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Diagnosis and management: infant reflux and regurgitation

In the first six months of life, infants are particularly prone to gastrointestinal (GI) signs and symptoms that have no obvious structural or biomechanical cause1. The immature GI tract and its associated nervous system and microbiota are not yet functioning at optimal level2. This can cause a range of disorders that are not classified as organic disease, but which can nevertheless be extremely distressing for both the infant and the concerned parents. The collective term for these conditions is Functional GI Disorders3.

Reflux refers to retrograde involuntary movement of gastric contents in and out of the stomach, and is often referred to as gastroesophageal reflux4. When the reflux is high enough to be visualized it is called regurgitation3. It is the most common functional GI disorder, affecting almost 1 in 3 infants4. Reflux often occurs because the infant’s digestive system is still developing and the lower oesophageal sphincter has not fully formed. The most visible symptom of reflux is regurgitation or spitting up5. Symptoms usually resolve within the first 12 months5, however, without effective management reflux can impact family quality of life6.

Lower oesophageal sphincter image

Diagnosis of reflux and regurgitation

Internationally agreed criteria for the diagnosis of functional GI disorders, first published in Rome in 1989, have been regularly updated. The most recent version was published in 2016 and it states that infant reflux must include both of the following in otherwise healthy infants 3 weeks to 12 months of age3.

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

Management of infant reflux

Guidance on the management of functional GI disorders from both NICE* and ESPGHAN** stresses that first-line management should be based around parental support and reassurance7,8,9.

As reflux usually improves spontaneously within the first year of life, the main goal of management is to await this resolution while providing parental reassurance and symptom relief3.

Parents should be offered information on9,10:

  1. The natural history of reflux

Nutritional management should focus on9,10:

  1. Supporting breastfeeding
  2. Impact of overfeeding on symptoms
  3. Correcting the frequency and volume of feeds if required.
  4. The use of thickener or, if formula-fed, thickened or anti-reflux formula

According to ESPGHAN, formula-fed infants who fail to respond to non-pharmacological treatment may be suffering from milk protein sensitivity and should be considered for a two-to-four week trial of extensively hydrolysed protein-based (or amino-acid based) formula12.

Pharmacological management is rarely required for infant reflux. NICE advises against the use of proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs), metoclopramide, domperidone, or erythromycin, although alginates may be considered in infants showing marked distress if thickened feed has been unsuccessful2. ESPGHAN advises against chronic antacids/alginates in infants and state that proton pump inhibitors should be prescribed at the lowest dose possible and only when there is a clear diagnosis of gastro-oesophageal reflux disease (GORD)12.

Conclusion

Nearly one third of all infants will suffer the signs and symptoms of infant reflux and regurgitation, usually within the first few months of life4. Although symptoms are usually self-limiting and not related to any organic cause, their impact should never be underestimated; Functional GI Disorders can cause considerable distress to the infants they affect, anxiety among their parents and constitute a significant financial burden on household and healthcare budgets2,13.

The current consensus is that correct management of infant reflux and regurgitation can be carried out entirely within primary care, starting with diagnosis according to the Rome criteria and NICE guidance3,9. Once an organic cause has been excluded, healthcare practitioners should focus on offering parental support and good nutritional advice. In most cases this is all that is required2,9.

  • *National Institute for Health and Care Excellence
  • **The European Society for Paediatric Gastroenterology Hepatology and Nutrition

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IMPORTANT NOTICE: Breastfeeding is best for infants. Infant formula is suitable from birth when infants are not breastfed. Follow-on milk is only for infants over 6 months, as part of a mixed diet and should not be used as a breastmilk substitute before 6 months. We advise that all formula milks including the decision to start weaning should be made on the advice of a doctor, midwife, health visitor, public health nurse, dietitian, pharmacist or other professional responsible for maternal and child care. Foods for special medical purposes should only be used under medical supervision. May be suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6–12 months. Refer to label for details.

  1. Vandenplas Y et al. Gut Health in Early Life: Implications and Management of Gastrointestinal Disorders. Essential Knowledge Briefings. Chichester, England: Wiley; 2015.
  2. Salvatore S et al. Review shows that parental reassurance and nutritional advice help to optimise the management of functional gastrointestinal disorders in infants. Acta Paediatr. 2018. doi:10.1111/apa.14378.
  3. Benninga MA et al. Childhood Functional Gastrointestinal Disorders: Neonate/ Toddler. Gastroenterology 2016;150:1443–1455.e2.
  4. Vandenplas Y et al. Prevalence and Health Outcomes of Functional Gastrointestinal Symptoms in Infants From Birth to 12 Months of Age. J Pediatr Gastroenterol Nutr 2015;61(5):531–7.
  5. Vandenplas et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines 2009; 49:498–547.
  6. Indrio F et al. Beneficial Microbes, 2015;6(2):195–198. Prevention of functional gastrointestinal disorders in neonates: clinical and socioeconomic impact.
  7. National Institute for health and care excellence. NICE Summary on Colic, infantile. https://cks.nice.org.uk/colic-infantile London: NICE; 2017.
  8. National Institute for health and care excellence. Constipation in children and young people: diagnosis and management. London: NICE; 2010.
  9. National Institute for health and care excellence. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. London: NICE; 2015. Available at: www.nice.org.uk/guidance/NG1 [Accessed: February 2019].
  10. Vandenplas et al. Functional gastro-intestinal disorder algorithms focus on early recognition, parental reassurance and nutritional strategies. Acta Paediatr 2016;105(3):244–52.
  11. Vandenplas 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(4):498–547.
  12. Rosen R 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 2018;66: 516–554.
  13. Gut Feelings Survey of 600 parents of children under 2, who experienced FGIDs as infants and 110 HCPs (40 GPs, 40 HVs, 30 Community Pharmacists) across the UK. Conducted in December 2017. Data on file.

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