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Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels.

Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And joining me today is Dr. Thomas Ciecierega. He's an Associate Attending Pediatrician at New York Presbyterian Hospital, Weill Cornell Medical Center and Associate Professor of Clinical Pediatrics at Weill Cornell Medical College Cornell University, and the Director of Pediatric Motility Program at Weill Cornell Medicine. And he's here to speak with us about GERD and reflux issues in kids.

Dr. Ciecierega, it's a pleasure to have you with us. People don't often think of GERD as something that happens in children. I'd like you to speak about what it really is and how common it is in children. And just as an aside, my daughter had it when she was like six to eight months old and she was arching her back and doing all kinds of things. So, I can know for parents listening this is very unpleasant if it's something that your children are experiencing. Speak about the prevalence a little bit.

Dr Thomas Ciecierega: Thank you very much for having me on, and giving me an opportunity to discuss GERD in pediatric patients and specifically in those little infants. So, I think the first thing that parents need to understand that there is a difference between the gastroesophageal reflux and the gastroesophageal reflux disease, so the D component that we frequently label kids with. And the difference is that in GER patients, so the patients that just have a reflux events, that tends to be a natural process. And there's number of reasons why the reflux can occur in a small infant.

But when we talk about the D component of it, so the disease part of the reflux events, then that sort of changes the ball game quite drastically for those infants. And that distinction needs to occur early on because, if we are talking about purely reflux in a baby, so baby who's otherwise happy, growing well, just spitting up, many times we don't have to do anything. This is just about education. This is about understanding what is the natural course of reflux events in infants and the fact that most of those babies will outgrow it at some point in their life, and that typically occurs somewhere between 12 to 18 months of age.

Unfortunately, in a very selective group of kids, the disease component can be present and that typically causes some troublesome symptoms that can affect their feeding, which can lead to the weight loss. If there is a risk of aspiration, it can also cause pneumonia. So, those two disorders need to be distinguished right early on.

Melanie Cole (Host): I'm so glad that you did that, doctor, because I think that was an important distinction that you made. Do we know what causes it, whether it is just a reflux event or actual GERD? Is it unformed digestive tracts? Is it obesity? Is it formula versus breast milk? Is there anything that we know about the causes?

Dr Thomas Ciecierega: Yes. So, we do know some aspects of it. But clearly because of early age, we can't ask our infants and young children about specific symptoms. So, the reflux events usually occur in the infants because of their immature GI system. So, GI system has tendency to mature around 12 plus months of age. we also have to understand that their dietary habits are quite different from us. So, not only they're relying on liquids, so we are talking about the breast milk or the formula. And we as an adult tend to rely on solids. Solids tend to settle in the stomach a little bit better than liquids. We also have to remember that infants will be frequently in a laying position, because they're asleep most of the time. So, the ability of that liquid in the stomach moving between the pharynx, so the oral cavity, and the stomach is much easier than somebody like an adult who walks around and the gravity brings the stuff down. We have to also remember the physical capacity of their esophagus, so the food pipe and the stomach, is very different than adults. So if you combine all of those factors, it is not unusual and actually almost guaranteed that most of the infants will spit up early on. If just spitting up doesn't lead to any significant compromise, so that means as we discussed, lack of weight gain or weight loss, excruciating pain or aspiration pneumonia, most of those events will get better with time, although there is a period somewhere around three to six months of age that the reflux events can increase and get worse before they get better with time.

Melanie Cole (Host): So then, let's talk a little bit about the symptoms, things parents would notice. And I remember, doctor, when I was so excited that I got to feed my daughter solids at four to six months because I was like, "I know this is going to help settle it a little bit. It's a little heavier in there." And we had all kinds of things we tried lifestyle-wise, and you're going to tell us about some of those. But meanwhile, for parents, kids spit up all the time and for no reason and we used to call it colic, but tell us a little bit about what we might notice, anything besides just sometimes spitting up.

Dr Thomas Ciecierega: Right. So, there's definitely certain things that we need to be on a lookout. In a baby who has a normal reflux, the weight gain should be appropriate. So if there's any deviation from their growth, that should be a concerning fact. If babies are choking or gagging with the feeds, and we are talking about majority of the feeds, not just sporadic choking or gagging, that should also be a flag of concern that needs to be further evaluated. If babies have vomiting in addition to spitting up, so we are not talking about the small volume of saliva or even breast milk or formula coming out, but really more of that projectile vomiting that people are aware of that needs to be evaluated.

Typically, around five to six months of age, we will start to introduce purées. And once the babies go through this initial stages of acceptance of the purées, their reflex events, their spitting up events should subside. Although, as we said in the past, they can continue to occur for another few months before they tend to dissipate somewhere in the second year of life.

Melanie Cole (Host): Then, how do you diagnose it? And at what point do we start to call our pediatrician, our medical home and get involved in whatever diagnoses might be involved? I mean, we're not doing endoscopies right away on kids. And my daughter had like a barium swallow, I think I remember. But tell us how you diagnose really what the issue is.

Dr Thomas Ciecierega: Well, a lot of the diagnosis is going to be based on the clinical judgment. So in majority of kids who are growing well, who are developing well, who just have occasional spit ups, they will have what we call a physiological reflux, so the reflux that is expected to occur because of all the factors that we discussed.

If there's any concern for, let's say a structural abnormality, if we are concerned that there may be a different disease process that is underlying the symptoms, especially in a child who's not growing and developing well, there's number of modalities you can consider to use to investigate this a little bit further. And those include imaging, so for example, as you mentioned, that barium swallow is a good indicator of anatomy of your upper GI system to make sure there's no strictures, kinks, that everything is emptied the way it's supposed to.

In certain babies who have more vomiting than is expected, doing something called an upper GI study makes sense. The difference is that the contrast that the baby is injected, we will follow this contrast on that study for a little bit longer period of time to make sure that not only the esophagus, the food pipe and the stomach look normal, but also the small intestine. In selective group of babies who are unresponsive to typical changes in their diet or they still continue to have reflux symptoms, we actually do use upper endoscopy as a diagnostics tool to make sure that we are not missing allergies, infections, and structural abnormalities.

And we also use what we called a gold standard testing. So, the gold standard testing that we have is called pH impedance testing, which means basically that we place a very small catheter through the nasal passages into the food pipe, the esophagus. And we keep this catheter in a child for about one to two days. That catheter has multiple sensors on it, which are going to allow us to record number of different events. And we are able to quite precisely decipher how many reflux events does the child have, how many events are acidic or non-acidic? Because when we talk about reflux events, we have to understand they can be acidic or non-acidic. And we also can correlate those events to any usual symptoms. So for example, a child who's coughing a lot, a child who has apneas and bradycardias, so that's especially a group of children within the NICU, the neonatal intensive care unit. So, that precise testing is quite informative to us. But as parents, we can imagine that keeping a little probe, even if it's a small caliber, in somebody's nose and the food pipe for a day or two probably is not the most comfortable test to be done. Nevertheless, it is quite informative for us and can often help us in deciding what way should we treat that underlying problem.

Melanie Cole (Host): So again, my daughter did have that test and we spent two nights at a children's hospital. And I thought it would look so uncomfortable, but she really didn't seem bothered by it too much. I mean, we got through that. But yeah, I just heard that when you just said that. That's so interesting, doctor.

So then what? Once you've decided whether it's motility or stricture or unformed digestive tract or whatever you decide that the cause is, tell us about the first line of defense. Because medications that we hear for adults for GERD aren't necessarily the same ones we might try for kids, right? Are they generally regarded as safe? What are you doing now?

Dr Thomas Ciecierega: So, the answer is yes and no, depending on underlying reasons. So if somebody has a structural abnormality, so let's say we have a child that has a vascular ring, or the child that has what we call a web or a narrowing, a lot of times this can be dealt with by using dilation technique that we can do during endoscopy. On a rare occasion, we also need a surgery to correct that abnormality.

In a child who otherwise is normal and just has reflux events, maybe just a little uncomfortable, time is probably the best answer. Now, it's easier said than done that the time will heal and sort of improve symptoms in the long run because those kids will require about six to 12 months to have significant improvement. There are modalities, and actually we have two international guidelines for reflux in infants, which teach us that we can actually look at something like cow's milk protein sensitivity and allergy to be responsible for more pronounced reflux symptoms, and also for the child not feeling well. So if the mom would prefer breastfeeding, we can offer a diet for mom that doesn't contain any dairy protein or any soy protein. In a majority of kids, this change in mom's diet in a child who's taking breast milk will make significant impact within the first two weeks of the treatment implementation. In a child who is on formula, we can start to look towards what we call an amino acid-based formula or broken down formula because sometimes body is not mature enough yet to deal with full protein that comes from the cow's milk. In center babies, we can thicken the formulas because, as we said, starting purées around five to six months of age frequently will improve some of the symptoms. So, you can thicken the formula a little bit with the guidance of dietician ideally to help with those symptoms.

Acid suppression medications are good, but they are what they are, which means they're acid suppression medications. And unfortunately with kids, the paradigm of the reflux is a little bit different. As we said, those medications will not change anatomy of the child. They will also have no impact on their maturity of the GI tract. And a lot of times if you look at all the available research data that we have, they really don't make that much of the difference.

Now, despite the fact that they do have side effects and we are always concerned about using a medication that is not specifically designed for a child for that specific reason, we have been using acid suppression medications in the past in sporadic cases, with sort of a little mixed results. So, it's not that they can't be used, but I think they have to be used with having a specific timeline in mind. Because those medications usually, if they work, they work within the first seven to 10 days. So if we have the child on the acid suppression medication for two weeks, we should see a positive impact. Most often, there is none. So at that time, we should consider stopping the medication because of the profile of side effects that are associated with them.

Melanie Cole (Host): And for kids for whom these are not working, and you've done some lifestyle, whether you've done mother's diet, we've looked at things that we can do with our kids, but tell us a little bit of things that we can do even around the holidays with our little babies, sitting them up. I mean, little babies, we sleep them on their backs with nothing in their cribs. So, sometimes any of those things that we might try if we had GERD as an adult aren't necessarily recommended, right, for kids? What can we try with our kids and what's next if none of these work?

Dr Thomas Ciecierega: As opposed to adults, although we have a lot of things available to us, you're correct, a lot of them will not work. So, for example, elevation of the bed by 10 to 15 degrees will make more of the difference for adults than for the pediatric patients. I mean, it is always a good idea to put the baby in a crib or a bed that has no stuffed animals around it. Remember, babies can turn on their side, so there's always this risk that their face can come very close contact with a stuffed animal, and that can be potentially dangerous. The best position for the infants is actually on their belly. But clearly the risk of SIDS, which we have been aware for the past 20, 30 years, outweighs that. So, the babies are still recommended to be put on their back. That being said during the day, if we would want to strengthen their muscles and allow them the tummy time, that would be beneficial. We should also try to burp the baby after the feed. Some babies are a little bit more successful, some babies are not, but it's always a good idea to decompress their stomach a little bit from the gas that they naturally take during the feeding.

Most of the remedies like chamomile teas, Mylicon drops have not been proven to work. There's many formulas right now that will contain probiotics or prebiotics in them that also seem not to work quite well. So, if all the options are exhausted, still the main recommendation would be to do dietary changes, so the babies who are in formula should be on hydrolyzed formula. Babies who are breastfeeding, mom should go on a dairy and soy elimination diet. A short course of acid suppression medication for two weeks is not unreasonable, although expectation is that majority of babies will not respond to it.

So, we are really left with very few options, and I think advancing purées around four to five months as opposed to typical five to six months would be reasonable. Exercising the baby, so giving them belly time, so they can get stronger in their upper body would also be important. But also, the time. So, very unfortunately, in some cases, the time will be the only answer and we start to see that once the baby grows to about six to seven months of age, the demeanor, the amount of spit up and their ability to hold onto the food that they eat is significantly improved.

Melanie Cole (Host): Well, I can certainly attest to that. My daughter did grow out of it, and we went through everything that you have described here today. What an informative podcast, doctor. Thank you so much for joining us today.

And Weill Cornell Medicine continues to see our patients in person, as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcast, Spotify, and Google Podcast. For more health tips, please visit weillcornell.org and search podcast. And don't forget to check out our Back to Health. I'm Melanie Cole.

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