Gastro-esophageal reflux 


Refluxes of the stomach content into the esophagus are common in babies. They present as a protracted problem, with unexplained crying, recurring malaise, pallor, sometimes respiratory arrests. They don't always occur  during meals, nor are obviously associated with spitting up or vomiting. 

Whenever an acid reflux causes the esophagus to become inflamed, the child typically stops sucking and cries, well before  having finished the feeding. This results from pain in the inflamed esophagus exposed to the transit  of  food. Refluxes associated with esophagitis lead to slow growth and sometimes failure to thrive. 

G-E refluxes tend to  decrease with time and  usually disappear  in response to three changes : upright position mastered at around 8 months of age,  introduction of solid foods which don't flow back as easily into the esophagus  and stomach maturation, but when symptoms are serious, it is not acceptable to wait and  a more active approach must be taken. 

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Medications are usually effective  but cannot replace other measures, always useful and sometimes effective enough alone, sparing  the use of drugs.  

Refluxes can result from a stomach too full or filled too fast. A breast fed baby usually drinks fairly  often (8 to 12 x a day) which offer some protection,  but this frequency  is unusual in bottle fed babies, who take more at each feeding.  It is therefore logical to fraction the child's intake into more and smaller bottles. 

A thickened formula may help : these are the so-called "AR" (anti-reflux) milks, available in pharmacies. 

Another advice is to keep the child as upright as possible, half sitting or at least  with a raised head, which can be obtained by lifting  one end  of the bed.

When these  measures  fail to control symptoms,  medications should be prescribed.

The drug of choice, the first to try, is  ranitidine (Zantac) (15 mg/ml)  given twice a day. The officially recommended dosage is often too low. Paediatric gastroenterlogists usually prescribe more : 10 to 15 mg / kg body weight / day, sometimes up to 20 mg.

It is commonly necessary to combine this treatment with Gaviscon, one teaspoonful at the end of the meal,  4 x a day, or a little less with each meal.  Gaviscon creates a sort of plug floating on top of the stomach content, and preventing  its reflux into the esophagus. 

When this double treatment fails, omeprazole (Losec, usually 10 mg once a day)  is often prescribed to replace ranitidine, and sometimes both medications are combined.

Anti-vomiting medications such as  domperidone (Motilium) 0.25 mg (= 0.25 ml) for each kg body weight up to 4 times a day may seem logical but are less dependable and  very seldom used alone.  Cisapride (Prepulsid) and metoclopramide (Primperan) are potentially more toxic.  

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These treatments are  commonly started  empirically to alleviate  a significant malaise, but it is unreasonable to maintain them, especially  for a long time,  without attempting to confirm the diagnosis and/or  to discontinue medications  which may have become unnecessary.  Obviously quite a few children  take  those  drugs  for too long without enough justification. 

An esophageal scintigraphy is a non-invasive and simple examination, able to diagnose a reflux. Measure of the esophageal pH  detects  an  abnormally acid esophageal content, but requires  discontinuation of  anti-acid medications to be dependable. 

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useful addresses    :  

esophageal pH measurement   :     Madame Danielle  Arnold, Clinique Universitaire Saint-Luc,
                                                             phone  02 - 764  1927

Scintigraphy  :   Service de médecine nucléaire, Hôpital  Brugmann, tél. 02 - 477 2649 (appointments),  
                              02 - 477  2650  (results)





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