Overview

• Contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
  • Due to immaturity of the LOS in infants.
  • Commonest cause of vomiting in infancy. Typically occurs in those <8 weeks old.
  • Normal for a baby to reflux feeds (if there is normal growth and no other issues then this is not an issue). 90% of infants stop having reflux by 12 months.
• Risk Factors → preterm delivery, neurological disorders.

Making Diagnosis

Clinical Features

• Normal for babies to have some reflux after larger feeds. Typically develops <8 weeks.
  • Milky vomits after feeds. May occur after being laid flat.
• Signs of Problamatic Reflux ⇒
  • Chronic cough.
  • Hoarse cry.
  • Distress, crying or unsettled after feeding.
  • Reluctance to feed.
  • Pneumonia.
  • Poor weight gain.
• Children >12 months → may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
• Posseting → baby ‘does not seem bothered by it’.

Investigations

Management Plan

• Reassurance (very common, normally resolves by 12m) + Advise → small + frequent feeds, burping regularly to help milk settle, not over-feeding, keeping baby upright after feeding.
• Indications for Review → projectile regurgitation, bile-stained vomit, haematemesis, faltering growth, difficulties feeding, persistent beyond first year of life.
• Initial Management ⇒
  • If Breastfed →
    • 1st → carry out breastfeeding assessment.
      • Trial smaller but more frequent feeds.
    • 2nd → if issue still persists: 1-2 week trial of alginate therapy (gaviscon).
  • If Formula-Fed →
    • 1st → review feeding history. Reduce feed volumes if excessive for infant’s weight.
    • 2nd → trial of smaller but more frequent feeds.
    • 3rd → trial of thickened formula or anti-regurgitant formula.
    • 4th → alginate therapy (gaviscon).
  • Pharmacological Management (if above measures not worked) →
    • 2-4 week trial of PPI or histamine agonist if → unexplained feeding difficulties, distressed behaviour, faltering growth, no resolution despite trial of alginate therapy.
  • Positional →
    • Upright positioning after feeds.
    • Infants should sleep on their back (reduces risk of cot death).

Complications → distress, failure to thrive, aspiration, frequent otitis media, dental erosion (in older children).