Introduction
How does reflux in infants present in primary care?
What are the possible contributory factors?
When should parents be referred on to secondary care?
What other practical information can you provide parents?
Where can you find information to help improve how effectively you reassure parents?
What is the recommended approach to managing reflux for breast and formula fed babies?
Medical intervention:
Why does it matter – reflux is a minor complaint?
References

Introduction

There are seven recognised functional GI disorders in childhood,1 [Table 1] which include reflux, colic and constipation. None of these disorders are caused by structural or biochemical factors. About 50% of babies suffer with at least one functional GI disorder in their first year.2 Gastro-oesophageal reflux (GOR) is defined as the persistent effortless regurgitation of stomach contents. Typically, regurgitation occurs two or more times per day, for three or more weeks, in otherwise healthy infants, aged three weeks to 12 months of age. There should be no associated retching, haematemesis, aspiration, apnoea, failure to thrive, feeding or swallowing difficulties.1

 

Table 1: Seven functional GI disorders in childhood1

Infant regurgitation

Infant rumination syndrome

Cyclic vomiting syndrome

Infant colic

Functional diarrhoea

Functional constipation

Infant dyschezia

 

Reflux is estimated to affect at least 30% of young infants in the first year of life, and usually starts before the baby is eight weeks old.3

It is a common condition, as it’s generally the consequence of the infant’s maturing gut.4 It does, however, cause distress to parents and carers, with many clinic consultations attributed to reflux concerns. It is therefore important that health professionals provide effective nutritional advice and support to relieve anxiety and to enable carers to be more able to manage the condition.

How does reflux in infants present in primary care?

A baby with reflux will typically take a feed and then usually, soon after a feed, some of the milk contents will dribble out from the mouth. Other signs to look out for can include hiccups and coughing. However, the infant should be gaining weight appropriately and have normal stools, with no evidence of abdominal pains, retching or blood in their stools.1 There is no simple diagnostic test to confirm whether the condition is simple reflux, but if the condition becomes severe and affects the baby’s wellbeing (such as not gaining weight, or if there are symptoms such as blood in the stools), then medical intervention would be advised.

Reflux may continue for some months, but if it persists beyond a year then medical advice should be sought.

What are the possible contributory factors?

Reflux is assumed to arise as a result of a gastro-intestinal/physiological immaturity.4 Gut immaturities can include a lax lower oesophageal sphincter from the stomach back to the oesophagus, allowing milk to flow back. The baby may have a short and/or narrowed intra-abdominal oesophagus.4 Giving large amounts of a liquid diet over a short period of time, an obtuse angle of His, feeding in a horizontal position and the position of the infant after the feed may all contribute and should be considered significant.4

Babies should be handled confidently and calmly, with a relaxed approach, e.g. when winding. Healthcare professionals should also offer effective support and nutritional advice.

When should parents be referred on to secondary care?

GOR is simple reflux, but it is important to know the difference when symptoms become severe and gastro-oesophageal reflux disease (GORD) should be suspected.6

If GORD is suspected it is vital that the infant is referred for medical review.

When reassuring parents, advise them they should return for review if the following occur:5

  • Regurgitation becomes persistently projectile
  • There is bile-stained vomiting or blood in vomit
  • There are new concerns such as signs of marked distress, feeding difficulties or faltering growth
  • Persistent, frequent regurgitation continues beyond the first year of life.

Red flags symptoms as laid out in NICE guidelines may suggest disorders other than GOR, and so should be investigated or referred using clinical judgement.5

Reflux is estimated to affect at least 30% of young infants in the first year of life, and usually starts before the baby is eight weeks old

What other practical information can you provide parents?

NHS Choices and NICE guidance provide useful support to improve knowledge and skills in this area.5,6,9

There is a new educational module available on MIMS Learning that healthcare practitioners can take, developed by the Gut Feelings panel, which gives an overview of the management of reflux, colic and constipation and also gives advice on how to provide effective reassurance to parents. Available at: www.mimslearning.co.uk.10

There is also information available for advice on ‘practical ways’ to manage infant functional GI disorders, as developed by Alison Wall for the educational module developed by Gut Feelings (NB. This downloadable information is for healthcare professional use only). For more information visit www.mimslearning.co.uk.10

 

Where can you find information to help improve how effectively you reassure parents?

The reassurance cycle detailed in a recent article on colic7 gives excellent guidelines for providing reassurance as a healthcare practitioner. Communication is at the core of giving reassurance. Parents and carers will not feel reassured if they believe their difficulties have not been heard and appreciated, with the likely result that the parents will make repeated consultations and make high use of healthcare resources.8

Parents want reassurance that they are good parents and they need to gain confidence in their role as parents and that they are doing all the right things.

The healthcare professional can ask the carer what a typical day is like coping with the reflux. This provides an opportunity for both to discuss and have a clear picture of the baby’s behaviour and milk intake over the whole day.

What is the recommended approach to managing reflux for breast and formula fed babies?

After ruling out red flags, the management should concentrate on parental reassurance and education and, for infants with frequent regurgitation associated with marked distress, the stepped-care approach as recommended by NICE.5

Initially, it is important to encourage to continue breastfeeding and signpost breastfeeding support services/ breastfeeding assessment in your area.

Reassure parents they are not alone and it is common and often the consequence of an infant’s maturing gut.

Explain when symptoms typically peak and resolve – i.e. they should resolve completely at one year.

Explain the importance of winding the baby and sitting the baby up during and after the feed. Demonstrate a good winding technique [see education resource below] and help the parent to hold the baby confidently, supporting the chin to help the baby to burp.

Suggest ensuring that clothing is not constrictive, especially around the baby’s tummy.

For infants with frequent regurgitation associated with marked distress, if breast-fed ensure someone with appropriate expertise and training carries out a breastfeeding assessment.

If formula-fed, in a stepped approach, after reviewing the feeding history, smaller more frequent feeding should be offered. The required daily amounts of milk should be offered but in smaller volumes. The teat size should also be checked to ensure that the baby isn’t gulping too much air with the feed, or struggling to take the milk with too small a teat size. The baby should then be monitored and if no improvement after two weeks should be offered a thickened (anti-reflux) formula. These contain either rice starch, corn starch, locust bean gum or carob bean gum.5

Medical intervention:

  • While there is slight variation between different guidelines, all agree that medication is seldom required to treat infant reflux.4 A careful stepped approach is recommended by NICE for infants with frequent regurgitation associated with marked distress, and should be explained to the parents and carers5
  • In breastfed infants, NICE suggests a trial of alginate therapy if frequent regurgitation associated with marked distress continues, despite breastfeeding assessment and advice
  • In formula-fed infants, NICE states that if the stepped-care approach is unsuccessful, thickened formula should be stopped and the infant offered alginate therapy for a trial period of one to two weeks.5 If the alginate therapy is successful continue with it, but try stopping it at intervals to see if the infant has recovered.

 

Why does it matter – reflux is a minor complaint?

Healthcare practitioners see a range of childhood conditions that are often unusual and serious to manage.

Functional GI disorders are very common and about 50% infants will experience at least one of the disorders in their first year of life.2 It is therefore vital that we understand their commonality and the impact they have on family life.

Parents need reassurance about how to manage these disorders and understanding that they are due to immaturity of the gut and nervous system. We need to use healthcare resources responsibly and effectively. Reassuring parents all is well and that the condition will gradually resolve is of enormous financial and emotional benefit to both parents and healthcare workers.

The evidence from a systematic literature review and cost calculation11 estimated that the total costs of managing functional GI disorders in infants in England were at least £72.3 million annually in 2014/15.

Key Messages

  • Functional GI disorders are very common
  • The prevalence of reflux is about 30% in the first year of life
  • It will resolve with time and with the maturity of the infant
  • Medical interventions are rarely necessary and are only required when GORD is diagnosed
  • Nutritional advice and reassurance is the approach that should be consistently adopted
  • If we manage this condition by reassuring and discussing nutritional guidelines with parents, we will avoid significant financial and emotional costs, both for families and for the NHS.

References

  1. Benninga MA, Faure C, Hyman PE, et al. Gastroenterol 2016. 150:1443-1455.e2
  2. Iacono G, Merolla R, D’Amico D et al. Dig Liver Dis 2005. 37(6):432-8
  3. Vandenplas Y, Abkari A, Bellaiche M, Benninga M, et al. J Pediatr Gastroenterol Nutr 2015. 61(5):531–7
  4. Salvatore S, Abkari A, Cai W, Catto-Smith A, et al. Acta Paediatr 2018. doi:10.1111/apa.14378.
  5. National Institute for Health and Care Excellence (NICE). Gastro-oesophageal reflux disease in children and young people: diagnosis and management. London: NICE; 2015.
  6. National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summary – GORD in children. Available online at https://cks.nice.org.uk/gord-in-children#!backgroundsub:1 [Last accessed August 2018]
  7. Wall A, Bogle V. BJFM 2018. 6(4):21-24
  8. Ring A et al. BMJ 2004. 328:1-5
  9. NHS Choices. Reflux in babies. Available online at https://www.nhs.uk/conditions/reflux-in-babies/ [Last accessed August 2018]
  10. MIMS learning. Available online at https://www.mimslearning.co.uk [Last accessed August 2018]
  11. Mahon J et al. BMJ Open 2017. 7:e015594.doi:10.1136/bmjopen-2016-015594.

Alison Wall

Health Visitor