Reflux and regurgitation

Reflux or gastro oesophageal reflux (GOR/ GER) occurs when the stomach contents leak back into the oesophagus after feeding, with or without regurgitation and vomiting6. GOR is a normal physiologic process occurring several times per day in healthy infants, children, and adults1. GOR is equally common in breastfed infants as bottlefed infants2. Reflux peaks at around 4–6 months and after 12 months it usually becomes less frequent or disappears entirely. Ongoing reflux past the age of 18-24 months is considered abnormal and would require further healthcare professional support1-2

Symptoms of GOR1

  • Regurgitation
  • Excessive crying / irritability during/after feeding
  • Weight loss or poor weight gain
  • Regular coughing
  • Arching their necks and back during or after eating
  • Poor sleep habits typically with frequent waking

Provided growth continues normally parents of infants with uncomplicated GOR should be reassured and offered parental support, reassurance and practical tips on how to manage reflux. However, in some cases dietary or medical management may be required 4.

 

 Diagnosis of Infant Regurgitation5

Must include both the following in otherwise healthy infants, aged 3 weeks to 12 months old5:

  • Regurgitation 2 or more times per day for 3 or more weeks
  • No retching, haematemesis, aspiration, apnoea, failure to thrive, feeding or swallowing difficulties or abnormal posturing

 

NEW: ESPGHAN Reflux Guidelines6

New 2018 ESPGHAN clinical guidelines for the diagnosis and management of reflux in infants and children, intended to be applied in daily practice6.

The guidance states:
  • No indication for the usage of proton pump inhibitors, prokinetic drugs, or H2 antagonists in so called uncomplicated regurgitation or GOR/GER.
  • No indication for the usage of antacids/alginates in chronic GOR/GER
  • No indication for the usage of positional therapy to treat symptoms of GOR/GER in sleeping infants

 

 Practical Advice

  • Parental reassurance
  • Try smaller teat hole size
  • Wind the infant
  • Avoid overfeeding
  • Feed smaller quantities more often
  • Feed the infant in the upright position
  • Avoid clothing that is too tight around the infant’s tummy
  • Encourage upright position after milk feeds

 

Nutritional solutions for bottle-fed infants

Thickened anti-reflux formula, e.g. Cow & Gate Anti Reflux 

 

Nutritional solutions for breast-fed infants

Instant gelling or thickening agent, e.g. Cow & Gate Instant Carobel 

 

References
  1. Vandenplas J et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009;49:498-547.
  2. Nelson et al. One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatric Practice Research Group. Pediatrics 1998; 102(6):E67.
  3. Hyman PE et al, (2006) Childhood functional gastrointestinal disorders: Neonate/toddler.  Gastroenterology; 130: 1519–1526
  4. Food Safety Authority of Ireland 2011. Scientific Recommendations for a National Infant Feeding Policy, 2nd Edition.
  5. Benninga MA. et al., Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016; 150:1443-1455
  6. Rosen R. et al., Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66(3) 516-554