Gastro-oesophageal reflux is where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents. This usually improves as they grow and 90% of infants stop having reflux by 1 year.
Presentation
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
Causes of Vomiting
Vomiting is very non-specific and is often not indicative of underlying pathology. Some of the possible causes of vomiting include:
- Overfeeding
- Gastro-oesophageal reflux
- Pyloric stenosis (projective vomiting)
- Gastritis or gastroenteritis
- Appendicitis
- Infections such as UTI, tonsillitis or meningitis
- Intestinal obstruction
- Bulimia
Red Flags
Certain features in the history should make you think about serious underlying problems:
- Not keeping down any feed (pyloric stenosis or intestinal obstruction)
- Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction)
- Bile stained vomit (intestinal obstruction)
- Haematemesis or melaena (peptic ulcer, oesophagitis or varices)
- Abdominal distention (intestinal obstruction)
- Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure)
- Respiratory symptoms (aspiration and infection)
- Blood in the stools (gastroenteritis or cows milk protein allergy)
- Signs of infection (pneumonia, UTI, tonsillitis, otitis or meningitis)
- Rash, angioedema and other signs of allergy (cows milk protein allergy)
- Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment
Management
In simple cases some explanation, reassurance and practical advice is all that is needed. Advise:
- Small, frequent meals
- Burping regularly to help milk settle
- Not over-feeding
- Keep the baby upright after feeding (i.e. not lying flat)
More problematic cases can justify treatment with
- Gaviscon mixed with feeds
- Thickened milk or formula (specific anti-reflux formulas are available)
- Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate
Rarely in severe cases they may need further investigation with a barium meal and endoscopy. Surgical fundoplication can be considered in very severe cases, however this is very rarely required or performed.
Sandifer’s Syndrome
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
- Torticollis: forceful contraction of the neck muscles causing twisting of the neck
- Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good. It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.
Last updated August 2019