Gastro-oesophageal reflux disease (GORD) in infants and Children

It is natural for an infant to have some regurgitation after feeding. The issue is whether GORD is causing a problem in your infant rather than whether GORD is occurring at all. Reflux is most common between one to four months and approximately 67% of infants have more than 1 daily episode of regurgitation at four months. By 12 months only 5% have symptoms. By 12-18 months, most cases of GORD will resolve as the sphincter (valve between oesophagus and stomach) matures, the infant adopts an upright posture and begins having a more solid diet.

Symptoms of reflux in infants

Reflux causes frequent or recurring vomiting. This is not the small mouthfuls of vomit seen in all infants, but the vomiting of large amounts of vomit. This can happen straight after a feed or right up until the next feed. When the infant’s oesophagus becomes sore from exposure to the regurgitated acid (the equivalent of heartburn) this leads to irritability, pain and poor feeding. If GORD is severe, the infant may have difficulty gaining weight.

Other common symptoms include;

• Sometimes screaming suddenly when asleep. Can be inconsolable when laid down flat
• Poor sleep habits typically with arching their necks and back during or after feeding
• Frequent burping or frequent hiccups
• Swallowing problems
• Frequent ear infections or sinus congestion
• Windy and extremely difficult to burp after feeds, failure to wind them successfully usually means reflux and vomiting is worsening
• Refusing feeds or frequent feeds for comfort
• Night time coughing
• Rarely inhaling vomit leading to respiratory problems such as asthma, bronchitis and even chest infections.

When to see doctor?

It is very rare for reflux to lead to serious complications but if the infant vomits severely or has any of the following symptoms you should see doctor:

• blood or bile (bile is a yellow fluid) in their vomit
• difficulty in swallowing or is choking easily
• a fever
• is irritable, crying and hard to settle
• listlessness, dark circles under the eyes, refusal to feed and dry nappies
• breathing problems that could lead to apnoea (the infant may temporarily stop breathing)
• is losing weight or not gaining weight as you they should

Treatment

Avoid overfeeding and try increasing frequency and decreasing volume of feeds. The infant should be supported in an upright position whilst feeding and for at least 45 minutes after feeding to bring up wind. The infant should be handled very gently after feeding and during winding; avoid vigorous patting or rocking.

GORD tends to be worse when lying flat and therefore a gentle raise of the head of an infant’s cot can help, so that the infants head is higher than the rest of their body while they sleep. This can be done by putting a pillow or folded blanket under the mattress to create a gentle up slope. Never attempt to let your infant sleep directly on a pillow which could be dangerous.

Products to add to an infant's food

By thickening infant's food, an infant is less likely to bring it back up. Products to thicken an infant’s milk include Instant Carobel^® and ready-thickened feeds such as Enfamil AR^® or SMA Staydown^®. Enfamil AR powder is used as an infant milk and as this product is a pre-thickened infant milk you may need to switch to a faster flow teat to help the infant suck it. If breastfeeding and the infant is having problems with bringing up food, Gaviscon^® Infant sachets may be used instead.

Infants are less likely to bring up food if they have sodium alginate (Gaviscon^® Infant) mixed with their feed or dissolved in water after their meal. Sodium alginate works in three ways; it thickens the milk making it easier for the infant to cope with, coats the oesophagus all the way down to the stomach and in the stomach it forms a raft over the stomach contents, helping to stop the contents of the stomach from escaping back up the oesophagus. Dosage depends on the weight of the infant. Gaviscon^® Infant sachet(s) can be mixed with cool boiled water, milk feed or expressed breast milk. Gaviscon^® Infant sachet(s) should not be administered more than six times in 24 hours. Gaviscon^® Infant should not be given to premature infants, young children who are ill with a high temperature, diarrhoea, vomiting, or if already using a food thickener.  

Medication

Anti-reflux medicines reduce the severity of the reflux by improving the downward movement (i.e. motility) of the oesophagus and stomach. They may also reduce acidity so that the reflux is less damaging to the oesophageal lining. They are used if other treatment options like thickeners do not work.

Motilium^® (Domperidone) helps tighten the valve between stomach and oesophagus stopping food from flowing back into the oesophagus. It comes in liquid or rectal (suppository form) form for infants and children but is only available with a doctor’s prescription. Dose depends on size of child so check with your GP or pharmacist. Motilium^® can rarely cause mild diarrhoea.

H2 blockers reduce acid in the stomach. Ranitidine which is a type of H2 antagonist and Zantac^® is a popular brand of the drug. It is only available on prescription; ask your GP or pharmacist about dosage.

Losec^® MUPS (omeprazole) is a popular brand of proton pump inhibitor. Losec^® MUPS  can be dissolved in water which is convenient for children’s dosage. A proton pump inhibitor reduces the acidity of the stomach’s contents and is more potent than H2 antagonists like Zantac^®. The dose for infants and young children is based on body weight and the doctor will decide the correct dose.

Surgery

Surgery is required in a minority of infants with severe GORD who do not respond to treatment but surgery is not always successful. Sometimes medication needs to be continued after surgery.

For comprehensive and free health advice and information call in to Whelehans, log on to www.whelehans.ie or dial 04493 34591 (Pearse St) or 04493 10266 (Clonmore). Find us on Facebook.