Diagnosis and management: infant reflux and regurgitation

An overview of the diagnosis and management of the most common functional gastrointestinal (GI) disorder: reflux and regurgitation

By Nutricia Early Life Nutrition

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.

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`¹¹:

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.

Our Careline

At Nutricia Early Life Nutrition, science is at the heart of our nutrition and health commitment to help healthcare professionals support mums during the first 1,000 days. Our research and innovation delivers evidence-based nutritional solutions to support a child’s lifelong health, combining our Early Life Nutrition expertise with years of professional experience to develop a portfolio of products to support the nutritional needs of mums, mums-to-be and their babies.

In addition to our research-based guides, we have a dedicated team of professional experts on hand to answer any feeding-related queries that healthcare professionals may have. Our free healthcare professional helpline is open from 8am to 8pm, Monday to Friday. Just phone 0800 996 1234 for expert advice on infant feeding and nutrition, including common infant feeding problems such as cows’ milk allergy, colic, constipation and reflux.

“We take calls from GPs, nutritionists, dietitians, midwives, health visitors…”

IMPORTANT NOTICE: Breastfeeding is best for babies. Infant formula is suitable from birth when babies are not breastfed. Follow-on milk is only for babies 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.

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

References

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.