Gastro-oesophageal reflux in children

Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes.

Risk factors

• preterm delivery
• neurological disorders

Features

• typically develops before 8 weeks
• vomiting/regurgitation following feeds

Diagnosis is usually made clinically

Management (partly based on the 2015 NICE guidelines)

• advise regarding position during feeds - 30 degree head-up
• infants should sleep on their backs as per standard guidance to reduce the risk of cot death
• ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
• a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
• a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
• NICE do not recommend a proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA), to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
• → unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
• → distressed behaviour
• → faltering growth
• prokinetic agents e.g. metoclopramide should only be used with specialist advice

Complications

• distress
• failure to thrive
• aspiration
• frequent otitis media
• in older children dental erosion may occur

If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered