By Dr Rosemary Marsh, GP Specialist Trainee, MRCPCH
What is Reflux and When is it Pathological?
Gastro-oesophageal reflux (GOR) describes the reverse flow of stomach contents back into the oesophagus which may result in regurgitation. In adults it is almost always abnormal but in infants it is a normal physiological process as a result of a lax lower oesophageal sphincter, a non-upright posture and relatively high volume liquid stomach contents. Many babies (approx. 40% of newborns)1 will have vomits after feeds but thrive despite this. Vomiting usually starts before 8 weeks of age, peaks at 4-6 months and improves by 12 months2.
Although in most cases reflux is physiological and does not affect a baby’s health, there are cases of pathological reflux or gastro-oesophageal reflux disease (GORD). In these cases babies may experience one or more of:
- Discomfort when stomach contents reflux into the oesophagus, typically during or after feeds (which may occur without vomiting: ‘silent reflux’)
- Feed aversion
- Faltering growth
- Respiratory complications from small recurrent aspirations
Distinguishing the small number of babies with pathological GORD who may benefit from treatment from the much larger number of babies with physiological GOR is a clinical challenge as many young infants have symptoms of discomfort and unsettled periods which are not caused by reflux. This diagnostic difficulty can lead to overdiagnosis causing harm from overtreatment and may make professionals doubt the existence of true pathological reflux, which in turn can lead to under-diagnosis of severe cases.
Where GORD is suspected, a trial of treatment may be required over a time-limited period to see whether there is a pathological component. It is imperative to make treatment time-limited as many infant symptoms of discomfort and vomiting will improve spontaneously with time and treatment itself may have adverse effects3.
Impact of Physiological Reflux (GOR) on Breastfeeding
Physiological reflux (GOR) need not adversely affect breastfeeding although many parents may have concerns about their babies vomiting after feeds. These can be addressed with reassurance and education about infant norms, likely improvement over time and advice about pragmatic steps such as upright positioning immediately after feeds (although not during sleep). It also may help to reassure parents that babies are often not distressed by effortless milky vomits even if they look dramatic to parents.
Healthy breastfed infants being fed responsively will regulate their own milk intake following regurgitation. Adequate weight gain, nappy output and a baby who settles well after feeds are indicative of this. As such there is not the risk of over-feeding that exists for formula fed infants which can exacerbate vomiting.
Impact of Pathological Reflux (GORD) on Breastfeeding
Pathological reflux (GORD) may have a more significant impact on breastfeeding. A baby who is distressed during or after feeds will be distressing for the parents and may result in a loss of confidence in breastfeeding. This can be reinforced if the baby then develops feed aversion and/or faltering growth. It is important to acknowledge parents’ concerns that their babies are distressed by feeds, but to reassure them that it is almost always possible to try to treat GORD without stopping breastfeeding.
Recommended Steps for Management of GORD in Breastfed Babies (as per NICE Guidance 2015)4
NICE Quality Standard QS112 specifies that all breastfed infants with frequent regurgitation with marked distress should have their feeding assessed, as correcting breastfeeding technique may eliminate symptoms5.
- Ensure that a person with appropriate expertise carries out a breastfeeding assessment.
- Consider a 1-2 week trial of alginate feed thickener (e.g. Gaviscon). If symptoms improve with this, it should be continued and then treatment stopped at intervals (for example every 2 weeks) to see if symptoms have improved or resolved.
- If an alginate feed thickener trial is ineffective, a 4 week trial of antacid medication (e.g. Ranitdine*) at an effective dosage is indicated.
- A proton pump inhibitor (Omeprazole or Lansoprazole) may also be considered but can be challenging to give as the liquid preparation is a ‘special’ and dispersible preparations (eg MUPS) are difficult and inaccurate to administer. If dispersible preparations are used, it is best to prescribe quantities that do not involve splitting tablets as dividing quantities of liquid after dispersion will give inaccurate doses. It is also worth being mindful of evidence that PPI use in infants has been linked to an increased risk of fractures in early childhood6.
- If symptoms persist despite the above, consider referral to a paediatrician (the urgency of referral depending on clinical severity)
*We are aware of current recalls of some forms of ranitidine and recommend referring to the MHRA via this link for up-to-date details of this when selecting antacid treatment (October 2019).
Impact of GORD Treatment on Breastfeeding
The treatments for pathological reflux (GORD) can also impact on breastfeeding. NICE guidance recommends alginate feed thickeners as a first-line treatment. However, this can be difficult to administer while breastfeeding and add to the burden on parents who are already struggling with a distressed and/or unwell baby. Alginate feed thickeners may be replaced by a trial of an antacid, but this may not be effective at low doses so clinicians need to consider titrating up to maximum dosage before diagnosing treatment failure.
In up to half of cases, pathological reflux is associated with cows’ milk allergy (CMA)7. If there are other features of CMA (eg. relevant family history, dermatitis or colitis) this this should be considered as a differential diagnosis and management trialled first.
Recommended Steps for Management of GORD in Formula Fed Babies
In formula‑fed infants with frequent regurgitation associated with marked distress, the following approach is recommended5:
- Review the feeding history
- Reduce the feed volumes only if excessive for the infant’s weight
- Offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) unless the feeds are already small and frequent
- Offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
- Proceed to medical management or referral as per the breastfed infant
First Steps Nutrition Trust has published information on thickened (anti-reflux) milks (green report ‘Infant Milks in the UK’, see section 5.7), including a review of the evidence for their use. Products are widely available over-the counter but are classified as ‘foods for special medical purposes’ and should only be used under medical supervision.
Information on the necessary volumes of artificial baby milk for infants can be found in Section 6 of the document First Steps Nutrition Trust: Infant Milks in the UK (see the green report).
Manufacturer guidance on how to make up thickened infant milks (designated ‘foods for special medical purposes’) are not currently in line with recommendations for making up standard infant formula safely, and suggest using water at temperatures lower than 70ºC. Where these milks are prescribed, advice should be taken from a health professional on how to make them up appropriately.
When to Refer?
- Refer urgently any young babies with very frequent very forceful vomits consistent with pyloric stenosis, bilious or blood-stained vomiting, malaena or other signs of acute illness.
- Refer any parents and babies experiencing distress or doubt around breastfeeds to local breastfeeding services where they can access support.
- If a baby is having very significant symptoms of reflux (eg feed aversion, faltering growth), symptoms persist after a trial of treatment or there is doubt around the diagnosis then refer to paediatrics for further assessment.
Reflux, both physiological and pathological, can be distressing for parents and unmask perinatal mental health problems. There should be a low threshold for asking about and treating these in parents of babies presenting with reflux.
NICE Quality Standard QS112: Gastro-oesophageal reflux in children and young people Includes a specific section on a feeding assessment for breastfed infants.
NICE CKS: GORD in Children (Revised February 2019) includes sections on prescribing.
NHS Website: Tongue-Tie Illustrates the importance of a breastfeeding assessment as some symptoms associated with reflux may be related to tongue-tie.
First Steps Nutrition Trust: Infant Milks in the UK Green report, see section 5.7 which covers thickened (anti-reflux) infant milks suitable from birth.
- Craig WR, Hanlon-Dearman A, Sinclair C, Taback SP, Moffatt M. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database of Systematic Reviews. 2010, Issue 5. Art. No.: CD003502.
- The Breastfeeding Network: Gastro Oesophageal Reflux (GOR) and GORD in infants May 2015
- Terrin G, Passariello A, De Curtis M, Manguso F, Salvia G, Lega L et al. Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns. Pediatrics. 2012;129(1):e40-e45.
- NICE Guidance NG1: Gastro-oesophageal reflux disease in children and young people: diagnosis and management January 2015
- NICE Quality Standard QS112: Gastro-oesophageal reflux in children and young people January 2016
- Malchodi L, Wagner K, Susi A, Hisle-Gorman E. Early Acid Suppression Therapy Exposure and Fracture in Young Children.
- Salvatore S, Vandenplas Y. Gastroesophageal reflux and cow milk allergy: is there a link? Pediatrics. 2002;110(5):972-84.