Reflux

Reflux, or gastro-oesophageal reflux (GOR), affects 30 per cent of infants. Also called regurgitation, it occurs when the stomach contents are brought back up into the oesophagus or mouth

Babies often bring up milk during or shortly after feeding. However, babies who repeatedly bring up their food may have a more serious, long-term form of reflux.

Symptoms

Infants will display the following symptoms between three weeks and 12 months of age:

  • Regurgitation twice or more a day for three or more weeks
  • No retching, vomiting of blood, inhalation of food into the lungs, cessation of breathing for 20 seconds or more, failure to thrive, feeding or swallowing difficulties, or involuntary flexing or extension of the arms and legs.

Causes

The main cause of reflux is an immature lower oesophageal sphincter muscle that allows stomach contents to pass back into the oesophagus. As this muscle matures, the frequency of reflux reduces and usually disappears by 12-14 months of age.

The main cause of reflux is an immature lower oesophageal sphincter muscle

Treatment

Guidance from NICE advises:

  • If breastfeeding, a healthcare professional should review mum’s technique
  • If formula feeding, a healthcare professional should review the baby’s feeding history and reduce the volume of milk, if excessive for the infant’s weight. A trial of smaller, frequent feeds can be offered, if appropriate, followed by a trial of thickened formula milk.

Top tips for easing reflux

To avoid reflux, advise parents to:

  • Try to make each feed as calm and relaxing as possible
  • Feed the baby little and often and as slowly as possible with regular pauses
  • Use the correct sized teat for the baby
  • Avoid letting the baby get too hungry so that air isn’t gulped down during a feed
  • Wind the baby during as well as after a feed, ensuring there is at least one good burp!
  • Keep the baby upright during and after feeding and avoid bouncing or active play after a feed.

Formula milks for reflux

A formula milk, such as Aptamil Anti-Reflux, Cow & Gate Anti-Reflux or SMA PRO Anti-Reflux may be suitable. Formulated with cows’ milk, these:

  • Are casein-dominant, so they take longer to digest
  • Contain a pre-cooked starch or a gum-based thickener (e.g. carob bean gum) that thickens before feeding. The viscosity is maintained and increases in the stomach, making it less likely that the feed will be brought back up
  • Can be used from birth until 12 months of age
  • Should only be used in infants who are already being formula fed and have been identified as suffering with reflux.

N.B. Because of their thickening agents, anti-reflux milks typically have different preparation instructions to standard formulas.

Feed thickeners, such as Cow & Gate Instant Carobel, increase the viscosity of a feed, which may prevent it from coming back up.

These can be added to expressed breast milk or cooled, boiled water and given as a paste before and during a feed. They can also be mixed with milk and fed through a teat with a larger hole.

Alginate-containing sachets are an alternative to thickened feeds.

If a milk has been tried for a few weeks without success, the cause of the reflux may be an allergy to cows’ milk, in which case an extensively hydrolysed formula milk may be appropriate.

N.B. If vomiting occurs with other symptoms (e.g. diarrhoea and a fever), refer to a GP.

Clinical summary:

For infants experiencing symptoms of reflux and regurgitation, a feeding assessment is the first line of approach for both breastfed and formula-fed babies. In formula-fed infants with frequent regurgitation associated with marked distress, NICE recommends that after a review of the feeding history, the following steps should be followed:

1 Reduce the feed volumes, if excessive for the infant's weight

2 Offer a trial of smaller, more frequent feeds, while maintaining an appropriate total daily amount of milk (unless feeds are already small and frequent)

3 Offer a trial of thickened formula

If this is unsuccessful, thickened feeds should be stopped and the infant should be offered alginate therapy for a trial period of one to two weeks. Breastfed babies whose symptoms do not improve despite the mother following the recommendations of an expert should be given a trial of one to two weeks of alginate therapy. Alginates should only be continued if they appear effective, though they should be stopped at intervals to see if the infant has recovered.

Acid-suppressing drugs (proton pump inhibitors such as omeprazole or H2-receptor antagonists such as ranitidine) should only be prescribed for infants with overt regurgitation and either unexplained feeding difficulties (such as refusing feeds, gagging or choking), distressed behaviour or faltering growth. Metoclopramide, domperidone or erythromycin should not be offered without specialist advice.

Gastro-oesophageal reflux disease (GORD) differs from the common and normal regurgitation of feeds that affects many infants in that the symptoms (usually pain or discomfort) are either severe enough to warrant medical treatment, or are causing complications such as oesophagitis or pulmonary aspiration. NICE clinical guidance states that premature infants and children with complex, severe neurodisabilities, both of whom have a high incidence of GORD, should be under specialist care, which will include management of this condition.

Red flag symptoms to be aware of include:

  • Frequent projectile vomiting (which suggests hypertrophic pyloric stenosis)
  • Bile-stained vomit (intestinal obstruction)
  • Haematemesis (upper GI blood)
  • Blood in stool or diarrhoea (bacterial gastroenteritis or infant cows’ milk protein allergy)
  • Abdominal distension or tenderness (intestinal obstruction).

Symptoms that start after six months of age or persist after the child’s first birthday also warrant investigation, as do systemic symptoms such as fever, altered responsiveness and dysuria.

 



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