Physiological Gastroesophageal Reflux in Infants

Physiological gastroesophageal reflux in infants is the passage of gastric contents into the oesophagus, with or without regurgitation or vomiting, in a healthy infant who is thriving and has no complications. It is a normal physiological event, occurring many times a day in most babies.

• Peak at 4 months (about 65 to 70 percent of infants regurgitate at least once daily); falls to about 5 percent by 12 months and resolves in over 90 percent by 12 to 18 months.
• Contributing factors: immature lower oesophageal sphincter with frequent transient relaxations, short intra abdominal oesophagus, horizontal posture, liquid diet, large feed volumes relative to stomach size, slow gastric emptying, and the fact that infants spend much time lying down.
• Distinguish from gastro oesophageal reflux disease (GORD): reflux with troublesome symptoms or complications (poor weight gain, oesophagitis with distress and feed refusal, respiratory disease, apnoea, Sandifer posturing, iron deficiency anaemia, haematemesis).
• Prematurity, neurological impairment, oesophageal atresia repair, congenital diaphragmatic hernia, and cystic fibrosis raise the risk of GORD.

• Effortless, small to moderate volume regurgitation (posseting) after or between feeds, with the infant otherwise content, feeding well and gaining weight appropriately; occasional hiccups and burping.
• Examination is normal: growth along centiles, no dehydration, no abdominal distension or mass.
• Red flags (investigate for GORD or other disease): bile stained (green) vomiting; forceful or projectile vomiting (pyloric stenosis, onset 2 to 8 weeks, hungry after vomiting, visible peristalsis, olive like mass); haematemesis or melaena; blood in stool; onset after 6 months; persistent vomiting beyond 12 to 18 months; failure to thrive or weight loss; refusal to feed, arching and persistent irritability; chronic cough, wheeze or recurrent pneumonia; apnoea or cyanosis; abdominal distension; fever; bulging fontanelle; seizures; dysphagia; diarrhoea; suspected cow's milk protein allergy (eczema, family atopy); dysmorphic features.

• Clinical diagnosis from history and growth. No investigations are needed for a thriving infant with typical symptoms.
• For red flags: weight and length charts; bloods (full blood count, electrolytes, venous gas, infection screen); abdominal ultrasound (pyloric stenosis); upper gastrointestinal contrast study (malrotation, stricture, hiatus hernia); pH-impedance monitoring (relationship of reflux to symptoms); upper endoscopy with biopsy (oesophagitis, eosinophilic oesophagitis) in selected cases; stool occult blood.

• Reassure parents and explain the natural history (improves as the infant starts solids, sits upright and the sphincter matures, by 12 to 18 months).
• Feeding changes:
  • Avoid overfeeding (about 150 mL/kg/day in formula fed infants; smaller, more frequent feeds); burp mid-feed and after; keep the infant upright for 20 to 30 minutes after feeds; avoid pressure on the abdomen (tight nappies); avoid bouncing.
  • Breastfed infants: continue breastfeeding and assess positioning.
  • Formula fed with troublesome regurgitation: use an anti-regurgitation (pre-thickened) formula with starch, carob bean gum or rice starch thickener; alternatively thicken feeds with an alginate thickener product.
• Positioning: always place the infant on the back to sleep (supine) on a firm flat surface; avoid prone or side positioning and head raised sleeping devices (sudden infant death risk). Avoid prolonged time in car seats and slumped positions.
• Drug therapy is not indicated for physiological reflux. Antacids, H2 blockers and proton pump inhibitors do not reduce regurgitation in thriving infants and are associated with adverse effects (infections, gastroenteritis, necrotising enterocolitis in preterm infants, fractures).
• Troublesome reflux or GORD (distress, feeding refusal, poor weight gain):
  • Alginate therapy (sodium alginate and potassium bicarbonate infant sachet): 1 dose (half a dual sachet) mixed with feeds for infants under 4.5 kg, 2 doses for over 4.5 kg; maximum 6 doses per 24 hours; not with thickeners; avoid in infants with renal impairment, constipation, dehydration; breastfed infants: mix with 5 mL of boiled water and give after feeds. Use for 1 to 2 weeks and reassess.
  • Omeprazole 1 mg/kg/day orally in one or two doses (range 0.7 to 3.3 mg/kg/day; typically 2.5 to 5 mg once daily for under 5 kg, 5 to 10 mg for 5 to 10 kg) for 4 to 8 weeks; stop if no benefit within 4 weeks; avoid long term use; or esomeprazole 2.5 mg daily for 3 to 5 kg.
  • If cow's milk protein allergy is possible (eczema, blood or mucus in stool, family atopy, no response): a 2 to 4 week elimination of cow's milk protein (extensively hydrolysed formula, or maternal dairy exclusion in breastfed infants), followed by supervised reintroduction.
• Refer to paediatrics for any red flag, failure to thrive, or no improvement in 4 to 8 weeks of conservative care. Surgery (fundoplication) is reserved for severe complicated GORD with neurological impairment.
• Review at 4 to 6 weeks and again at 9 to 12 months.