It has been interesting to read you comments on the subject of GER.
There seems to be a lot of confusion as to whether to treat or not and if
so what do you do about it.  This is one of my favorite topics and I will
try to be brief.  Please feel free to adress more specific questions in
the future or to give me a call at the office.

First let me give you one good reference to read:  Article by Judith
Sondheimer in the Pediatric Clinics of North America Vol 35 (1) pp
103-113, feb 1988. (deals with the mechanism of ger)

1.  Who has GER:  Nearly all babies do.  Some you see (spit up and
sometimes projectile spits) and some you don't (often premies).

2.  What is GER: contents of the stomach refluxing into the esophagus

3.  Why babies have more than adults: because of at least 2 factors.  One
is that the area between stomach and esophagus (not a muscle in the
strict sense of the term but area of higher pressure) is
"weaker"(generates less pressure therefore more easily overcome).  Two,
is pressure in the belly: when they cry, get agitated and yes, are held in
a vertical position.  You know how babies slump over (cant sit up
straight): that increases the abdominal pressure and makes babies spit up
more!!!

4. What does this mean in clinical practice: usually babies have less
impressive reflux in the 1-2 weeks post birth (not very active) but it
"gets worse" (meaning you see more impressive spit ups) when baby gets
more active (2-3 months) but have not yet matured. This usually worries
moms and docs a big deal!

5.  What happens to babies with GER:  Usually they improve spontaneously
around 6 months of age and the GER is usually resolved by 1 year. A few
kids will have symptoms til 2 years.  About 10% will have problems
associated with the GER (those are the kids who require treatment).

6.  Do you need to run tests on all babies who spit up.  No.  If they
spit up they have GER. It's obvious.  My rule of thumb is that if the
baby is growing well, does not have recurrent problems whith wheezing and
or pneumonia, no blue spells and no apnea, you can just let it happen!!!
If they have a lot of projectile vomitting I usually get an Upper GI
series (stomach X ray) to rule out Pyloric stenosis or some type of
obstruction or twist in the bowel that would explain the vomitting.
Other tests like measuring the acid in the esophagus (pH probe
test)continuously for 24 hour are helpful if the baby has spells (like
turning blue) so you can see if the spells are related to the reflux
happening.

7.  Why do some babies spit up at a distance: because often they swallow
a lot of air which then acts as a propellent and pushes the milk out of
the stomach. Sometimes you dont know but often if you sit the baby up
they tend to spit up more! (this is the opposite to adults).

8.  Is fussyness due to reflux:  In general it is really hard to
determine if the baby cries because of heartburn or for other reasons.
Usually  when I see parents they are very worried and getting them
reassured gets everyone to calm down  including the baby. I hate to say
it but often, the things we try to do to help backfire and make babies
even more fussy!!!

9.  Do you need to treat GER:  I only treat babies who have complications
such as described under #6.  You want to treat those babies  because then
GER may be harmful (causing poor growth and respiratory problems).  For
all the others, I believe that the potential side effects of the
medications are more dangerous than letting the baby spit up.  What I do
is spend a lot of time with the parents to explain what I wrote above.  I
emphasize that GER is temporary and will go away in most with time and
even though it is messy, it is not dangerous.  Many babies have been
already on medication by the time they see me and parents are worried
because things seem to get worse despite the meds.  SO my job is a little
easier because I can say :" since the meds dont work, lets try to stop. It
probably doesnt make a difference!!".  Most parents are very happy because
they are also concerned about side effects.
In general I go out of my way to help parents understand that their baby
is not sick and that this condition does not need to be treated.  I can
sympathize because my own daughter was a very bad spitter and it took me
a while to rationalize and calm down!!! My goal is not to get the baby
to spit up less!!! It never works and increases axiety.

10.  What about the things you do about GER:

        1. Sitting the baby up:  in a great article by Orenstein (around
1988-89) she showed that this position increases GER.  The only position
she found decreased GER is the on the belly 45 degrees slanted head up
(that's where that sling came from--- highly impractical and I reserve it for
sick babies when I try to delay surgery).  In my impression it is not
worth the trouble for average otherwise healthy baby who spits up.
Remember that any time you intervene, you send the non verbal message
that there is something wrong with the baby and that it should be fixed.

        2.  Burping the baby frequently: makes the baby so angry that I
think it defeats the purpose: I leave it an option for the parents.  If
it helps in their common sense do it.  If not dont!! its not a rule.

        3.  Small frequent feeds: how do you do that at the breast!!! For
bottle feds I remind parents that cry is a late feeding cue.  Get all
babies to feed at early cue so they are not so ravenous and will be
better able to not overeat.

        4. Cereals?  Forget it.  Orenstein in a related paper showed that
providers were more happy, it does not decrease the GER.  I therefore do
not use cereal (how do you add it to the breast anyway!!)

        5. Changing milk: doent work, unless you have other symptoms to
suspect allergies (I can talk about that some other time)

        6. Medications:  I do not use for the baby with no complications.

                they include:

                -Antiacids (maalox, gaviscon) have to be used too often
                -Antiacids (tagamet, Zantac) May be helpful if evidence of
irritation in the esophagus, Usually not needed.  Tagamet has quite a few
side effects and zantac is in a syrup with 12% alcool which can also
cause problems
                - Motility agents: Bethanechol, Metoclopramide and Cisapride

Bethanechol is a cholinergic drug which increases Lower esophageal
pressure and increases the motility of the esophagus.  Side effect  is
wheezing because also acts on bronchus.

Metoclopramide (Reglan) is a dopamine antagonist which increases the LES
pressure and speeds up the gastric emptying.   Side effect on Central
Nervous System (Irritability, spasms and sometimes seizure like
activity). Still widely used but more people are cautious because of side
effects.

Cisapride (propulsid) Recently approved in US.  Increases acetylcholine
release and therefore increases motility in the entire GI tract.  Side
effect diarrhea in some patients.  Looks promising and so far no major
side effects identified.


I hope this brief summary of GER management will help you in caring for
patients.  Please send me any further questions you may have about the
topic.  For more specific discussion you may want to give me a call at
the office 501 320 1004.

Good luck.

Remember, most babies with GER are OK and do not need treatment.  Just a
lot of TLC.

Maryelle Vonlanthen, MD