When the Pediatrician Says “GER” (Gastroesophageal Reflux)

During her pregnancy, Sarina ate all the right things, attended maternity yoga classes, and perused a nice stack of parenting books, but she was unprepared for what lay ahead.

Modified from Article first published
in Pathways Magazine, 2008
Updated August 2013

By Linda Folden Palmer, DC
Author of “BABY MATTERS” and “BABY POOP”

She and Garrett bragged about how peaceful their newborn daughter was, but their bubble soon burst.

Within weeks their baby was crying inconsolably several times a day, sleeping poorly and waking with screams, spitting up,fussing at the breast, and experiencing occasional watery stools. Advice came from all directions. Sarina heard about gassy foods and gave up broccoli. They tried some drops for gas, constant carrying, classical music, and even a vibrating chair, but nothing brought any relief to their daughter, nor to their own wired nerves and baggy, bloodshot eyes.

The Doctor Visits

The doctor assured them there was nothing wrong with their baby. In tears herself, Sarina tried telling her story to another pediatrician and was told her baby had GER, or gastroesophageal reflux. They were sent home with drug samples and a prescription and told to elevate the head of the baby’s bed. They were not the kind to rely upon drugs, but Garrett worried that their baby may be permanently harmed somehow if they did not provide the medications. At the end of their rope and eager to see some relief for their daughter, they gave the drugs a try, but they saw no improvement. The doctor told them to give the medications some time to work and added a second drug. Sarina and Garrett then thought they might have seen a little improvement in their daughter, but it surely wasn’t enough for any of them. While the names and details have been changed, this story is based on an actual case study.

The End of Colic Diagnoses: Now GER is the Diagnosis of Choice

More and more parents are hearing the diagnosis of reflux or GER and being sent home, perplexed, with an array of medications and a few odd pieces of advice. Do they help?

It used to be that when a baby displayed excessive crying, the diagnosis was colic. What does colic mean? It means the child cries a lot. This vague diagnosis has not led parents to helpful answers. Today, most of these crying babies are given a diagnosis that has escalated incredibly over the last two decades: GER, meaning reflux, or GERD, standing for gastroesophageal reflux disease. Think heartburn. These diagnoses imply that the child is experiencing surges of acid from the stomach up into the throat.

But Some GER is Normal

Actually, a weak lower esophageal sphincter that allows some acid to regurgitate is rather normal in young babies, as is some spitting up. Studies suggest that 50 to 67% of young infants have gastric reflux symptoms. One could hardly call this a disorder. Still, one should try to address the needs of a baby who is frequently exhibiting distressed crying and other worrisome symptoms. Earlier literature reports 10 to 30% of babies as suffering from colic. This is about the number of babies given a diagnosis of reflux today, based upon the same symptoms. Whether either of these diagnoses leads to effective resolution is quite questionable.

The initial diagnosis of GER is usually made simply upon the parents’ description of symptoms such as frequent crying, irritability, appearance of pain, poor sleep, arching back, spitting-up, chronic sinus congestion, or frequent ear infections. Then the “disease,” GERD, is suggested based upon further symptoms such as fussy eating, gagging, sinus infections, red throat, breathing problems, or poor weight gain.

A Drug-Driven Diagnosis

The ever-growing popularity of these diagnoses developed along with the popularization of relatively new drugs for gastric acid reflux; various new proton pump inhibitor (PPI) drugs such as Prilosec and Prevacid. Currently, hundreds of thousands of babies and toddlers are prescribed expensive PPI drugs each year in the U.S. (a total of 2 million children up to the age of 16).

True GERD

The main concern with true, excessive reflux is that there can be severe repercussions from mucus membranes being chronically “burned” by stomach acid. Anemia can develop as well, due to blood loss from bleeding tissues. The medical paradigm is that acid blocking drugs are beneficial in serious cases to prevent further consequences. The term GERD is assumed by most to represent these extreme cases that may warrant medication. Authoritative sources report only 1 in 300 babies as actually having GERD. This sounds more reasonable, but the number of babies prescribed drugs for reflux is 10 to 15 times this amount.

Some parents report gradual improvement in their infants on PPIs over time. Of course, a majority of babies naturally out-grow colic/GER symptoms during their first year whether medicated or not. Sudden withdrawal from acid blocking drugs can cause symptoms in any person as the body adjusts to the imposed regular acid reduction by creating greater amounts of acid. An increase of symptoms upon removal of the drug does not necessarily prove it was helping.

An Uncertain Treatment… 

More often, parents find that PPI drugs provide little, if any, help. Multiple studies performed by these very drug manufacturers support this observation.

For a Vague Diagnosis

Current studies reveal that there is great randomness to the symptoms used to diagnose GER,1 meaning that true diagnosis is rather ambiguous. Additionally, there is little correlation found between symptoms and the gold standard esophagus examinations: endoscopy and biopsy.2 There is even little correlation found between these two tests. Even measuring a child’s response to PPI drugs does not correlate to a diagnosis of GER; their response does not correspond to the amount of acid measured in their esophagus.3

It has also been shown that while the drugs reduce acid in the stomach and esophagus, they do not reduce baby’s colic symptoms or other symptoms that initially lead parents to seek treatment4—so does the acid really need reducing? GER drugs increase pneumonia5 and triple the risk of gastro-intestinal infections6 while long-term safety tests are non-existent. Other side effects of PPI drugs include headache, constipation, vomiting, stomach pain, and rashes. Absorption of nutrients is reduced, and prolonged use can lead to osteoporosis. Additionally, a systematic review of PPI studies in treatment of reflux determines that they provide no more benefit than placebos.7

Getting More Invasive

If a baby’s symptoms do not improve over time, invasive tests are often recommended, more drugs may be added, and occasionally surgery is suggested.

It has been customary in the past to prescribe intestinal motility enhancing drugs such as metoclopramide for colic or GER cases, but the evidence has not shown any true benefits. It’s thought that these drugs only sedate babies—they don’t address the causes. The consensus today is that the frequent and sometimes quite serious side effects of these are too dangerous to warrant use in babies. Still, there are over 2 million prescriptions per year of metoclopramide for children under the age of 16 years.

Putting PPI’s in Their Place

In tribute to PPI drugs, there has been a drastic reduction in the number of surgical repairs for children experiencing extreme reflux damage, although such cases are rare. Medication may be well warranted in cases where it is confirmed that major acid reflux is causing chronic, certain damage to membranes. There are also cases where drug relief in the child is certain, as observed by the parents. Still, in either case, a search for the cause of reflux should be included. Even when a condition known as hiatal hernia is discovered, it still is not associated strongly enough with severe reflux to be considered a sole cause.

Other Questionable Recommendations

Another medical recommendation for reflux is thickening the child’s formula with rice starch. Again, studies on thickened formula suggest there’s no real benefit. Sadly, the thickened formula suggestion is often made to breastfeeding moms without consideration for the facts that babies are healthiest when breastmilk is exclusive, and GER is diagnosed less often when babies are not receiving formula. An even worse recommendation is for babies to switch entirely from human milk to a hypo-allergenic formula. Not only is it difficult to find a formula that a food-allergic baby will tolerate well, but the loss of immune protection and enhanced healing from mother’s milk do much disservice to the already distressed infant.

The Most Common Cause

Crying, poor weight gain, appearance of pain, frequent congestion, arching of the back; these are symptoms that today lead to a diagnosis of reflux, whether there has been any observation of esophageal damage or not. Exposure to cigarette smoke can cause such symptoms in some babies. Often the pain is likely not even in the esophagus, rather coming from the stomach or intestines. There is one cause that is most commonly at the crux of all of these symptoms, as well as rashes, diarrhea, constipation, and wild behavior: allergy to or intolerance of certain food proteins—most often from cow’s milk, but also sometimes from wheat, soy, and an array of other foods consumed by breastfeeding mom, in formula, or otherwise in baby’s diet.8 These can cause irritation and inflammation in the intestines that lead at times to reflux, and more often to signs of distress that mimic reflux.

Some believe that raw animal milks will not cause the same problems, but this idea has yet to be well documented. An equal number of reactions was measured in one study. Evaluation of thyroid function and consideration of adrenal stress may provide cues in a few babies. Evaluation for H. pylori may also provide insight in some cases.

True Resolution

Strict, complete removal of offending foods from a child’s diet usually brings true resolution to the symptoms. While blood and scratch tests are only weakly diagnostic, simple elimination diets for the nursing mom and the eating child can provide easy, safe, and accurate diagnosis. Amino acid formula should provide at least partial relief for formula-fed infants. Avoidance of offending foods can bring delightful relief to all. It makes more sense to try this conservative approach first before opting for potentially hazardous and seldom effective medications.

EE: Eosinophilic Esophagitis

There is another inflamed esophagus diagnosis that is sometimes made instead of GER. Eosinophilic esophagitis (EE) is diagnosed based upon visualization of a certain diagnostic threshold of eosinophils in the lining of the esophagus. Eosinophils are major immune cells involved in allergic reactions. This condition is extreme enough to be recognized in certain medical forums as not responding to acid reducing drugs, though these, and steroids, are still often prescribed. Sometimes a surgical stretching of the tissues is performed. Studies of EE clearly demonstrate that recovery can be achieved by dietary restrictions.

Zantac and Other Histamine-2 Blockers

While drug treatments are potentially dangerous and not highly effective for symptoms ascribed to colic or GER, one partial exception may be the older type of acid-reducing drugs such as Zantac, still prescribed today. These drugs are histamine-2 blockers and these histamines are often involved in food intolerance reactions, so some relief may be seen with these, while the prescriber and parent are unaware of the real reason why.

Why Food Intolerance?

There are many theories as to why food allergies and sensitivities have become so common, especially in children—much more common than generations ago. Some attribute it to vaccines or pesticides and others to air and water pollution or stressful lifestyles. None of these theories bear out yet to any significant degree. Certainly some of these are involved, as may be excessive processing of foods, drug residues in foods and water, now-common deficiencies in DHA and vitamin D, excessive hygiene, lack of challenging childhood diseases, and likely other nutritional and environmental causes we have yet to learn of.

What Else Can We Do?

Other dietary considerations that have shown some benefit for food sensitivities in the research are fish oil or vegan DHA supplements, and probiotics. Both of these will be delivered in breast milk in good doses, and increased when supplemented in the breastfeeding mother, or they can be given directly to the solid-food-consuming child. Some parents find benefits from chamomile, mint, and other herbs, as well as deglycerrized licorice root and aloe vera leaf.

Back to Sarina and Garrett

In Sarina and Garrett’s case, they were determined to find a solution to their daughter’s distress. Sarina started to search the web for answers. There Sarina found information that babies can be sensitive to proteins from various foods in their breastfeeding mother’s diets, as well as in most infant formulas, accounting for all the symptoms their daughter was experiencing. Eager for results, Sarina embarked on a rather complete elimination diet, eating little more than turkey, rice, dark greens, and yams for a few days. She found it easy to continue her course because she suddenly had a happy baby, and some good nights of sleep. By adding foods back one at a time and watching for reactions, it wasn’t long before she discovered that cow’s milk, soy, and corn in her diet were causing her daughter’s pain. She even noticed that the diaper rash went away. In fact, like so many moms going this route, she also found relief from her own mild but chronic intestinal complaints. Elimination dieting can be challenging but the results bring healthy rewards. Information on the limitations of GER medication and the power of natural solutions was key to this happy ending.

 

1. Stavroulaki, “Diagnostic and management problems of laryngopharyngeal reflux disease in children.” Int J Pediatr Otorhinolaryngol. 2006 Apr;70(4):579-90.

2. Morgenstein, “Gastroesophageal Reflux Disease in Infants.” CME material,Children’s Memorial Hospital. 2008. http://www.childrensmemorial.org/cme

3. Aanen et al., “Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care.” Aliment Pharmacol Ther. 2006 Nov 1;24(9):1377-84.

4. Omari et al., “Effect of omeprazole on acid gastroesophageal reflux and gastric acidity in preterm infants with pathological acid reflux.” J Pediatr Gastroenterol Nutr. 2007 Jan;44(1):41-4.

5. Canani et al., “Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children.” Pediatrics.2006 May;117(5):e817-20.

6. García Rodríguez et al., “Use of acid-suppressing drugs and the risk of bacterial gastroenteritis.” Clin Gastroenterol Hepatol. 2007 Dec;5(12):1418-23.

7. Karkos and Wilson, “Empiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematic review.” Laryngoscope. 2006 Jan;116(1):144-8.

8. Palmer, Linda F., “The Baby Bond: The new science behind what’s really important when caring for your baby,” Sourcebooks 2009: 432pp.