Information
Editors
Infant Gastric Reflux
Essentials
- Some regurgitation of feeds occurs more than 5 times a day in half of infants aged 3 months.
- This is a normal physiological process and does not usually occur after the age of 12-18 months.
- Physiological reflux, even if copious, does not require treatment unless accompanied by warning signs.
- Pyloric stenosis, paediatric gastro-oesophageal reflux disease (GORD) and systemic diseases must be identified as possible causes of vomiting.
- If regurgitation is associated with poor growth or failure to gain weight, or other general symptoms, a referral to a paediatrician is indicated.
Benign reflux
- Aetiology
- The principal cause of infant reflux is a transient relaxation, irrespective of swallowing, of the lower oesophageal sphincter, which results in a retrograde flow of gastric contents into the oesophagus.
- Also a sudden increase in the intra-abdominal pressure caused, for example, by a severe bout of crying or the handling of the baby may result in a reflux of gastric contents into the oesophagus.
- Symptoms
- Benign reflux is not accompanied by symptoms suggestive of a somatic disease.
- The child's growth and development are not affected.
- Hiccups and rumination are also normal phenomena in infancy and, when there are no other symptoms, do not necessitate investigations for a reflux disease.
- Treatment
- The parents should be informed of the benign nature of the condition and its good prognosis; a follow-up appointment is warranted
- The end of the cot should be elevated
- The child should be handled as little as possible after a feed (effective burping, however, is important)
- Thickening the formula with proprietary products
- An (early) introduction/increase of solid food
- More frequent and smaller feeds
- Exclusion of cow's milk allergy in a formula-fed infant
- The parents' anxiety and the fear of a serious disease, induced by the child's symptoms, should be discussed.
- No research data is available to support the symptomatic use of acid antisecretory agents in children aged less than 1 year (with no evidence of an acid-related condition).
Pyloric stenosis
- The symptoms usually emerge during the first weeks of life, by 6 weeks at the latest.
- Symptoms include projectile vomiting and poor weight gain.
- As soon as a suspicion is aroused a referral to a paediatrician is immediately indicated.
Paediatric gastro-oesophageal reflux disease (GORD)
- A disease where gastro-oesophageal reflux (= regurgitation of feeds) is associated with one or more warning signs or symptoms.
- Risk groups include children with neurological impairment/disease or a congenital disease of the gastrointestinal tract, preterm infants and those with chronic respiratory disorders (e.g. severe asthma).
- Diagnosis
- Diagnosis is based on clinical presentation.
- No single symptom or cluster of symptoms is specific for GORD.
- Symptoms which, when co-occurring with regurgitation of feeds, may be suggestive of GORD
- Weight loss
- Expiratory airway obstruction, stridor, hoarseness, chronic cough
- Dysphagia, feeding difficulties
- Apnoea
- Iron deficiency anaemia
- Crying or fretfulness with temporal association to feeding or regurgitation (not only night-time crying or waking up)
- Sandifer syndrome (posturing with opisthotonus or torticollis not associated with bouts of crying)
- A child whose regurgitation is associated with any of the above symptoms should be referred to a paediatrician for further evaluation.
- Pharmacotherapy
- In general, prescribed by a paediatrician.
- If the symptom picture is severe and becomes worse during follow-up, the child must be referred to specialized care for an assessment. Treatment with PPIs should not be routinely used.
- A proton pump inhibitor may be started in specialized care in a symptomatic child aged less than 1 year if the child has endoscopically confirmed reflux-induced oesophagitis, clearly pathological pH recordings (reflux index > 10%) or if a medical evaluation regards the symptoms to be related to acid reflux and severe enough to justify the risk of adverse effects associated with the medication (hyperplasia of acid secreting cells, small intestinal bacterial overgrowth, increase in infections and allergies). If the drug therapy is based on symptoms only, an attempt to discontinue the medication should be made at 4-week intervals.
- The effect of proton pump inhibitors in the treatment of GORD symptoms in infants is equal to placebo.
- The dose of omeprazole in infants is 1 mg/kg/day, and the dose of esomeprazole is 0.5 mg/kg/day.
Feeding difficulties associated with physiological reflux and GORD
- A suspicion of dysphagia or odynophagia in an infant who regurgitates feeds is an indication for endoscopic examination.
- An infant's refusal to feed from a breast/bottle or spoon in the absence of regurgitation is not suggestive of GORD but calls for the exclusion of other disorders and, if indicated, a caregiver-child interaction assessment may be carried out by a child psychiatry professional in order to exclude a feeding disorder of infancy.
- Prolonged GORD may lead to the development of a secondary (psychological) feeding disorder, and its possibility should be anticipated already at the start of treatment. Parental anxiety and the fear of the child being seriously ill play a part in the development of an infant's feeding disorder.
Signs and symptoms suggestive of other disorders associated with vomiting
- The warning signs below, among others, indicate the need for additional investigations.
- Vomiting other than regurgitation of feeds
- Bilious vomiting
- Haematemesis
- Persistent forceful vomiting (retching)
- Onset of vomiting after the age of 6 months
- Other intestinal symptoms
- Diarrhoea
- Bloody diarrhoea
- Severe constipation
- Abdominal distension or tenderness
- Other local signs and symptoms
- Hepatosplenomegaly
- Bulging fontanelle
- Microcephaly or macrocephaly
- General disorders
- Marked slowing of growth or failure to gain weight
- Abnormal tiredness, lethargy
- Suspicion of genetic/metabolic disorder
References
- Rosen R. Gastroesophageal reflux in infants: more than just a pHenomenon. JAMA Pediatr 2014;168(1):83-9. [PubMed]