Managing gastro-oesophageal reflux in infants
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4420 (Published 27 August 2010) Cite this as: BMJ 2010;341:c4420
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Most infants, referred to our Feeding Clinic, with suspected Gastro-
oesophageal reflux disease (GORD) are often treated or tried with alginate
combinations and less often attention is paid to the feed volume and/or a
trial of postural therapy.
The paper on Managing gastro-oesophageal reflux in infants (from
Drugs and Therapeutics Bulletin), reports postural therapy to be
ineffective and considers that elevating the head end of the crib not
justifiable.1
There is clear evidence to suggest that the management of significant
GORD should start with non-pharmacological approach; reduced feed volume
with frequent feeding and controlled postural therapy that nurses the
infant at 40 degrees supine body position reduces regurgitation, acid
reflux and reflux associated symptoms.2
Prescribing clinicians should be aware of the Sodium content of
compound alginate combinations.
Gaviscon Infant powder, for example, has a Sodium content of 0.92 mmol per dose and an
infant taking 5-6 feeds would receive an additional Sodium load of 4.5-5.5
mmol of Sodium/day; this may partly account for the symptom of
constipation observed in these infants.
References:
1 From Drugs and Therapeutics Bulletin (DTB 2009; 47:134-7). Managing
gastro-oesophageal reflux in infants. Brit Med J 2010; 341; 495-498
2 Y Vandenplas, J De Schepper, S Verheyden, et al. A preliminary report on
the efficacy of the Multicare AR-Bed in 3-week-3-month-old infants on
regurgitation, associated symptoms and acid reflux. Arch Dis Child
2010;95:26-30 doi:10.1136/adc.2008.156497
Competing interests: No competing interests
The clinical review on the management of gastro-oesophageal reflux
(GOR) in infants underline that there is poor evidence in the use of
different class of drugs, most frequently prescribed as off-label in
children (1).
However, in order to provide clear management guidelines, we believe that
the first step is to differentiate GOR (i.e., physiological) from gastro-
oesophageal reflux disease (GORD) (i.e., pathological). Many symptoms
usually attributed to GORD (crying, regurgitation, feeding refusal,
wheezing) may more appropriately be attributed to a "misalignment"
between culture of the mother and of paediatrician and the biological
events (2). The improper diagnosis of GORD and the consequent unjustified
and ineffective prescription of anti-reflux therapy, as well as
elimination diets, may confuse the family and lead to food refusal in the
baby or other side effects (i.e., lower respiratory tract infections) (4).
The largely inappropriate prescription of proton pump inhibitors (PPIs) in
children with physiological GOR has already been reported and is confirmed
by the more than sevenfold increase of prescriptions in infants documented
from 1999 through 2004 (3).
On the other hand, when GORD is true and proven (i.e. in children with
cerebral palsy or oesophageal atresia) and its management with PPIs
necessary, it seems unreasonable - as reported in the Clinical Review (1)
- that in Europe omeprazole only has a paediatric indication, while all
other PPIs are still off-label. At present, the appropriateness of the
use of PPI in children may be based on a large body of clinical evidence
(5) and in the USA esomeprazole and lansoprazole beside omeprazole are
currently authorized for children (although with exclusion of infant and
neonate age groups).
Therefore regulatory agencies should translate clinical evidence into
clinical practice providing formal paediatric indication, and ethical
committees should cope with this issue to avoid unnecessary trial
replication.
References
(1) Drug and Therapeutics Bulletin. Managing gastro-oesophageal
reflux in infant. BMJ 2010; 341:c4420.
(2) Tornese G, Maschio M, Marchetti F, Ventura A. To GERD or not to
GERD, this is the question. J Pediatr 2009;155:601.
(3) Barron JJ, Hiangkiat T, Spalding J, Bakst AW, Singer J. Proton
pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol
Nutr 2007;45:421.
(4) Ventura A, Marchetti F, Cannioto Z, Barbi E, Martelossi S.
Feeding difficulties in infants: how much a iatrogenic condition?
[eLetter] Arch Dis Child 2008. Available at:
http://adc.bmj.com/cgi/eletters/adc.2006.108829v1
(5) Tafuri G, Trotta F, Leufkens HGM, Martini N, Sagliocca L,
Traversa G. Off-label use of medicines in children: can available evidence
avoid useless paediatric trials? The case of proton pump inhibitors for
the treatment of gastroesophageal reflux disease. Eur J Clin Pharmalcol
2009;65:209-216.
Federico Marchetti, Gianluca Tornese, Alessandro Ventura
Department of Paediatrics, Institute of Child Health, IRCCS Burlo
Garofolo, University of Trieste
Via dell'Istria 65/1, 34100 Trieste, Italy
Corresponding author:
Federico Marchetti, MD
phone +39 040 378454; fax +39 040 3785362
e-mail: marchetti@burlo.trieste.it
Competing interests: No competing interests
Epidemic of gastro-oesophageal reflux in young infants
The paper on Managing gastro-oesophageal reflux in infants highlights
the importance of its recognition and the rationale for the treatment in
the symptomatic case (1).
Gastro-oesophageal reflux (passage of gastric contents into distal
oesophagus) is considered as physiological in majority of the infants;
however symptomatic reflux, often associated with regurgitation extending
above the distal oesophagus accounts for over 7 % of infants to seek
medical attention (2). The symptoms pose a management dilemma for the
practitioner to differentiate between a simple reflux and the ones that
need treatment. We have observed that an increasing number of infants are
referred to our Feeding Clinic with the symptoms of feed regurgitation and
gastro-oesophageal reflux disease (GORD).
The main symptoms of GORD, feed regurgitation and crying, are also
common in normal infants and sometimes make it difficult to differentiate
between physiological reflux and pathological GORD (3). However, infant
Gastroesophageal Reflux Questionnaire Revised (i-GERQ-R) has been
validated as reliable and clinically responsive measure of infant GORD
symptoms in an international observational study (4, 5).
There has been steady decline in the rate of Sudden Infant Death
Syndrome (SIDS) and Unascertained Deaths in the last two decades. This has
been partly attributed to the increasing public awareness about the safety
of infants sleeping in supine position (6). Previous studies have shown
that prone and left lateral position reduces GOR in preterm infant and it
has been postulated that this may be due to the delayed gastric emptying
in supine position and that gastric delaying is the starting phenomenon in
half of the cases of GORD (7). Relationship of nursing in supine position
and the pathogenesis of GORD in young infants is not known and its causal-
effect needs to be excluded.
Impact of baby's reflux on parents
a) Feeding problems
A persistently crying baby who is refusing feeds is a source of great
distress to the parents and causes considerable loss of parental sleep;
many parents feel that the magnitude and severity of the reflux symptoms
and its impact on the family are not fully appreciated by the health
professionals. It has been clearly shown that feeding problems,
characterised by oral motor dysfunction, episodes of dysphagia, food
aversion and negative feeding practices for the mother and baby, are
common in
infants with GORD (8). In our Feeding Clinic, we see a significant
proportion of mothers of refluxing babies, experiencing low self esteem
and mood low levels related to negative feeding practice experience;
studies have also demonstrated adverse psychological effects of the
refluxing as anxiety and depression in mothers of infants with GORD (9).
b) Apparent life threatening event (ALTE)
ALTE refers to a constellation of unexpected patho-physiologic events
in an otherwise infant that is witnessed by and always very distressing to
the caregiver. The most typical symptoms of ALTE syndrome are: breathing
disorders with or without apnoea, changes in skin colour as pallor or
cyanosis, disorder of muscle tension as hypo/hyper-tonia and/or frank
anoxic seizure, gagging, choking, salivation, loss of consciousness,
cardiac arrhythmia and bradycardia (10). While these symptoms are non-
specific and can occur in a variety of disorders, GORD has been observed
to be one of the leading causes (10, 11).
Occurrence of ALTE symptoms is a frightful experience for the
parents/carer. As many babies seem to make a full recovery by the time
they are seen by a health professional, the true nature of the symptoms
and its impact on the family may be underestimated. While most paediatric
units have access to clear guidelines for the management of ALTE in young
infants, there is inconsistency of approach among the health professionals
(12). In our region, we consider severe or recurrent ALTE symptoms as
potential SIDS and following a period of in-patient observations, with
appropriate investigations, we offer extended home care with health
visitor and paediatrician input and use of apnoea alarm monitoring,
through the national CONI (Care Of Next Infant) programme.
Conclusion
(a) While physiological feed regurgitation and reflux are common in
infants, symptomatic reflux with vomiting, feed refusal, persistent
crying, arching and failure to thrive suggests a pathological reflux and
merits thorough review by an experienced clinician.
(b) Medical professionals should be aware of the psycho-social impact
of the condition on the family.
(c) Further studies are indicated to see if sleeping the infant in
supine position contributes to or aggravates what would otherwise have
been a physiological gastro-esophageal reflux.
References:
(1) From Drugs and Therapeutics Bulletin (DTB 2009; 47:134-7).
Managing gastro-oesophageal reflux in infants. Brit Med J 2010; 341; 495-
498
(2) Nelson SP, Chen EH, Synair GM et al. Prevalence of symptoms of
Gastroesophageal reflux disease during infancy; a paediatric practice
based survey. Arch Pediatr Adolesc Med 1997; 151: 569-572
(3) Tighe MP, Beattie RM. Managing gastro-oesophageal reflux in
infancy. Arch Dis Child 2010;95:243-244 doi:10.1136/adc.2009.170407
(4) Kleinman L, Rothman M, Strauss R, Orenstein SR, Nelson S,
Vandenplas Y, Cucchiara S, Revicki DA. The infant gastroesophageal reflux
questionnaire revised: development and validation as an evaluative
instrument. Clin Gastroenterol Hepatol. 2006;4(5):588-96.
(5) Stanghellini V, Armstrong D ,M?nnikes H, Bardhan KD Systematic
Review: Do We Need a New Gastro-Oesophageal Reflux Disease Questionnaire?
Digestion 2007;75 (Suppl. 1):3-16 (DOI: 10.1159/000101077)
(6) American Academy of Pediatrics. Changing Concepts of Sudden
Infant Death Syndrome; Implications for Infant Sleeping Environment and
Sleep Position.
Pediatrics 2000; 105(3): 650-656
(7) EwerA, JamesM, TobinJ Prone and left lateral position reduce
Gastroesophageal reflux in preterm infants. Arch Dis Child Fetal &
Neonatal Ed 1999:81(3): F201-F205
(8) Mathisen B, Worral L, Mase J et al. Feeding problems in infants
with gastro-esophageal reflux disease; A controlled study. J Pediatr Child
Health 1999; 35: 163-169
(9) Blakely K. Psychological impact of a refluxing baby on the
family.
MIMS Advances. Infant Nutrition 2005;4:1-4
(10) Semeniuk J, Kaczmarski M, Wasilewska J, Nowowiejska B.
Is acid Gastroesophageal reflux in children with ALTE etiopathogenetic
factor for life threatening symptoms. Advances in Medical Sciences. 2007;
52: 213-221
(11) Mir, Nisar A. Presentation and Diagnosis of Gastro-oesophageal
Reflux in babies
MIMS Advances. Infant Nutrition 2005;4:1-4
(12) Davies F, Gupta R. Apparent life threatening events in infants
presenting to an emergency department. Emerg Med J 2002;19:11-16
doi:10.1136/emj.19.1.11
Nisar A Mir
Consultant Paediatrician
Warrington & Halton Hospitals NHS Foundation Trust
Clinical Lecturer (Hon)
University of Liverpool
E-mail: nisar.mir@whh.nhs.uk
Competing interests: No competing interests