Differentiating GER and Colic in Young Infants

Andrew E. Mulberg, MD, FAAP

Disclosures

January 25, 2006

Question

In infants younger than 3 months of age, is it possible to differentiate between GER and colic? If so, when do you recommend starting H2 blockers in such young infants?

A. Zaki, MD

Response from Andrew E. Mulberg, MD, FAAP

The differentiation of colic and gastroesophageal reflux (GER) will always remain one of the more challenging diagnoses for the pediatrician, as there are common and overlapping symptom complexes. Colic is a poorly defined state of prolonged or excessive crying in young infants who are otherwise well. Classic definition cites more than 3 hours per day of irritability or crying on more than 3 days per week for more than 3 weeks in a child younger than 4 months of age. Absence of any defined organic basis for the irritability is critical. By contrast, GER is defined as effortless regurgitation of gastric contents; it is extremely common in infants. GER occurs physiologically at all ages, and most episodes are brief and asymptomatic. GER may progress to gastroesophageal reflux disease (GERD). Physiologic reflux (the normal GER of infancy) is the more common form. Most infants eventually outgrow the symptoms by the end of the first year of life.[1,2]

Pathologic reflux is defined by increased number of reflux episodes according to age-accepted norms and often includes complications such as esophagitis, esophageal stricture, failure to thrive, or chronic/recurrent respiratory tract disease. Signs/symptoms of complicated GER include irritability, chest/abdominal pain, heartburn, blood loss, dysphagia, food refusal, cough, wheezing, obstructive apnea, dysphonia, or aspiration pneumonia. Other complications that are suspected include chronic or recurrent otitis media and sinusitis. GER may be asymptomatic and still carry the risk of complications. The differential diagnosis of GER keeps in mind that not all vomiting in infants is GER. Other causes of vomiting include infection; gastroenteritis; urinary tract infection; sepsis; neurologic causes, metabolic causes, food intolerance including milk/soy protein allergy; and anatomic causes.[2]

Many authors have reported on the shared signs and symptoms of infants with colic and feeding difficulties and infants with GER. Miller-Loncar,[3] in a study of 19 colicky and 24 normal infants, demonstrated a statistically significant increase in GER signs and symptoms among infants with colic as reported by parents and standardized questionnaire. The signs and symptoms of colic and GER overlap, as demonstrated by Iacono and colleagues[4] in an Italian study involving 2879 infants. Regurgitation was the most common disturbance (present in 23.1% of infants), followed by colic (20.5%), constipation (17.6%), failure to thrive (15.2%), vomiting (6%), and diarrhea (4.1%).

Shephard and colleagues[5] studied the clinical profile, course, and therapy outcomes of 126 infants and children with GER, diagnosed at a median age of 2.5 months and followed for 1.5 to 3.5 years. Common clinical features included regurgitation or rumination (99%), signs suggesting esophageal pain (49%), excessive crying, "colic," sleep disturbance, Sutcliffe-Sandifer syndrome, respiratory symptoms (42%), failure to thrive (18%), and minor hematemesis (18%). The authors cited that treatment was initially conservative (eg, posture, thickening of feeds, antacids, bethanechol), and was augmented by cimetidine in those with proven esophagitis (n = 34, 0.27%). GER is a cause of considerable morbidity in infants, but with active therapy, it is self-limiting in the majority.

It must be stressed that the treatment of colic has been associated with apparent life-threatening events in 8 infants, as a result of the use of a 1:1 concentration of dimenhydrinate (Dramamine) and phenobarbital, hyoscyamine sulfate, atropine sulfate, and scopolamine hydrobromide (Donnatal).[6] Conservative management in the absence of medical treatment is recommended for colic. Others have studied a formula containing fructo- and galacto-oligosaccharides, partially hydrolyzed proteins, low levels of lactose, and palmitic acid derivatives to reduce the occurrence of infantile colic.[7]

Treatment of GER has been achieved with chalasia precautions, positioning after meals, and medical therapy including use of H2 antagonists and proton pump inhibitors, depending on the severity of symptoms. There is considerable off-label use of proton pump inhibitors in this population as well. Recently, a provocative newer study by Davidson and colleagues[8] has demonstrated the lack of efficacy of omeprazole, a proton pump inhibitor, in the treatment of irritability in infants with GER. Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability, which improved with time, regardless of treatment model. Whether the infants in the sample had "colic" remains unconfirmed in this study.

In summary, it is clear that pathological GER or severe colic, which does not respond to conservative treatment paradigms, should be evaluated. The generalist should consider consulting with a pediatric gastroenterologist if there is a lack of symptomatic improvement after either chalasia precautions or a trial of H2-antagonists.[2,9] The latter are well recognized as safe and can be tried in the appropriate clinical scenario to determine effectiveness.

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