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 studies^16-18
  • 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 placebo^20-22
  • However, two RCTs did find statistically significant reduction in reflux events^21,23
  • 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 scores^24,25
  • 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 monitoring^27,28
  • Two RCTs found no difference in acid reflux episodes^29-30
  • 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.