Infant GORD in focus

The latest guidance on diagnosis and management of reflux and gastro-oesophageal reflux disease in infants

Gastro-oesophageal reflux (GOR), commonly referred to as reflux, is a physiological process frequently observed in infants. When reflux becomes symptomatic and leads to complications, it is termed gastro-oesophageal reflux disease (GORD).

While GOR is a common and generally benign occurrence in infants, GORD refers to a more severe and persistent form that can lead to complications. Understanding the distinction between GOR and GORD, along with the symptoms, causes, and management strategies, is essential for healthcare providers and parents.

GOR vs GORD

Reflux involves the involuntary passage of gastric contents into the oesophagus, which may or may not include regurgitation or vomiting. It is a physiological process that occurs frequently in infants, largely due to the immaturity of the lower oesophageal sphincter (LOS). This muscle, located at the junction between the oesophagus and the stomach, acts as a barrier to prevent reflux. However, in infants the LOS may not function optimally, leading to regurgitation or spitting up.

Reflux affects up to 40 per cent of infants, with regurgitation being the most prevalent symptom. This typically begins before eight weeks of age, peaks at around four months, and resolves in most cases by one year. Most instances of reflux do not require extensive investigations and can often be managed through parental education and reassurance.

In contrast, GORD arises when reflux becomes chronic and causes distress.

Symptoms of GORD in infants

Symptoms of GORD are often non-specific and may overlap with other common infant conditions, such as cow’s milk protein allergy, pyloric stenosis, malrotation, tracheoesophageal fistula, and constipation. A detailed clinical history is critical for accurate diagnosis and management.

The symptoms of GORD in infants can vary in severity and may include:

1. Frequent regurgitation or vomiting: Unlike the occasional spit-up seen with GOR, GORD-related vomiting is often forceful and frequent.

2. Irritability during or after feeding: Infants with GORD may exhibit signs of discomfort, such as crying or arching their back.

3. Feeding aversion: Pain associated with reflux may lead infants to refuse feeding, resulting in inadequate nutrition.

4. Poor weight gain: Persistent vomiting and feeding difficulties can affect an infant’s growth.

5. Chronic cough or wheezing: Refluxed material entering the airways may lead to respiratory symptoms.

6. Apnoea or breathing difficulties: In rare cases, GORD may cause pauses in breathing or other severe respiratory issues.

Several factors are associated with an increased prevalence of GORD, including:

▶ Prematurity;

▶ Parental history of heartburn or acid regurgitation;

▶ Obesity;

▶ Hiatus hernia;

▶ History of congenital diaphragmatic hernia or oesophageal atresia repair;

▶ Underlying neuro-disability.

Infants and young children are unable to articulate their symptoms, requiring reliance on non-verbal indicators such as irritability and back-arching.

It is essential to distinguish GORD from physiological reflux, which does not require specific treatment. While GOR typically resolves by 12-to-18 months of age as the LOS matures, GORD may require medical intervention. Key distinguishing features include the persistence and severity of symptoms, impact on growth and feeding, and the presence of complications such as oesophagitis or respiratory issues.

Pathophysiology

The pathophysiology of reflux and GORD in infants involves multiple anatomical and physiological factors:

▶ Immature LOS: The underdeveloped LOS in infants contributes to transient relaxation, increasing susceptibility to reflux. This immaturity is most pronounced during the early months of life.

▶ Delayed gastric emptying: Prolonged retention of stomach contents elevates the likelihood of reflux.

▶ Diet composition: The liquid nature of infant diets can predispose to reflux, with certain components, such as fat content, potentially exacerbating symptoms.

▶ Abdominal pressure: Crying or straining increases intra-abdominal pressure, promoting reflux.

▶ Neurological immaturity: Inadequate neuromuscular coordination affects swallowing and LOS control.

▶ Gut microbiota: Alterations in gut flora may influence reflux occurrence.

▶ Hiatal hernia: Though rare in infants, it can contribute to GORD symptoms.

Complications

Complications of GORD vary with age and severity. In infants, severe regurgitation may lead to calorific loss and failure to thrive. Acidic reflux can cause peptic oesophagitis, haematemesis, melena, and anaemia. Respiratory complications include reactive airway disease, recurrent pneumonia, and potential links to sudden infant death syndrome (SIDS). Chronic reflux reaching the oral cavity may lead to dental erosion and increased susceptibility to infections like otitis media.

Red flags for specialist referral

▶ Large vomits with every feed (to rule out pyloric stenosis).

▶ Bile stained vomit/abdominal distension (to rule out a surgical cause).

▶ Melena or haematemesis (to rule out surgical cause) – note that if a breastfeeding mother has a cracked/bleeding nipple this may be the cause of blood in vomit.

▶ Recurrent choking and coughing with feeds (may need ENT assessment).

▶ Apnoeic episodes with feeding.

▶ Episode of pneumonia (suggests severe GORD with aspiration).

Diagnosis

Diagnosis is primarily clinical, based on history and physical examination. A thorough history of feeding patterns, symptoms, and growth is crucial.

Diagnostic tests such as barium radiography, pH monitoring, and endoscopy are rarely required and are reserved for cases with ambiguous presentations or suspected complications. Red flags warranting specialist referral include bile-stained vomiting, forceful or persistent regurgitation, poor weight gain, and abnormal neurological findings.

Management

Treatment of GORD in infants aims to alleviate symptoms, prevent complications, and improve quality-of-life. Management options range from conservative measures to pharmacological and, rarely, surgical interventions.

Conservative measures

▶ Positioning: Keeping infants upright for 20-30 minutes post-feeding can help reduce reflux episodes. Prone sleeping is not recommended due to SIDS risk.

▶ Feeding practices: Smaller, frequent feeds and avoiding overfeeding are beneficial.

▶ Thickened feeds: Thickening agents can reduce regurgitation frequency, though they may cause constipation.

▶ Maternal dietary adjustments: For breastfeeding mothers, avoiding potential irritants such as caffeine and spicy foods may help.

Dietary modifications

In formula-fed infants, switching to hydrolysed formulas can be effective, particularly in cases where cow milk protein allergy (CMPA) is suspected. A two-week trial of cow milk protein elimination is recommended if CMPA is suspected, with referral to a paediatrician if symptoms persist.

Pharmacological interventions

Pharmacological treatment is reserved for infants with severe GORD unresponsive to conservative measures. Options include:

▶ Proton pump inhibitors (PPIs): Effective for reducing gastric acid secretion, PPIs such as omeprazole are preferred over histamine-2 receptor antagonists (H2RAs) for their superior efficacy.

▶ Prokinetics: Medications like domperidone may be used to enhance gastric motility and LOS tone, though their use is limited by potential side-effects.

▶ Alginate-based formulations: These create a protective barrier to prevent reflux but are less commonly used in infants.

Surgical interventions

Surgical treatment, typically laparoscopic fundoplication, is reserved for severe cases with life-threatening complications or failure to respond to medical therapy. Indications include intractable vomiting, significant oesophagitis, or recurrent aspiration pneumonia.

Complications of untreated GORD

If left untreated, GORD in infants can lead to several complications:

▶ Oesophagitis: Chronic acid exposure may cause inflammation and pain in the oesophagus.

▶ Strictures: Scarring from repeated inflammation can narrow the oesophagus, leading to swallowing difficulties.

▶ Barrett’s oesophagus: A rare condition in infants, where oesophageal lining changes increase the risk of later developing cancer.

▶ Respiratory issues: Aspiration of refluxed material can result in recurrent pneumonia, chronic cough, or asthma.

▶ Failure to thrive: Poor weight gain and growth may occur due to inadequate nutrition.

Prognosis

Most infants with reflux outgrow the condition by 12 months, with significant improvement noted by eight-10 months as they begin sitting upright. Persistent symptoms beyond 18 months may indicate chronic GORD, particularly in children with neurodevelopmental disabilities or a strong family history of the condition.

Parental education and support

Empowering parents with knowledge about the benign nature of reflux and its natural resolution is vital. For severe cases, multidisciplinary care involving paediatric gastroenterologists and dietitians ensures optimal management.

Conclusion

GORD in infants is a condition that requires careful assessment and individualised management. While most cases resolve with time and conservative measures, some infants may need medical or surgical intervention. Early recognition and treatment are key to preventing complications and ensuring the wellbeing of the infant and their family. By understanding the nuances of GOR and GORD, healthcare providers can deliver effective care and support to affected families.

Useful resources

UK NICE guideline [NG1]: Gastro-oesophageal reflux disease in children and young people: Diagnosis and management. Last updated: 9 October 2019. Available at: www.nice.org.uk/guidance/ng1

References on request