Vomiting after feeding is quite common in infants. This situation, which is known as “he has taken out more” among the people, rightly worries most families. Is this a disease? Do I need to take him to the doctor? How long it will take? When should I be nervous? What should I do to prevent it? Questions come to mind one after the other. These vomiting are mostly due to physiological and sometimes pathological reflux. Gastric reflux, or as we say, gastroesophageal reflux among the people…
Gastroesophageal reflux is the involuntary backflow of stomach contents into the esophagus as a result of the valve between the stomach and the esophagus remaining open as a result of insufficient functioning. This content, which escapes into the esophagus, can be solid and liquid foods that are eaten, as well as stomach, bile and pancreatic fluid. Physiologically, reflux is common in the first 2 months of life and resolves spontaneously. These babies are very peaceful and happy babies with a leak from the corner of the mouth.
This reflux, which normally appears physiologically in most of the healthy babies and children, manifests itself as a 1/300-1000 GASTROESEFAGIAL REFLUX DISEASE, that is, by giving symptoms in our body.
The most important cause of vomiting in infancy is gastric reflux (gastroesophageal reflux). Initially normal (physiological) vomiting due to reflux is expected to subside within 6-12 months. However, reflux that continues after the age of 2 should be investigated.
What is Gastric Reflux?
The foods we eat pass through the esophagus to the stomach and then to the duodenum. At the entrance and exit of the stomach, there are gates (sphincter) formed by thickening of the muscles.
These gates keep the incoming food in the stomach during the digestion process. The port between the esophagus and the stomach (gastroesophageal sphincter) prevents the stomach contents from escaping backwards into the esophagus. The most important reason for reflux seen in infancy is that this structure has not yet been formed.
What are the Symptoms of Reflux in Babies?
• Vomiting due to reflux in infants occurs immediately or after feeding and usually overflows from the mouth. The milk or food that is absorbed in babies has a cheese-like appearance and a sour smell.
• The younger the baby, the more dangerous the problems that may arise due to vomiting. During vomiting, some of the food may escape into the windpipe, usually in supine infants. A picture of lung infection, manifested by coughing, respiratory distress and bruising, may occur. This picture, also known as aspiration pneumonia, requires hospitalization and treatment. Sudden infant death syndrome (Sudden Infant Death Syndrome) may occur if the food escaping into the windpipe completely blocks it, usually in newborn babies.
• If the necessary precautions are not taken in a timely manner in children who vomit for a long time, the necessary caloric needs cannot be met, and the child may experience retardation in growth and development compared to their peers.
• Vomiting may not be present in every patient with gastric reflux. Stomach contents may come up to part of the esophagus or into the mouth and stay there. This situation, especially seen at night, can cause recurrent otitis media, bad breath and early decay in the teeth.
• In older children, it is burping, burning sensation in the chest, aversion to food, vomiting, hiccups, mouthing food and rumination, retching and chronic cough. More rarely, wheezing, sore throat-burning, hoarseness, recurrent pneumonia attacks, exacerbation of asthma attacks and difficulty in swallowing due to narrowing of the esophagus.
• In young children, reflux may affect the nerve pathways and cause conditions that require emergency care such as respiratory arrest and slowing of heart rate.
Until When Should Reflux Be Considered Normal in Babies?
It is expected that the vomiting that occurs due to reflux will decrease in the first six months, and that it will respond to the supportive treatment up to the age of one. However, if the baby’s vomiting increases rather than decreases in the first month or two, then it should be investigated in terms of congenital stenosis at the gastric outlet.
Diagnosis of Reflux in Infants:
Vomiting that comes out of the mouth after a while and has a cheesy appearance because it waits in the stomach is a vomit that occurs due to reflux. If a response cannot be obtained with preventive measures and treatment, then certain imaging methods are used to define the presence and degree of reflux. There are many tests used in the diagnosis of gastroesophageal reflux disease. The order and necessity of these tests are selected according to the doctor’s opinion and the patient’s condition.
1. Lung X-ray: It is used to see if there is pneumonia development in the lungs due to vomiting.
2. Esophagus-Stomach-Duodenum X-ray (OMD): The passage to the esophagus, stomach and duodenum is visualized with a drug administered orally to the child. At this time, the baby’s feet are lifted up or pressed to the stomach to see if there is any escape into the esophagus. If there is an escape only to the lower part of the esophagus, it is mild, if there is an escape to the middle of the esophagus, it is moderate, and if there is an escape to the mouth, it is a severe type of gastric reflux. In addition, it can be seen with these films whether there is an obstruction / obstruction in the esophagus, stomach or small intestines.
3. Reflux Scintigraphy: Just like in the stomach film, the baby is given food containing a special substance. Then, the baby is laid down and it is observed whether the formula passes into the esophagus. With this method, it can be determined whether there is an escape to the lungs in severe type of reflux.
4. Endoscopy: Endoscopy is performed to examine the inside of the esophagus, stomach and intestines. This is a camera system with a thin bendable light source. It is investigated whether reflux causes any structural changes in the esophagus.
5. 24-Hour Ph Meter: It is a thin tube-shaped instrument developed to measure acidity in the esophagus. It records all pH values for 12-24 hours and transfers them to a computer program. It is a definitive diagnostic method.
6. Intraluminal Impedance Measurements: Records all stomach contents coming back into the esophagus. It records all that comes back into the esophagus when your child cries, bends, coughs, gags, and vomits. It records whether it is acidic and how long it remains in the esophagus. It is appropriate to do it together with a pH meter to distinguish acid refluxes from non-acid ones.
Gastric reflux treatment mainly consists of two parts:
1. Preventive Treatment:
It is aimed at preventing the child from vomiting. The main points to be considered here are:
• First of all, the baby should be fed frequently and little by little.
• Care should be taken not to cry while the baby is feeding. Crying while feeding, the baby swallows air, which makes it easier to vomit.
• Babies should not be laid down immediately after feeding, but should be kept upright on the lap for a while.
• Babies who vomit should not be placed on their backs. It is more correct to lay them at an angle of approximately 45 degrees and lay them on their side.
For this purpose, either a pillow can be placed under the baby’s head or a cradle produced for this purpose can be used. Today, there are reflux mattresses and reflux pillows for babies produced for this purpose in many children’s stores. I recommend my patients to keep their babies in the stroller seat after feeding as an option.
2. Food and Drug Treatment:
It is applied to babies who continue to vomit despite the use of preventive treatment.
• The consistency of breast milk and breast milk substitutes is watery. The denser the content in the stomach, the less backward escape will be. Antireflux formulas produced for this purpose can be used in infants who vomit.
• The contents of the stomach are acidic. In order to prevent this from damaging the esophagus, it is useful to use syrups with antacid properties.
• The use of certain drugs that will accelerate stomach and bowel movements will prevent earlier emptying of the stomach and therefore reflux.
• These two treatment methods above are sufficient in 90% of the patients.
3. Reflux Surgery
The vast majority of babies with gastric reflux respond to the treatment methods applied.
• Surgery is required in patients who fail drug therapy or develop serious complications.
• However, sometimes an abnormality in the anatomical structure at the junction of the esophagus and stomach prevents reflux from disappearing during follow-up. In these patients, surgical treatment may be required to prevent the negative effects of reflux in the future.
• Reflux seen in babies with congenital brain-nervous system abnormality usually does not respond to preventive measures and formula and drug treatment. Surgical treatment should be applied at an earlier age in these babies.
The aim of reflux surgery is to increase the lower esophageal pressure while allowing the passage of food from the lower esophagus to the stomach. For this, the upper part of the stomach is wrapped around the lower part of the esophagus, so that the food does not go back to the esophagus after passing into the stomach. Today, this surgery is performed by many pediatric surgeons with a closed method (laparoscopic).
