Infants Spitting up Won't Prevent with Acid Reflux Medications
"Spitting up", or regurgitation, is very common during a baby's first few months of life. About 40% of normal, healthy babies spit up, usually right after feeding. In older children and adults, an elastic-like muscle at the entry to the stomach closes like a valve to prevent liquids from being pushed back up. Since it isn't fully developed yet until between 6 and 12 months of age, the valve is easily pushed back by the contents of the stomach - resulting in regurgitation or spitting up. More than half of all infants have occasional spitting up ("happy spitters").
If your otherwise healthy baby throws up right after eating or out of the blue, chances are gastro esophageal reflux disease (GERD) is to blame. Reflux happens when the muscle between your baby's esophagus and stomach isn't working properly, allowing food and gastric acid to gurgle up from the stomach into the throat. During your baby's first few months, vomiting is probably linked to feeding problems, such as overfeeding or indigestion; not always GERD. But when this happens a lot or the infant has other symptoms like extreme fussiness or poor weight gain, it could be GERD.
Gastro esophageal Reflux Disease (GERD) is very common in children of all ages, but it is usually mild. About half of all infants up to three months regurgitate milk at least once a day. Spitting up is perfectly natural. Almost all babies do it. Your little one may spit up after she burps. Or if she has eaten more than her stomach can hold. The reflux means that certain positions make him uncomfortable, that he starts wailing and thrashing his legs while nursing, and that burping can make him unhappy.
Sudden relaxation of the stomach results in its forceful decompression, characteristically with projectile vomiting. The vomiting usually occurs soon after feeding, and the baby is typically hungry immediately after vomiting. Frequent causes of vomiting in infants include gastro esophageal reflux, gastroenteritis, intolerance of formula, and sepsis, such as meningitis or urinary tract infection, sometimes rarely for pyloric stenosis. Vomiting resulting from intestinal obstruction due to malrotation or volvulus is typically bilious.
Gastro esophageal reflux, often referred to as GERD, occurs when acid from the stomach backs up into the esophagus. Some simply spit up; others vomit large amounts after feedings. Vomiting in infants and older children is rarely a sign of GERD. Severe vomiting -- particularly if it is bilious (green colored) -- always requires a doctor's visit, since it could be a symptom of severe obstruction. If a baby with GERD is fed formula, a mother should ask the doctor how to thicken it in order to prevent splashing up from the stomach.
GER occurs when stomach contents back up into the esophagus. The treatment for reflux depends on an infant’s symptoms and age. Some babies may not need treatment because GER often resolves by itself. Any potential complications related to the medication will be explained. However, most infants don’t need medication and outgrow reflux by 1 or 2 years of age. Because the diagnosis of reflux is often more complicated in children than in adults, only your pediatrician can assess the situation and determine what is best for your child.
In fact, Children's has participated in studies that have established the efficacy and safety of PPIs in children. In patients with severe GERD, treatment with PPI drugs is extremely effective. However, long-term use may produce side effects that should be monitored by a gastroenterologist. These may include liver problems and hyperplastic polyps in the stomach. Even though their use seems to be safe, they should be used only when a diagnosis of severe GERD has been established. Data on long-term use of medications in children is still being gathered.
Researchers in an NIH's National Institute of Child Health and Human Development Neonatal Research Network have found that premature infants given a common class of non-prescription drugs used to treat acid reflux are slightly more likely to develop a potentially fatal bowel disorder than are infants who are not treated with the drugs. The drugs, known as H2 blockers, inhibit the production of stomach acid and may put premature infants at risk of necrotizing enterocolitis, a serious inflammation of the intestines.
Over treatment could be dangerous because there are no known safe or effective antacid dosages in infants. Like most drugs, they're prescribed off-label to children, meaning they are untested for that use. Also, long-term use of proton-pump inhibitors, particularly at high doses, is associated with an increased risk of hip fracture, according to a preliminary study in the Journal of the American Medical Association.
Pediatric gastroenterologist Vikram Khoshoo, MD, PhD, says, "We know that up to 70 percent of otherwise completely healthy babies spit up up to four times a day," he says.” Parents have come to view normal spitting up as a medical condition that requires treatment. But in many cases it is more of a laundry issue than a medical issue," he tells WebMD. "We are replacing Tide and Febreze with Prevacid and Zantac."
Doctors may be over prescribing anti-reflux medications to infants, new research suggests. The study found that fewer than one in five babies given anti-reflux medications, which work by lowering levels of stomach acid, actually had elevated acid levels. That means four out of five infants included in the study likely didn't need anti-reflux medications, and may have simply been experiencing normal infant regurgitation commonly referred to as "spitting up."
"In the absence of red flags, such as a child who is not gaining weight, has feeding problems or a learned aversion to food, a chronic cough or recurrent respiratory problems or apnea, regurgitation may not require medication," said study author Dr. Vikram Khoshoo, a pediatric gastroenterologist at the Pediatric Specialty Center at West Jefferson Medical Center in New Orleans.
"Regurgitation won't improve with anti-reflux medications. Acid suppression will improve irritability and feeding problems, but it won't change spitting up. As long as the child is gaining weight and happy, and has no recurrent red flags, regurgitation is a laundry problem, not a medical problem," Khoshoo said.
Reflux is common in infants. In fact, more than half experience reflux symptoms during the first three months of life, according to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms of reflux include spitting up, vomiting, coughing, feeding difficulty and irritability.
Khoshoo and his colleagues reported that back in 1998 and 1999, infants with regurgitation made up about 14 percent of their referrals, and about 40 percent of those babies were already on anti-reflux medication or on special easier-to-digest formula. But by 2006 to 2007, infants with regurgitation accounted for 23 percent of their referrals, and 90 percent were already on medications or special formula.
"We felt it was unlikely that the incidence had increased so suddenly," Khoshoo said. To measure whether or not these infants' symptoms were caused by acid reflux, the researchers conducted pH studies on 44 babies with persistent regurgitation. The average age of the babies was 18 weeks.
To complete a pH study, doctors must thread a wire down the nose and leave it in place for 24 hours, Khoshoo said, so it's not a test that would be practical to do on every child with regurgitation.
Of the 44 babies tested, only eight showed elevated pH levels, meaning they had excess levels of stomach acid, and anti-reflux medications would be indicated in these cases. However, 42 of the babies were already on such medications, meaning that many were taking a medication they didn't need.
While these medications are generally considered safe, Khoshoo said there is some concern that they may affect calcium metabolism, and they've been associated with osteoporosis in older people who take them for long periods of time. Because infants are building new bones, this potential side effect is even more concerning, Khoshoo added.
Dr. David Keljo is a pediatric gastroenterologist and director of the Inflammatory Bowel Disease Center at Children's Hospital of Pittsburgh. He said, "Reflux in babies is a tough issue, and I think the concerns in this study are well-raised. Babies may be cranky from reflux or from something else. The vast majority will outgrow their reflux whether we do anything or not."
Both Khoshoo and Keljo said these medications are probably over prescribed because parents want to do something, anything to try to stop their babies' regurgitation and irritability.
Khoshoo said that taking care not to overfeed your infant and making sure he or she is positioned so that their bodies are at least somewhat upright after eating will help to lessen reflux symptoms. Another critical thing parents can do, he said, is make sure that children aren't exposed to secondhand smoke, which can increase reflux symptoms.
Keljo said there are certain signs that indicate your baby should be evaluated by a specialist. If your child throws up blood, a substance that looks like coffee grounds, or if there's green in the vomit, your child should be seen right away. Also, if your child isn't gaining weight or is even losing weight, if you can hear significant choking sounds, if there's a chronic cough or hoarseness that accompanies regurgitation, your child should see a gastroenterologist, he said.
Occasional spitting up is normal. Contact the doctor if your baby begins to spit up a large portion of every feeding or vomit forcefully after feedings. If your baby has reflux problems, hold him or her upright for 1 to 2 hours after feeding. Let your baby decide his mealtimes. Burp the infant frequently (after every 1-2 ounces) to prevent the build-up of air in the stomach. This allows gravity to help prevent the stomach contents from coming up.
A baby's diet is 100 percent liquid, so it sloshes up easily. Most young infants are in a horizontal position-they're lying down or sitting up just slightly in a car seat, for example. So gravity isn't helping very much and a baby needs to take a huge amount of calories per day. They take around three to four times the calories per pound that an adult does. And as a result, they're filling up their tanks with basically a liquid bag that wants to come back up. And that gets better as they get older and that's why babies stop spitting up.
Sitting usually is the worst position for reflux. Minimizing the use of carriers and swings that keep small babies in a sitting position makes a big difference for some babies. When the baby is awake, carrying the baby upright and encouraging spending time on the tummy is associated with the least reflux for most babies. Babies should not be put to sleep on their tummies, but tummy-time is great for babies when they are awake.
Have your baby sleep in an inclined position. For babies consuming formula or expressed breast milk, add 1 teaspoon of rice cereal to each bottle. keeping the infant away from cigarette smoke. A trial of hypoallergenic formula (if your child isn't breastfed) or eliminating dairy products from mom's diet if the baby is breastfed — some milk-allergic infants can develop symptoms resembling GERD symptoms of GERD or LPR in children should be discussed with your pediatrician for a possible referral to a specialist.
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