Gastro-oesophageal reflux: Management

Investigations

  • Serious pathology is unlikely in well, hydrated infants without concerning features in the history or examination3.
  • Otherwise investigations should be used based upon the specific situation (i.e. septic screen, upper GI contrast study, USS abdomen).

Management: evidence base

  • Positioning:
    • There is evidence that prone and left lateral positioning is effective at reducing GOR in infants when measured by pH study2
    • Useful when infants are awake and supervised
    • However, when asleep the child should not be placed prone as the potential benefit is outweighed by the real risk of SIDS
  • Feeding changes:
    • One low quality comparative study found smaller volume feeds were associated with fewer reflux episodes when measured by pH monitoring15
  • Thickened feeds:
    • Fourteen comparative studies showed that thickened feeds reduced overt regurgitation and reflux acid exposure in infants2
  • Alginates:
    • Acts as a raft on the top of the stomach contents
    • Three small RCTs comparing alginates to placebo suggested improvement in pH studies16-18
    • Only one suggested an improvement in overt regurgitation<sup19
    • However, highly variable quality, Gaviscon formulation and different study ages prevent meta-analysis
  • Proton pump inhibitors:
    • Three RCTs reported no significant difference in reflux reduction when compared with placebo20-22
    • However, two RCTs did find statistically significant reduction in reflux events21,23
    • Studies very low to moderate quality
  • H2 receptor antagonists:
    • One RCT reported reduction in overt regurgitation when compared to placebo but not to statistical significance24
    • Two RCTs reported outcomes relating to the resolution of oesophagitis or improvement in histology scores24,25
    • Studies very low to low quality
  • H2RA vs. PPI:
    • Evidence from one very low quality RCT found no difference in outcome between PPIs and H2 receptor antagonists, but both improved symptom scores25
  • Prokinetics:
    • Increase gastric emptying
    • One RCT found a statistically significant reduction in overt regurgitation26
    • Two RCTs reported reduced acid reflux episodes based on 24 hour pH monitoring27,28
    • Two RCTs found no difference in acid reflux episodes29-30
    • Studies very low to moderate quality
  • Prokinetics:
    • Adverse effects:
      • Risk of extrapyramidal disorders and tardive dyskinesia with metoclopramide
      • Small risk of ventricular arrhythmia and sudden cardiac death with domperidone

Management: general principles2

  • Most require reassurance and safety-net advice only.
  • The child should be placed on their back to sleep to reduce risk of SIDS.
  • Parents should return if:
    • Persistently projectile, haematemesis or bilious vomiting
    • New concerns (marked distress, feeding difficulties or faltering growth)
    • Persistent, frequent regurgitation beyond the first year of life
  • Treatment nor investigation should not be offered for isolated overt regurgitation.
  • Treatment nor investigation should not be offered for isolated;
    • Unexplained feeding difficulties
    • Distressed behaviour
    • Faltering growth
    • Chronic cough
    • Hoarseness
    • Single episode of pneumonia
  • Hence, only treat if frequent regurgitation and marked distress.

Management: step-wise approach2

  • Formula fed infants:
    • Review the feeding history
    • Reduce feed volume if excessive (see next section)
    • Then, offer smaller more frequent feeds
    • Finally, offer a trial of thickened formula
  • Breast fed infants:
    • Breast feeding assessment by a person with appropriate expertise

Management: if step-wise approach fails2

  • If formula fed, stop thickened formula.
  • Offer an alginate (i.e. infant Gaviscon┬«) trial for 1-2 weeks.
  • Continue if successful but try stopping at intervals to see if the infant has recovered.
  • If cow’s milk allergy suspected:
    • Elimination of cow’s milk from the diet for 2-3 weeks
    • Maternal diary-free diet or nutramigen formula
    • If symptoms resolve the diagnosis is highly likely
    • NB: primary lactose intolerance (i.e. congenital absence of lactase enzyme) is extremely rare so do not offer lactose-free or other formula.

Management: if alginates fail2

  • Consider a four week trial of a PPI or H2 receptor antagonists.
  • Do not offer prokinetics without seeking specialist advice.

Management: when to refer acutely2

  • Haematemesis
  • Melaena
  • Dysphagia
  • Persistent, faltering growth associated with overt regurgitation
  • Feeding aversion and a history of regurgitation
  • Unexplained iron-deficiency anaemia
  • A suspected diagnosis of Sandifer’s syndrome.

Prognosis

  • 90% of affected infants will be asymptomatic by one year of age2.