Infant

    Infant

    Success stories of Gaviscon treatment

    The patient

    Rosie, a 3-month old baby, has been regurgitating most of her milk (formula) within 1 hour of feeding. For the last 2 weeks, she has been crying uncontrollably during and after her feeds and is uncharacteristically irritable. 3 days ago, she began to refuse feed, creating great anxiety for her parents.

     

    Understanding the potential underlying cause(s)

    Gastro-oesophageal reflux (GOR) symptoms such as regurgitation after feeding are common in infants.(1-3) Symptoms generally begin before 8 weeks of age and can occur as often as six times a day.(1-3) Data have shown that infant reflux is most prevalent 4 months of age (4,5) with 67% of infants who experience reflux.(5)

    Several factors make infants prone to reflux. For example, they have an immature lower oesophageal sphincter (LOS), which allows their stomach contents to pass into the oesophagus more easily.(6) Their liquid diet and mainly recumbent positioning can also contribute to their reflux.(2)

    However, some infants display marked distress alongside their reflux symptoms. Identifying marked distress can be challenging but generally refers to outward signs of pain and unhappiness outside of what is considered to be normal by a healthcare professional.(1) Careful evaluation of distress must include parents or carers who can explain whether this is usual or unusual for the infant.(1)

    Aside from reflux, other conditions cannot be entirely ruled out based on the above symptoms described. Conditions such as colic and cows’ milk protein allergy have overlapping symptoms with GOR/GORD and may warrant differential diagnosis.(1,7)

     

    Consultation advice

    Before diagnosing or treating Rosie, you should carry out a thorough discussion with her parents to obtain a detailed medical history and examination. This should include information on:(2)

      • The formula used
      • The volume and frequency of feeds
      • The volume and frequency of regurgitation/vomiting
      • Any respiratory symptoms
      • Any back arching or features of Sandifer's syndrome
      • Growth using centile charts
      • Potential risk factors that could increase her risk of GORD
      • Any red flag symptoms

    If no red flag symptoms arise and Rosie’s symptoms are consistent with GOR then you should reassure her parents that her condition is normal and will not require treatment. Provide sources of additional information for her parents to refer to.(2)

     

    However, if you feel Rosie demonstrates marked distress, you should consider treating her for reflux symptoms using the following stepped approach:(2)

     

    1. Feed modifications

      As Rosie is formula fed, you should:(1,2)

      Advise Rosie’s parents to return for another consultation if new symptoms develop or if her symptoms do not improve/worsen after 2 weeks.(3)

    2. Non-systemic therapies: Alginates

      If feeding modifications do not relieve Rosie’s symptoms, you should stop the thickened formula and consider prescribing her an alginate therapy.(8) Alginates thicken the stomach contents into a gel making it more difficult for reflux to occur.(8)

      Begin the treatment as a 1–2 week trial but continue prescribing the alginate if it proves successful in managing her symptoms. It is recommended that you stop treatment at specific intervals to check if Rosie’s symptoms have resolved while on treatment.(1,2)

    3. Acid-suppression drugs if necessary

      Consider treating Rosie for 4 weeks with a proton pump inhibitor (PPI) or histamine 2 receptor antagonist (H2RA) if her symptoms persist after alginate therapy.(1,2) PPIs and H2RAs reduce gastric acid secretion by blocking proton pumps and histamine receptors on parietal cells, respectively.(9)

      However, unlike adults, less than 10% of infant reflux is acid related.(10) Therefore, you should carefully evaluate which therapy is most appropriate for Rosie’s age and take into consideration Rosie’s symptoms and her parents’ preferences.(1,2)

     

    If symptoms are not resolved with treatment or recur when treatment is stopped, consider referring Rosie to a specialist.(1,2)

     

    References

    1. NICE. NICE guidelines: Gastro-oesophageal reflux disease in children and young people: diagnosis and management. 2015. Available: www.nice.org.uk/guidance/ng1 [accessed August 2019]
    2. NICE. GORD in children. 2019. Available: https://cks.nice.org.uk/gord-in-children#!topicSummary [accessed August 2019]
    3. NHS. Reflux in babies. 2019. Available: https://www.nhs.uk/conditions/reflux-in-babies/ [accessed August 2019]
    4. Baird DC, Harker DJ, Karmes AS. Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children. Am Fam Physician 2015;92(8):705–14
    5. Nelson SP, Chen EH, Synair GM, et al. Prevalence of Symptoms of Gastroesophageal Reflux During Infancy. Arch Pediatr Adolesc Med 1997;151(6):569–72
    6. Kuo B, Urma D. Esophagus - anatomy and development. GI Motility. 2006. Available: www.nature.com/gimo/contents/pt1/full/gimo6.html [accessed August 2019]
    7. NICE. Colic – infantile. 2017. Available: https://cks.nice.org.uk/colic-infantile#!diagnosisSub:1 [accessed August 2019]
    8. NICE. Gastro-oesophageal reflux in children and young people. 2016. Available: https://www.nice.org.uk/guidance/qs112 [accessed August 2019]
    9. Hirschowitz BI, Keeling D, Lewin M et al. Pharmacological aspects of acid secretion. Dig Dis Sci. 1995;40(2 Suppl):3S–23S
    10. Vandenplas Y, Goyvaerts H, Helven R, et al. Gastroesophageal reflux as measured by 24-hour pH monitoring, in 509 healthy infants screened for risk of sudden infant death syndrome. Pediatrics 1991;88(4):834–40

     

    RB-M-02499
    Date of preparation: June 2020

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