Gastroesophageal Reflux in Premature Infants

By Dianne I. Maroney

Having an infant or child with Gastroesophageal Reflux (also called GER or reflux) can be extremely overwhelming for parents and families. Reflux is painful, causing infants to cry constantly, refuse to eat, spit up frequently, and sleep poorly. The daily routine of giving medication, dealing with the constant vomiting and special feedings, and the frequent doctor visits can be exhausting.

Making sure that you and your physician work together to treat the reflux using whatever methods are best suited for your child will help. If GER is left untreated, long-term complications such as feeding disorders, inadequate weight gain, narrowing of the esophagus, and damage to the tissue in the esophagus (called Barrett's syndrome) can develop.

Although GER is a common gastrointestinal problem in premature infants, some physicians may not be familiar with its signs, symptoms, and treatment, leaving parents feeling frustrated and overwhelmed. If your child suffers from GER, the following will help you understand the disorder and provide information for you to discuss with your doctor.

Gastro means stomach, and esophageal refers to the esophagus, the tube inside the throat that connects the mouth to the stomach. A muscle at the top of the stomach (also called the Lower Esophageal Sphincter or LES) naturally opens and closes to allow swallowing, burping, and vomiting. Refluxing occurs when the stomach acid and partially digested food flow back up through the LES into the esophagus. All children and adults will naturally reflux throughout the day, especially after eating. However, if the muscle opens too frequently and refluxing occurs too often, complications can develop.

Premature infants have an increased risk of developing GER. There are several medical conditions that can cause reflux, but in preterm infants, the most common causes are immature muscles and abnormal breathing from chronic lung disease. If the lower esophageal sphincter is weak or underdeveloped, it can remain open when it should be closed, letting the stomach contents flow back up the esophagus. When an infant or child breathes abnormally because of chronic lung disease, the muscles used for breathing work harder. As these muscles work hard to breathe, they can pull on the muscles near the top of the stomach, stretching the sphincter and causing it to remain open.

When the stomach contents flow inappropriately up into the esophagus they bring acid from the stomach. As the acid irritates the tissue inside the esophagus, it becomes inflamed and reddened. This condition is called esophagitis. Esophagitis is painful, similar to the pain of heartburn. This is why an infant will refuse to eat or stop eating - she is protecting herself from the pain of the acid touching the damaged tissue. If the reflux is severe, the stomach contents may go high enough into the esophagus to be aspirated or spilled into the lungs causing choking, color changes, frequent respiratory infections, apnea (breathing slows or stops) and/or bradycardia (slowed heart rate).

An infant with mild reflux can spit up with burps, but continue to eat well and grow normally. However, when the symptoms are significant enough to cause problems for the infant, such as poor weight gain or eating difficulties, medical intervention is needed. The symptoms of reflux are: