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Gastro Oesophageal Reflux (GOR) and GORD in infants

Some gastro-oesophageal reflux (GOR) occurs in most babies. Up to 40-50% of babies younger than 3 months regurgitate their feeds at least once a day (Craig 2004). Incidence peaks around 4 months. GOR is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. Most of us are familiar with it in the later stages of pregnancy. In reflux there is no retching as associated with a gastric infection, milk simply comes up and out of the baby’s mouth.

Symptoms

The predominant symptom is frequent regurgitation of feeds (posseting). Diagnosis is usually made by description of symptoms. Other signs include:

Irritability or excessive crying
Recurrent hiccups
Frequent night waking
Frequent coughing

Studies show that frequency of regurgitation declines over the first 6 months and dramatically after 12 months (NICE 2015). This interestingly corresponds with the time when babies can sit and stand.

Regurgitation of at least 1 episode a day with age (Nelson 1997)

Age	Percentage
0-3m	50
4m	67
6m	61
7m	21
12m	5

NICE 2015 recommends to healthcare professionals that GOR is a normal physiological process in infancy. Parents should be reassured that it does not need any investigation or treatment unless the child presents with symptoms such as unexplained feeding difficulties, distressed behaviour, or faltering growth. Overfeeding is a common cause in artificially-fed infants who may benefit from smaller, more frequent bottles.

Silent Reflux

Silent reflux is described as reflux where the regurgitation is swallowed rather than being spat out. Babies may cry and show signs of distress but not posset. Symptoms may otherwise be identical to GOR.

Managing reflux symptoms

Most cases of reflux clear up without intervention but simple changes can help reduce symptoms.

Feed more frequently and respond at the baby’s first cues that he/she is hungry – crying is a late sign of hunger and will increase the air swallowed making regurgitation of feeds more likely. Scheduling feeds with longer intervals and larger volumes may increase symptoms.
Keep the baby upright after feeds over your shoulder ideally for at least 30 minutes with a muslin to catch milk if necessary.
Using a sling to keep the baby upright may help but ensure there is no pressure on the stomach and do not bend yourself.
Do not put the baby down in a car seat where they become somewhat slumped. Try not to jiggle or move the baby too much as the feed settles.
Take time to burp the baby in a sitting position with his/her head supported with your hand – be prepared with a muslin cloth over your shoulder and a bib on the baby to protect clothing (and reduce washing!)
Put the baby to sleep flat on his or her back.
Ensure that breastfeeding has been optimised to ensure the baby has access to all the milk and that your breasts are well drained after a breastfeed (Woolridge 1988).

Caring for a baby with reflux can be difficult, exhausting and confusing. It can be isolating as you may be concerned about the baby vomiting when outside the family home. You may worry about whether you will need changes of clothes for yourself and the baby, or about what other people will say. You can be reassured that reflux is common and not a cause for concern as long as your baby is thriving and not overly distressed. Using the suggestions for managing reflux above can help, along with carrying plenty of muslin cloths and spare baby clothes.

Treatment for GOR

With GOR, medication is not essential. However you may wish to try remedies to relieve symptoms of excessive crying and posseting in the baby. Medication should not be commenced without support by an expert in breastfeeding to optimise attachment.

If frequent regurgitation associated with marked distress continues despite a breastfeeding assessment and advice, NICE recommends that alginate therapy can be considered for a trial period of 1–2 weeks. If the alginate therapy (Gaviscon Infant sachets ®) is successful you can continue with it, but it should be stopped at regular intervals (e.g. 2 weeks) to see if the infant has recovered as we know that it may resolve with time as described above.

The sachets of alginate should be dissolved in water or expressed breastmilk as described below.

Side effects: Alginates, such as Gaviscon®, can cause constipation in the baby as they thicken the gastric contents. This may cause further distress to the baby and anecdotally can lead to prescription of bulk forming laxatives in addition to the alginate. This is inappropriate and symptoms would be better managed with other drugs

Dose: infant body-weight under 4.5 kg, 1 ‘dose (sachet)’ mixed with feeds (or water in breast-fed infants) when required (max. 6 times in 24 hours); body-weight over 4.5 kg, 2 ‘doses’ mixed with feeds (or water or expressed breastmilk in breast-fed infants) when required (max. 6 times in 24 hours).

Manufacturer Gaviscon® directions: Bottle fed infants; Mix each sachet into 115ml (4 fl oz) of feed in the bottle and shake well before feeding as normal. Breast fed infants and other infants up to 2 years mix each sachet with 5ml (1 teaspoon) of cooled boiled water until a smooth paste is formed, add another 10ml (2 teaspoons) of cooled boiled water and mix. For breast fed infants give Gaviscon Infant® part way through each feed or meal using a spoon or feeding bottle.

Gastro-oesophageal Reflux Disease (GORD)

Symptoms:

The baby is not gaining weight
The baby vomits frequently and forcefully
The baby spits up green or yellow fluid
The baby spits up a liquid which looks like coffee grounds
The baby repeatedly refuses feeds
The baby has blood in the bowel motions

It is reported by Salvatore (2002) that in up to half of the cases of GORD in infants younger than 1 year, there may be an association with Cow’s Milk Protein Allergy. Heine (2006) noted that infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet but that only a few randomized clinical trials have been conducted.

The NICE guidelines on GORD (NG1, updated 2019) recommend:

“In breast‑fed infants with frequent regurgitation associated with marked distress that continues despite a breastfeeding assessment and advice, consider alginate therapy for a trial period of 1 to 2 weeks. If the alginate therapy is successful continue with it, but try stopping it at intervals to see if the infant has recovered.”

If symptoms remain troublesome despite a 1–2 week trial of alginate therapy, a doctor may consider prescribing a 4-week trial of a proton pump inhibitor (PPI) or a histamine-2 receptor antagonist (H2RA).

NICE Guideline NG1 (updated 2019) recommends that metoclopramide, domperidone or erythromycin to treat GOR or GORD are not prescribed unless the potential benefits outweigh the risk of adverse events, other interventions have been tried and there is specialist paediatric healthcare professional agreement for its use.

References

British National Formulary, https://bnf.nice.org.uk/
Craig WR1, Hanlon-Dearman A, Sinclair C, Taback S, Moffatt M. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003502
Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol. 2006 Jun;6(3):220-5.
Jones W Breastfeeding and Medication Routledge 2013
Nelson SP, Chen EH, Syniar GM; Christoffel KK Prevalence of Symptoms of Gastroesophageal Reflux During Infancy. A Pediatric Practice-Based Survey , Arch Pediatr Adolesc Med. 1997;151(6):569-572.
NICE NG1 (updated 2019) Gastro-oesophageal reflux disease in children and young people: diagnosis and management, https://www.nice.org.uk/guidance/ng1
Salvatore S, Vandenplas Y Gastroesophageal reflux and cow milk allergy: is there a link? Pediatrics. 2002 Nov;110(5):972-84)
Woolridge MW and Fisher C. Colic, “overfeeding”, and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management. The Lancet, 1988; ii:3

Reflux and Breastfeeding