infants and toddlers.

What is the treatment of silent reflux?

Silent reflux is when there is no vomiting, so the GERD isn't obvious, but there is reflux of acid from the stomach into the lower esophagus that causes burning and pain - this acid reflux in babies causes them to cry and often arch their backs in pain.

Silent reflux can be confirmed with a pH study. The treatment is anti-acid medication like Ranitidine (Zantac) or Omeprazole.

Sometimes, if silent reflux is considered the problem, a trial of an anti-acid medication like Ranitidine or Omeprazole is given to see if symptoms improve. If acid is the problem, the symptoms should improve.

If the symptoms do not improve with anti-acid medication, it might be because silent acid reflux is not the problem. Babies of 1-4 months of age can have colic and anti-acid medication will not help colic.

If it is not clear what the problem is, it is best to have a pH study, which will show whether acid reflux is causing the symptoms.

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