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Symptoms

The full medical name for reflux is gastro-oesophogeal reflux (GOR)1. Strictly speaking, GOR is defined as the passage of the stomach (gastric) contents into the food tube (oesophagus)2. It is the term used when a baby with reflux doesn’t get any symptoms or the symptoms are not troublesome2. The main signs of reflux in babies is bringing up a small amount of feed without requiring any effort or causing any distress to the baby1.

Reflux in babies is very common, affecting about 4 out of 10 babies1. Reflux in newborns usually begins before they are 8 weeks old1. Around 5 in 100 babies with reflux get more than 6 episodes a day, but it settles down in about 9 out of 10 babies before they are one-year old1. Reflux can also occur in older children but is less common than in babies1.

You may also see the term regurgitation (“posseting”)2. This is where some or all of the stomach contents reach the mouth and sometimes come out of the mouth. It is common in babies under one year of age2.

Silent reflux – also called occult reflux by doctors – is the term used when all or part of the stomach contents comes up into the oesophagus but does not enter the child’s mouth1. It’s not obvious to the child, parents or any healthcare professional observing the child1.

Gastro-oesophageal reflux disease (GORD) is the term used when symptoms are troublesome or complications occur2. GORD occurs in otherwise healthy infants and children with some specific underlying risk factors1.

These include1:

  • premature birth
  • parental history of heartburn or acid regurgitation
  • obesity
  • hiatus hernia (a condition in which part of the stomach rides up into the chest)
  • history of repaired congenital diaphragmatic hernia (a birth defect where there is a hole in the diaphragm)
  • history of repaired congenital oesophageal atresia (a birth defect affecting a baby’s oesophagus)
  • a neurodisability ( a condition affecting the nervous system)
  • Sandifer syndrome (a condition where a baby gets episodes where their neck muscles go into spasm (torticollis) causing the neck to stretch backwards and rotate1, their back to arch and their chin to lift up3)1.

To be honest, there is considerable overlap between GOR and GORD, and some confusion even among health professionals1. The ‘take home’ message is that babies with simple GOR have no other symptoms, feed well and thrive3. They are sometimes known as ‘happy spitters’3.

In contrast, babies or older children with GORD may have3:

  • Irritability
  • Excessive crying
  • Poor appetite
  • Feeding refusal
  • Gagging
  • Failure to thrive
  • Sleep disturbance
  • Chronic cough
  • Wheezing
  • Stridor
  • Grimacing

Red flags

If your baby or older child has been diagnosed with GOR, you need to be aware of features which may appear later and may indicate that the symptoms may be due to GORD or even some other cause1. These features are called ‘Red Flags’1. If they occur, you need to obtain further advice from your healthcare provider1. They include1:

  • Frequent forceful vomiting
  • Bile-stained (green or yellow-green) vomit
  • Blood in vomit (except for babies who have swallowed blood – for example, from a cracked nipple during breast feeding)
  • Blood in the poo (for example, in some cases of cow’s milk allergy)
  • A swollen tummy, a lump in the tummy, or the tummy appears to be tender when you press it
  • Runny poo (which may suggest cow’s milk allergy)
  • If your child appears unwell or has a fever
  • If your baby cries when doing a wee or older child complains of pain
  • The fontanelle (the soft spot in a baby’s skull) appears swollen, the head circumference is increasing rapidly, the vomiting is worse in the morning (sometimes seen in meningitis or other conditions causing pressure in the fluid around the brain) or your child complains of morning headaches
  • Unusual behaviour (for example your baby is not as alert as usual, irritable, drowsy)
  • Baby develops allergy symptoms as well as reflux (this could be cow’s milk allergy)

A doctor may also want to investigate your baby or child if they develop a complication of reflux such as1:

  • Reflux oesophagitis (inflammation of the oesophagus due to acid reflux, eventually leading to ulcers)
  • Repeated episodes of pneumonia
  • Frequent ear infections (3 or more in 6 months)
  • Dental erosion (acid damaging the teeth) particularly in children with neurodisability such as cerebral palsy

Causes

There is a muscular valve between the oesophagus and stomach called the lower oesophageal sphincter3. Anything which causes this valve to relax will allow the acid contents of the stomach to flow into the oesophagus3. Also, anything which increases the pressure in the stomach will force the valve to open, with the same result3.

Some of the causes have already been mentioned. These include, for example, defects affecting the structure of the oesophagus (gullet), such as congenital oesophageal atresia and hiatus hernia. A certain amount of reflux in babies under a year is quite normal4. It’s all to do with the baby’s anatomy and physiological features4.

The oesophagus is shorter and narrower than in older children4. The stomach is slower to empty4. The lower oesophageal sphincter is short and sits above rather than below the diaphragm (the muscle shelf that divides the chest from the tummy cavity)4.

Add to this a large volume of milk sloshing round in the baby’s tummy, the small volume of the oesophagus compared to the large volume of the stomach, and the fact that babies are often fed lying on their backs, and you have a perfect storm for regurgitation4. All these features are more marked in premature babies3.

In older children, greasy, acidic food, caffeine and overeating may result in reflux3. Obesity increases the tendency to get reflux because of the double whammy of a stomach under increased pressure and a lower oesophageal sphincter that relaxes more than usual3.

Reflux occurs more commonly in children with some long-term (chronic) lung diseases such as cystic fibrosis and interstitial lung disease. This is thought to be due to a combination of over-inflated lungs pressing down on the diaphragm combined with increased pressure on the stomach from coughing3. It is also more likely in children with congenital heart disease3.

There may be lots of different things going on in children with neurodisabilities such as cerebral palsy. Tube feeding, long-term vomiting, constipation and curvature of the spine may all increase the risk of reflux1.

Cow’s milk allergy is associated with regurgitation and vomiting similar to reflux, but it’s not clear whether it can actually be labelled as a cause3. It is known that in breast-fed babies, reflux tends to clear up quicker than in babies who are formula-fed3.

Twin studies suggest that genetic factors may play a part3.

Diet

Thickening expressed breast milk or formula with cereal may be worth a try when the baby is weaning3. A rough guide is to add one tablespoon of cereal to every ounce of formula or breast milk3. You can buy anti-reflux milk (formula which has already been thickened) from supermarkets and pharmacies3. Thickened formula is associated with increased weight gain, so make sure you don’t overfeed your baby3.

Keeping babies in an upright position for 20-30 minutes after feeding is known to reduce regurgitation3. However, you shouldn’t leave babies to sleep with their head raised, on their side or on their front in an effort to prevent reflux, due to the risk of sudden infant death syndrome3. However, this may be recommended for older children3.

As mentioned above, breast-fed babies get less problems with reflux than formula-fed babies, so if your baby has reflux and you can manage it, breast-feeding is the best option3.

Regurgitation and vomiting mimicking reflux can be a particular problem in babies with cow’s milk allergy3. If your baby is suspected of having this and has not improved with thickened formula and changes of posture, a healthcare professional may recommend that a special formula is tried3. This may be extensively hydrolysed hypoallergenic formula or amino acid-based formula3. If you are breastfeeding you may also be advised to cut out cow’s milk, any foods containing cow’s milk protein, and potentially allergy-producing foods such as nuts, eggs and chocolate in your own diet3.

For older children, the advice is pretty much the same as in adults. Eating too much, putting on too much weight, and eating just before bedtime, can all trigger reflux3. Foods which can slow the speed with which the stomach empties, such as spicy and greasy foods, should be avoided3. Your child should also steer clear of caffeine-based drinks, chocolate and peppermint which can lower the oesophageal sphincter pressure3.

Treatment

Anti-reflux medicine for babies is not usually recommended if your baby is bringing up milk or formula without effort and it doesn’t seem to be causing distress5. As mentioned above, regurgitation is a temporary occurrence which usually clears up by itself5.

If reflux becomes a problem or your baby or child is diagnosed with GORD and thickening the feeds and sitting the baby upright doesn’t help, your doctor may suggest a type of medicine called an alginate5. If it helps, they may recommend that you keep going with the medicine but stop every couple of weeks to see if your baby should still use it5.

If alginate doesn’t work after a couple of weeks’ trial, your doctor may prescribe a type of medicine called a proton pump inhibitor (PPI)5. Omeprazole liquid is the only one available for babies5. Another option is a type of medicine called an H2 receptor antagonist (H2RA) such as ranitidine. These medicines are also suitable for older children, especially if they complain of persistent heartburn, pain under the breastbone (retrosternal) or in the upper part of the tummy (epigastric)1. Specialist treatments available include tube feeding1 and surgery1. These treatments would usually only be considered for your child if anti-reflux medicine didn’t help5.

 

For infants aged 1 to 2 years. Not to be used in premature infants or infants under one year except under medical supervision.

This healthcare professional does not endorse a specific medicinal brand or product.

RB-M-32995

 

 

References

1 NICE Guidance NG1 Gastro-oesophageal reflux disease in children and young people: diagnosis and management, 2015. Available from https://www.nice.org.uk/Guidance/NG1 last accessed 04/01/2021

2 NICE CKS GOR in Children: Diagnosis, 2020. Available from https://cks.nice.org.uk/topics/gord-in-children/background-information/definition/ last accessed 04/01/2021

3 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, Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586172/ last accessed 05/01/2021

4 NICE CKS GOR in Children: Causes. Available from https://cks.nice.org.uk/topics/gord-in-children/background-information/causes/ last accessed 05/01/2021

5 NICE CKS GOR in Children: Management. Available from: https://cks.nice.org.uk/topics/gord-in-children/management/management/ last accessed 06/01/2021

Article published January 1, 2021