gastro-oesophageal reflux in infancy

Last edited 08/2021 and last reviewed 07/2022

Gastro oesophageal reflux (GOR) is the uncontrolled passage of gastric contents into the oesophagus (1). Commonly seen in pre term infants (2) but is a frequent occurrence in most of the healthy infants (1).

Regurgitation (posseting or spitting up) is the effortless passage of swallowed food back into the pharynx or mouth or sometimes out of the mouth (3). It is the most common presentation in infants with GOR. Regurgitation of at least 1 episode a day is seen in

• 50% of infants between 0-3 months
• 67% of infants at 4 months
• 5% at 10 to 12 months of age (1)

Reflux may sometimes cause vomiting due to stimulation of pharyngeal sensory afferents by refluxed gastric content (3). Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. The vomiting may commence soon after birth but is more frequently delayed for a few weeks.

GOR can be physiological or pathological

• physiological GOR – when the infant has normal weight gain and experiences no complications
• pathological GOR – also known as gastro oesophageal reflux disease (GORD) is when reflux is associated with other symptoms like failure to thrive or weight loss, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis etc.(1)

NICE emphasise the distinction between GOR and GORD and state (4):

• gastro-oesophageal reflux (GOR) is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. In contrast, gastro-oesophageal reflux disease (GORD) occurs when the effect of GOR leads to symptoms severe enough to merit medical treatment.

  Give advice about gastro-oesophageal reflux (GOR) and reassure parents and carers that in well infants, effortless regurgitation of feeds:

  • is very common (it affects at least 40% of infants)
  • usually begins before the infant is 8 weeks old
  • may be frequent (5% of those affected have 6 or more episodes each day)
  • usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year old)
  • does not usually need further investigation or treatment

  When reassuring parents and carers about regurgitation, advise them that they should return for review if any of the following occur:

  • the regurgitation becomes persistently projectile
  • there is bile-stained (green or yellow-green) vomiting or haematemesis (blood in vomit)
  • there are new concerns, such as signs of marked distress, feeding difficulties or faltering growth
  • there is persistent, frequent regurgitation beyond the first year of life

A review states (5):

• regurgitation is the most frequent symptom of gastroesophageal reflux and is present in nearly all cases
• gastroesophageal reflux occurs normally in infants, is often physiological, peaks at 4 months of age, and tends to resolve with time
• gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce troublesome symptom(s) and/or complication(s)
• a thorough clinical history and a thorough physical examination are usually adequate for diagnosis
• when the diagnosis is ambiguous, diagnostic studies may be warranted
  • a combined esophageal pH monitoring and multichannel intraluminal esophageal electrical impedance device is the gold standard for the diagnosis of gastroesophageal reflux disease if the diagnosis is in doubt
• in most cases, no treatment is necessary for gastroesophageal reflux apart from reassurance because the condition is benign and self-limiting
  • thickened feedings, postural therapy, and lifestyle changes should be considered if the regurgitation is frequent and problematic
  • pharmacotherapy
    • should be considered in the treatment of more severe gastroesophageal reflux disease for patients who do not respond to conservative measures
    • proton pump inhibitors are favored over H2-receptor antagonists because of their superior efficacy
  • antireflux surgery is indicated for patients with significant gastroesophageal reflux disease who are resistant to medical therapy

Reference:

• (1) Salvatore S, Vandenplas Y.Gastroesophageal Reflux and Cow Milk Allergy: Is There a Link? Pediatrics 2002;110(5):972-984
• (2) Poets C.F.Gastroesophageal Reflux: A Critical Review of Its Role in Preterm Infants. Pediatrics 2004;113(2):e128-e132
• (3) 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). Journal of Pediatric Gastroenterology and Nutrition 2009; 49:498–547
• (4) NICE (January 2015). Gastro-oesophageal refllux disease: recognition, diagnosis and management in children and young people
• (5) Leung AK, Hon KL. Gastroesophageal reflux in children: an updated review. Drugs Context. 2019;8:212591. Published 2019 Jun 17. doi:10.7573/dic.212591