Childhood gastro-oesophageal reflux

Who gets reflux?

Gastro-oesophageal reflux is extremely common in babies. Regurgitation of a small quantity of milk after a feed, without any other symptoms (possetting), is harmless in young infants. Around one in two babies in the UK have regurgitation. This occurs when some of their feed effortlessly returns into their mouth from their stomachs. This is most commonly caused by reflux. On its own, reflux is essentially normal in babies, given how common it is.

It occurs because the muscle at the lower end of the gullet (oesophagus) is too relaxed. It's normal for this to not be fully developed in babies, but it eventually matures as they get older. So, some of the contents of the stomach pass up into the gullet, leading to regurgitation or being sick (vomiting). As the contents of the stomach are acidic this can irritate the lining of the oesophagus. When gastro-oesophageal reflux is associated with troublesome symptoms (such as poor weight gain, unexplained crying or distressed behaviour) it is known as gastro-oesophageal reflux disease (GORD).

So, there is an important difference between gastro-oesophageal reflux (GOR), which is essentially normal and doesn't need treatment, and gastro-oestrophageal reflux disease (GORD), which is when reflux is causing problems that may need medical treatment.

Gastro-oesophageal reflux is more common in babies who are born prematurely and also in those who have a very low birth weight. It is also more common in babies or children who have some impairment of their muscles and nerves (for example, those with cerebral palsy) or those with cow's milk allergy.

Reflux can occur both in breastfed and in bottle-fed babies.

What are the symptoms of reflux?

Many babies and children have some gastro-oesophageal reflux which leads to being sick (vomiting) or regurgitation of some of their feeds. If this is happening on its own, without any other symptoms, it's simply called reflux, gastro-oesophageal reflux, or GOR.

Some babies and children get other symptoms if the reflux is causing problems, which is known as gastro-oesophageal reflux disease or GORD. GORD can cause:

• Pain in the chest or stomach, which can make babies cry a lot, arch their back, and be generally irritable and difficult to settle. Older children may be able to explain the pain they are feeling.

  • However, crying is very common in babies, and isn't necessarily related to reflux.

• Disrupted sleep.

• Refusal to feed, or taking only small amounts of feed.

• Difficulty gaining weight and growing.

• Problems with swallowing and breathing, such as choking, gagging, or wheezing.

Older children with GORD may complain of heartburn and a foul-tasting, watery fluid intermittently coming into their mouth.

Some people talk about 'silent reflux', which means reflux without vomiting or regurgitation. This is very controversial, as there is no scientific evidence that this exists as a cause of irritability or crying in infants. Research also shows that babies without vomiting or regurgitation are unlikely to have GORD.

How is the diagnosis of reflux made?

For most babies and children, further tests are not needed as your doctor will be able to make the diagnosis by talking with you and examining your baby or child. You may be asked to keep a diary of the amount of fluid and food your baby or child is taking and also how often they are bringing up food.

Your doctor may refer your baby or child for further tests if they are having more severe symptoms. These may include:

• pH monitoring of the gullet (oesophagus). This involves inserting a very small probe down into the gullet to measure the amount of acid there.

• Endoscopy. This involves a small tube with a camera at the end being inserted into the gullet to look for any inflammation of the lining of the oesophagus and/or the stomach.

• Barium swallow. This involves having a drink of barium followed by an X-ray. This test is not often performed nowadays.

What treatments for reflux are there without using medicines?

Regurgitation of a small quantity of milk after a feed without any other symptoms (possetting) is harmless in young infants and does not need any investigations or treatment.

• Many babies or children with reflux who are otherwise well do not need any specific treatment, as they grow out of it eventually without having any problems. Your baby's (or child's) weight will be monitored closely to ensure they are growing well and putting on weight appropriately.

• It can help to keep your baby held in a more upright position whilst feeding, and to then keep them upright for about 20 minutes after feeding.

• In-between feeds, keeping your baby upright or on their tummy may reduce episodes of reflux, but you should only do this if they are awake and supervised by an adult.

• For babies, avoid raising the head of the cot, as this makes it more likely for them to roll onto their side, which can increase the risk of sudden infant death syndrome (SIDS). For the same reason, babies with GOR or GORD should still sleep flat on their backs.

• For breastfed babies, it's worth having a breastfeeding assessment by someone skilled in breastfeeding technique, such as a lactation consultant. Getting breastfeeding positioning and attachment correct can help to reduce reflux symptoms.

• It can sometimes be beneficial to try increasing the frequency of feeds and also reducing the volume of each feed.

• Some babies have symptoms of reflux due to a cow's milk allergy. This is more likely if there are other symptoms as well, such as blood in poo, persistent diarrhoea, or eczema, and should also be considered if GORD symptoms are unusually severe or non-responsive to other treatments.

  • If cow's milk is eliminated from their diet then their sickness (vomiting) will reduce substantially over a two-week period. If cow's milk is eliminated but your baby's (or child's) vomiting remains the same, it is extremely unlikely that your baby (or child) has cow's milk allergy.

  • If you are breastfeeding then this means excluding cow's milk from your diet; for formula-fed babies, this means using special formulas made for infants with cow's milk allergy.

• Thickening feeds can sometimes help. There are different products available which work to thicken your baby's feeds. Examples of these include Nestargel® and Carobel® which thicken milk. You should talk with your doctor before using these products. You may have to make the hole of the teat larger if you use these products.

• Anti-regurgitant formula milks are available - for example, Enfamil AR® and SMA Staydown®. These can be prescribed by your doctor if your baby has more severe gastro-oesophageal reflux. These should not be given for more than six months and should not be given with any other feed thickener or antacids.

• Gaviscon® (sodium alginate) works by making the contents of the stomach thicker so they are then more likely to stay in the stomach. It also forms a protective coating over the lower part of the gullet (oesophagus). In doing so, any stomach contents that rise up into the gullet are less likely to irritate the gullet and cause symptoms.

  • Gaviscon® is a powder which is mixed either with your baby's milk or, for breastfed babies, with water. It can be given up to six times each 24 hours. You should not give this if you are already using a food thickener.

  • Gaviscon® can cause constipation as a side-effect.

What medications are available to treat reflux?

The vast majority of children do not need any treatment with medicines for their reflux. Acid-reducing medicines do not help possetting or GOR.

However, acid-reducing medications are sometimes used for infants and children with GORD, particularly if other measures haven't worked.

Acid-reducing medicines include:

• Proton pump inhibitors (PPIs), such as omeprazole and lansoprazole.

• H2 receptor antagonists (H2RAs), such as famotidine.

These medications should be used carefully, because they can cause harm. Babies taking PPIs or H2RAs have a higher risk of developing gastroenteritis and pneumonia, and are more likely to get broken bones (fractures). So, they should generally only be used where there is good evidence that reflux is causing problems (GORD), and if other options haven't helped.

If they are used, they should be reviewed regularly by a doctor, and stopped if they are no longer needed.

Surgery for reflux

A very small number of children have GORD that causes severe symptoms, and cannot be controlled using the options above (including acid-reducing medications). For those children, surgery might be recommended.

This is usually an operation called a fundoplication, which essentially involves wrapping the top part of the stomach (the fundus) around the bottom part of the oesophagus (gullet or food pipe) to tighten the sphincter.

What is the outlook (prognosis)?

As mentioned before, reflux is a self-limiting condition for the vast majority of babies and infants. It usually improves completely by the age of 18 months, even without any treatment.