SYMPOSIUM: NUTRITION
Gastro-oesophageal
reflux in infancy
Vinod Kolimarala
R Mark Beattie
Akshay Batra
Abstract
Gastro-oesophageal reflux is very common in infancy. It is important
to differentiate benign physiological reflux from gastro-oesophageal
reflux disease, which is associated with significant morbidity. This re-
view summarises the approach to infants with symptoms and signs of
reflux, differential diagnosis, investigations and management including
non-pharmacological, pharmacological and surgical treatments. Most
infants with physiological gastro-oesophageal reflux do not require
any medical management if the infant is thriving. Severe cases require
a careful diagnostic work, treatment of associated conditions and
aggressive medical management of the reflux. Involvement of the
multidisciplinary team is essential and in persistent refractory reflux
surgical intervention may need to be considered.
Keywords gastro-oesophageal reflux; infancy; oesophagitis; reflux;
vomiting
Gastro-oesophageal reflux
Gastro-oesophageal reflux (GOR) is the involuntary passage of
the gastric contents into the oesophagus. It is a normal physio-
logical phenomenon, particularly common in infancy. Most epi-
sodes, in healthy individuals, last less than 3 minutes, occur in
the postprandial period, and cause few or no symptoms. It is a
very common presentation; both in primary and secondary care
setting and can affect nearly 50% of infants less than three
months old. Major factors include the high volume of milk
ingested compared with older children/adults, posture and the
functional immaturity of the lower oesophageal sphincter.
The natural history of GOR is generally of improvement with
age, with less than 5% of children with vomiting or regurgitation
in infancy continuing to have symptoms after the age of 14
months. This is due to a combination of growth in length of the
Vinod Kolimarala MBBS MRCPCH, Speciality Trainee, Paediatric
Gastroenterology, Department of Paediatric Gastroenterology,
University Hospital Southampton NHS Trust, Southampton, UK.
Conflicts of interest: none declared.
R Mark Beattie MBBS BSc (Hons) FRCPCH MRCP, Professor in Paediatric
Gastroenterology and Nutrition, Department of Paediatric
Gastroenterology, University Hospital Southampton NHS Trust,
Southampton, UK. Conflicts of interest: none declared.
Akshay Batra MBBS MD MRCPCH, Consultant, Paediatric
Gastroenterology, Department of Paediatric Gastroenterology,
University Hospital Southampton NHS Trust, Southampton, UK.
Conflicts of interest: none declared.
PAEDIATRICS AND CHILD HEALTH 29:9
oesophagus, a more upright posture, increased tone of the lower
oesophageal sphincter, and a more solid diet.
Gastro-oesophageal reflux disease (GORD)
Gastro-oesophageal reflux disease (GORD) is defined as ‘gastro-
oesophageal reflux associated with troublesome symptoms or
complications’ although the authors caution that this definition is
complicated by unreliable reporting of symptoms in young chil-
dren. Gastrointestinal sequelae include oesophagitis, haema-
temesis, oesophageal stricture formation, and Barrett’s
oesophagus. Extra-intestinal sequelae can include acute life-
threatening events and apnoea, chronic otitis media, sinusitis,
secondary anaemia, and chronic respiratory disease (chronic
wheezing/coughing or aspiration), as well as failure to thrive.
Oesophagitis can develop as a result of acid or non-acid reflux
and presents with symptoms of crying and irritability in infants
and can lead to food aversion. This is likely to be a significant
factor in faltering growth seen in some children with GORD.
Epidemiology
GORD is a significant problem for infants in the community and
in hospital setting. Determination of the exact prevalence of
GORD at any age is difficult because of a lack of specific symp-
toms but approximately 33% of infants seek medical attention
for symptoms suggestive of reflux, of whom up to 20% require
diagnostic evaluation. The problem is more pronounced in
certain groups like infants born prematurely, infants with neu-
rodisability, with congenital malformations like repaired oeso-
phageal atresia or congenital diaphragmatic hernia, and those
with chronic lung disease. Over 50% of children with neuro-
disability have GORD, due to oesophageal dysmotility and a
poorly functioning lower oesophageal sphincter. They have
trouble expressing their symptoms, and may also have co-
morbidities, which may impact on the ability to perform
investigations.
Pathophysiology
The physical barrier between the oesophagus and stomach is
provided by the lower oesophageal sphincter (LOS) and the
diaphragm. The LOS, or internal sphincter, is a specialised part of
the circular smooth muscle of the distal oesophagus. Both com-
ponents work together to stop refluxing of gastric contents into
the oesophagus. The major mechanism of reflux is transient
lower oesophageal sphincter relaxation (TLOSR). This is a
normal phenomena. Relaxation of LOS occurs in response to
swallowing but this is brief and lasts less than 10 seconds. In
contrast, in infants with GORD, TLOSR is prolonged (more than
10 secs) and accounts for 75e90% episodes of reflux in infants.
Other causes for GORD include abnormal position of LOS as
seen in hiatus hernia. This results in inability of diaphragm to
contribute to lower oesophageal tone and contraction to prevent
reflux. Delayed gastric emptying is felt to be a contributing factor
in worsening of reflux and is especially seen in children with
neurodisability. It exacerbates GOR by prolonging gastric
distension and increasing the frequency of transient LOS relax-
ation. There is an associated delay in clearance of reflux contents
377 Ó 2019 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NUTRITION

from oesophagus increasing oesophageal exposure to gastric

contents, leading to oesophagitis. Symptoms and signs that may be associated with GORD
Atypical symptoms Wheeze/intractable asthma
Symptoms, signs and history Cough/stridor
Gastro-oesophageal reflux disease can be oesophageal or extra- Cyanotic episodes
oesophageal depending on the presenting symptoms. The Generalised irritability
symptoms, signs and typical historical features of GORD are Sleep disturbance
summarised in Tables 1 and 2. Neuro-behavioural symptoms e breath
holding, dystonia, seizure like events
Differential diagnosis Worsening of pre-existing respiratory disease
Apnoea/apparent life threatening events/
Given the frequency of gastro-oesophageal reflux it is easy to sudden infant death syndrome
forget that other conditions can present with similar features. Typical symptoms Excessive regurgitation/vomiting
The commoner alternative diagnoses include: Nausea

Infection, e.g. urinary tract infection, gastroenteritis, peptic Weight loss/faltering growth
ulcer disease Irritability with feeds, arching, colic/food

Intestinal obstruction e.g. pyloric stenosis, malrotation, in- refusal
testinal atresia, Dysphagia

Food allergy and intolerances e.g. cow’s milk allergy, soy Chest/epigastric discomfort
allergy, coeliac disease Excessive hiccups

Eosinophilic oesophagitis Haematemesis/anaemia e iron deficient

Metabolic disorders e.g. diabetes, inborn errors of Aspiration pneumonia
metabolism Oesophageal obstruction due to stricture

Intestinal dysmotility Signs Oesophagitis

Drug induced vomiting e.g. cytotoxic agents Oesophageal stricture

Primary respiratory disease e.g. asthma, cystic fibrosis Barrett’s oesophagus

Factitious induced illness Laryngeal/pharyngeal inflammation

Child neglect or abuse Recurrent pneumonia
It is important to remain vigilant for other diagnoses. Anaemia
Dental erosion
Management Sandifer syndrome
Physiological reflux is common in infancy and is a clinical
Table 1
diagnosis. For most parents reassurance that the condition will
resolve without treatment is all that is needed. It is important to
carefully consider the differential diagnosis, particularly if in oesophageal pH less than 4. Common parameters obtained
symptoms persist or worsen. from pH monitoring include the total number of reflux episodes,
Full assessment of infants is essential including a full feeding the number of reflux episodes lasting more than 5 minutes, the
history to explore possibility of overfeeding or difficulty with duration of the longest reflux episode, and the reflux index which
feeding. Careful attention needs to be paid to severity of symp- is the percentage of time when pH was less than 4.
toms, faltering growth and relevant social factors, e.g. parental Specific indications for pH Study include diagnostic uncer-
anxiety and stress. Severe cases need further assessments and tainty in presence of extra oesophageal symptoms, poor response
investigation. These may include barium study, pH study, to medical treatment or to quantify the degree of reflux
impedence study, gastro-oesophageal scintigraphy, gastroscopy (Figure 1).
and biopsy (described below).
Interpretation of oesophageal pH studies
Difficult cases require assessment by multidisciplinary team
The North American Society of Pediatric Gastroenterology,
including dietician, speech and language therapist, paediatric
Hepatology and Nutrition (NASPGHAN) consensus recommen-
gastroenterologist and paediatric surgeon.
dation is that a reflux index greater than 7% is abnormal. In
general reflux index up to 10% is mild, 10e20% is moderate
Investigations
which is usually controlled by medical therapy and more than
Oesophageal pH monitoring 30% is severe and may require surgical intervention. When
Acid reflux into the oesophagus occurs in all infants as a physi- interpreting studies it is important to consider the following:
ological phenomenon and is only significant when it occurs in
It is useful to correlate symptoms (e.g., cough, chest pain)
excess. The pH probe is designed to measure acidity (i.e. acid with acid reflux episodes and to select those infants and
reflux) in the lower oesophagus and monitors the frequency and children with wheezing or respiratory symptoms in whom
duration of reflux into the oesophagus. It is a microelectrode GOR is a causative/aggravating factor.
passed through the nose and down the back of the throat to sit 3
The sensitivity, specificity and clinical utility of pH moni-
e5 cms above the lower oesophageal sphincter and records for a toring for diagnosis and management of possible extra
set period, usually 24 hrs. A reflux episode is defined as the drop oesophageal complications of GOR are not well established.

PAEDIATRICS AND CHILD HEALTH 29:9 378 Ó 2019 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NUTRITION

There are several limitations to pH studies. These include:

History required in an infant with suspected GORD
pH studies are unable to detect anatomical abnormalities
(e.g. stricture, hiatus hernia, malrotation) or aspiration.
Pattern of vomiting (predominant symptom)
Non-acid reflux will not be detected. This should be borne in
Frequency/amount mind with non-acidic feeds such as infant formula and in
Associated pain/discomfort particular when infants are continuously fed.
Is the vomit forceful?
The changes in environment, diet and behaviour as a result
Does the vomit contain blood or bile of investigation and admission to hospital may impact on
Are there any associated constitutional symptoms e.g. fever, lethargy, the result.
diarrhoea
There is potential for technical difficulties and reproducibility
Feeding and dietary history is poor.
Amount/frequency (overfeeding)
pH studies provide no objective measures of inflammation,
Preparation of formula and thus are less useful than endoscopy and biopsies for the
Recent changes in feeding type or technique diagnosis and grading of oesophagitis.
Position during feeding
The severity of pathologic acid reflux does not correlate
Burping consistently with symptom severity or demonstrable
Behaviour during feeding complications.
Choking, gagging, cough, arching, discomfort, food refusal
Medical history Combined multiple intraluminal impedance (MII) and
Prematurity pH monitoring
Birth weight, growth and development Some of the limitations of the pH study in detecting nonacid
Past surgery, hospitalizations reflux and proximal reflux can be overcome by combining it with
Respiratory illnesses, especially croup, pneumonia, asthma intraluminal impedance monitoring. This measures changes in
Other respiratory symptoms including hoarseness, hiccups, Apnea the electrical impedance (i.e. resistance) between multiple elec-
Features of atopy trodes located along an oesophageal catheter. Oesophageal
Other chronic conditions impedance tracings are then analyzed for the typical changes
Medications caused by liquid, solid, air or mixed bolus and can differentiate
Current, recent, prescription, nonprescription between antegrade and retrograde flow.
Family psychosocial history and family set up MII reflux episodes can be categorized as acidic (pH less
Sources of stress than 4 lasting 4 seconds or more), weakly acidic (pH4-7) or
Postpartum depression weakly alkaline (pH7). Studies on the normal values in in-
Maternal or paternal drug use fants and children are lacking. Normal values are results of
Family medical history consensus agreements, data extrapolation and studies on
Significant illnesses symptomatic children. ESPGHAN EURO-PIG suggests up to 100
Family history of gastrointestinal disorders reflux episodes in Infants aged less than 1 and oesophageal acid
Family history of atopy exposure time up to 10% and up to 70 episodes in children
Growth chart including height, weight, and head circumference more than 1 year and oesophageal exposure time less than 3%
is regarded as normal.
Table 2

Figure 1 An example of a pH study in an infant showing moderate reflux.

PAEDIATRICS AND CHILD HEALTH 29:9 379 Ó 2019 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NUTRITION
The indications are the same as those for pH monitoring. MII-
pH recording provides more information than simple pH mea-
surement because it allows the study of non-acid reflux, extent of
reflux and the temporal association between symptoms and
reflux. MII still has the following limitations: high cost; limited
contribution to medical therapeutic implications; and lack of
evidence-based parameters for the assessment of GOR and
especially symptom association in children (Figure 2).
Radiological investigations
Barium swallow: assesses the patient over only short periods
and may therefore miss pathological reflux or overdiagnose
physiological reflux. It is therefore neither a sensitive or specific
test. Its main role is in detecting anatomical abnormalities such
as hiatus hernia, intestinal malrotation, oesophageal stricture or
web, atypical pyloric stenosis, gastric web, duodenal web or
volvulus.
Gastro-oesophageal scintigraphy: uses continuous evaluation
for up to an hour after radiolabelled meal. Food or milk labelled
with 99Technetium is given to the infant and stomach and
oesophagus are scanned. The standards for interpretation of this
test are poorly established and it is not recommended for the
routine evaluation of paediatric patients with suspected GORD.
Its main role is in the assessment of gastric emptying times to
identify the group of children with foregut dysmotility and
delayed gastric emptying. It also has a limited role in diagnosis of
pulmonary aspiration in patients with chronic and refractory
respiratory symptoms. Delayed gastric emptying is especially
Figure 2 Combined MII and pH monitoring demonstrating acid reflux in an infant.
PAEDIATRICS AND CHILD HEALTH 29:9
common in children with cerebral palsy in whom vomiting may
reflect an overall gut dysmotility rather than GORD.
Oesophageal manometry: measures the pressures and peristaltic
contractions in the oesophagus. It is now increasingly used to
help in the diagnosis of pathological reflux and has a role in
identifying the position of lower oesophageal sphincter and
assessing its morphology and function. The transient relaxation
of the sphincter can be better defined with high resolution
manometry and provocative tests with multiple swallows help
assess severity.
Its main role lies in looking for conditions, which can mimic
GORD, e.g. achalasia or other motor disorders of the oesophagus
such as diffuse oesophageal spasm, Chagas disease, isolated
hypertensive lower oesophageal sphincter.
Gastroscopy and biopsy: is used in children with suspected
oesophagitis. Upper gastrointestinal endoscopy is a useful
investigation and should be considered in all children with se-
vere symptomatic reflux. Presence of active oesophagits either
macroscopically or on histology is the most specific test for
GORD though normal oesophageal histology does not exclude
significant gastro-oesophageal reflux. The histological features
include an increased eosinophil count, intrapapillary blood
vessel dilatation, intraepithelial bleeding, basal cell hyperplasia,
dilated intercellular spaces, and enhanced cellular proliferation.
Endoscopic biopsy is important to identify or rule out other
causes of oesophagitis and to diagnose and monitor Barrett
oesophagus.
380 Ó 2019 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NUTRITION
The indications for endoscopy in GORD include:

Gastrointestinal bleeding which can present as haemetem-
esis or malena

Failure of resolution of symptoms beyond 1 year of age
despite medical therapy

Faltering growth

Food aversion

Suspected Sandifer’s syndrome
Management
Most patients with physiological gastro-oesophageal reflux are
managed in primary care by the health visitor and general
practitioner and do not require any specific treatment. Non-
pharmacological measures include:

Review of feeding and feeding practice e checking for
overfeeding, trial of smaller more frequent feeds, too
small or too large a teat (both of which can cause air
swallowing).

Review of feeding posture e Infants have significantly less
reflux when placed in the prone position than in a supine
position. However, prone position is associated with a higher
rate of sudden infants death syndrome (SIDS). In infants
from birth to 12 months of age with reflux, the risk of SIDS
generally outweighs the potential benefits of prone sleeping.
In children more than 1 year it is likely that there is a benefit
to right side positioning during sleep and elevation of the
head of the bed.

Use of feed thickeners and use of anti-regurgitation milks e
these are useful in reducing the symptoms of GOR and
should be considered in children with persistent symptom-
atic reflux impacting on nutrient intake or through excessive
vomiting on lifestyle. They should not be used for healthy
children who regurgitate.

Extensively hydrolysed or amino acid based formula e In-
fants with persistent symptoms with associated red flags like
blood in stools, history of eczema or atopy could have non
IgE mediated cow’s milk protein intolerance and may benefit
from a 2e6 week trial of elimination diet. This can be done
by elimination of cow’s milk in maternal diet in breast fed
infants. In bottle fed infants extensively hydrolysed formula
should be used. Soya formulae should be avoided as there is
significant cross reactivity between cow’s milk and soya
protein and because of the presence of phytoestrogens in
soya milk they are not recommended in infants less than 6
months.
Drug treatment
Drug treatment is indicated in children with severe symptomatic
reflux or signs and symptoms suggestive of gastro-oesophageal
reflux disease.
The major pharmacological agents currently used for treating
GORD in children are gastric acidebuffering agents, mucosal
surface barriers, and gastric anti-secretory agents. Acid sup-
pressant agents are the mainstay of treatment for all but the
patient with occasional symptoms. The potential adverse effects
of acid suppression, including increased risk of community-
acquired pneumonias and GI infections, need to be balanced
against the benefits of therapy.
PAEDIATRICS AND CHILD HEALTH 29:9
Compound alginates: (e.g. Gaviscon Infant-Rickett Benckiser)
are effective for symptomatic treatment for GOR. Infant gaviscon
works by reacting with gastric acid to form a viscous gel. Infant
Gaviscon comes in a dual sachet and each half is a dose. 1 dose
for babies weighing less than 4.5 kg and 2 doses for those more
than 4.5 kg given a maximum 6 times a day.
Infant gaviscon can be added to formula feed or for breast fed
infants dissolved in cooled boiled water and given by spoon after
a feed. Chronic use of alginates is not recommended for GORD.
Occasionally they can cause constipation and bloating. They
should be used with caution in children with renal impairment as
the product contains sodium and can cause hypernatraemia. An
overdose can lead to a bezoar formation which may require
surgical removal.
Acid suppression agents: include H2-receptor blockers and
proton pump inhibitors.

H2 receptor blockers are widely used in the management of
reflux. They are safe and well tolerated and can be consid-
ered before any further investigation in children who are
thriving and in whom the diagnosis is robust. There are
several studies that have suggested that H₂-antagonists are
efficacious in children. Ranitidine is the most commonly
used H2-receptor blocker. Ranitidine is well tolerated and
has a low incidence of side-effects (common side-effects
include fatigue, dizziness or diarrhoea). Oral ranitidine pro-
vides symptomatic relief and endoscopic improvement of
oesophagitis in children with GORD. Dosage for neonates is
between 2 and 3mg/kg TDS. Child 1e5 months 1e3mg/kg
TDS. Child 6 months-2 years 2e4mg/kg BD.

Proton pump inhibitors (PPI) such as omeprazole and lan-
soprazole are a group of drugs that irreversibly inactivate
Hþ/Kþ ATPase: the parietal cell membrane transporter. This
increases the pH of gastric contents and decreases total
volume of gastric secretion, thus facilitating emptying. Side
effects reported with long term use include hypomagnese-
mia, gastric fundal polyps and small increase in risk of
osteoporotic fractures.
Omeprazole is the most commonly used PPI and is shown to
be effective in children with GORD resistant to ranitidine. For
healing of erosive oesophagitis and relief of symptoms, PPIs are
superior to H2-receptor blockers. Omeprazole is available as
dispersible tablets or capsules given once daily. The tablet can be
gently mixed or dispersed (not crushed) or the capsule broken for
ease of administration in children. Dosage is 0.7e1.4 mg/kg per
day although higher doses can be used, up to 3mg/kg. When acid
suppression is required, the smallest effective dose should be
used. Most patients require only once-daily PPI. Lansoprazole is
the other commonly used PPI. Dosage 0.5e1mg/kg OD a
maximum dose of 15mg OD can be used.
Prokinetic drugs: can be helpful in some circumstances.
Gastroesophageal reflux is primarily a motility disorder, and the
use of pharmacologic agents that improve oesophageal and
gastric motility are conceptually attractive as therapies. Unfor-
tunately, the currently available prokinetic medications have
only modest efficacy in relieving GORD symptoms, and the side
effect profile makes them less useful clinical practice. Examples
include metoclopramide, domperidone, and erythromycin.
381 Ó 2019 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NUTRITION
Domperidone is a dopamine-receptor (D2) blocker that has
relatively fewer side effects but case reports of extrapyramidal
side effects exist, as well as an effect on the QT interval (pro-
longation). Domperidone acts to increase lower oesophageal
sphincter pressure improve oesophageal clearance and promote
gastric emptying. Domperidone is commonly used in clinical
practice either as part of empirical medical therapy of gastro-
oesophageal reflux disease or if delayed gastric emptying has
been demonstrated on nuclear scintigraphy.
In view of a small increased risk of cardiotoxicity, it is
advisable to use domperidone in lower doses and only in cases
with overt vomiting secondary to reflux. All infants should have
an ECG to rule out prolonged QT interval before starting treat-
ment and should be referred to a specialist if treatment is
required for greater than 3 months.
Buffering agents (magnesium hydroxide and aluminium hy-
droxide) and sucralfate: are useful for occasional heart burn.
Buffering agents carry significant risk of toxicity and are not
recommended for long term use. Sucralfate binds to inflamed
mucosa and forms a protective layer that resists further damage
from gastric acid.
Enteral feeding
In infants with faltering growth who are not responding to usual
medical treatments a period of enteral tube feeding (ETF)
should be considered. This ensures slow delivery of feeds and
thus reduced distension of stomach and subsequent reflux.
When tube feeding is started small oral stimulation in the form
of small amount of oral feeds (milk or solids) should be
continued.
Post pyloric feeding, is reserved for severe cases not
responding to other forms of management and associated with
complications. As the stomach is bypassed there is no
distension of stomach and there is reduction in reflux of
gastric contents. This is particularly helpful in children with
failure to thrive, severe oesophagitis and reflux related pul-
monary aspiration. Continuous post pyloric feeding is most
commonly used in children with neurodisability where the
volume of feed is limited because of discomfort associated
with feeding.
Surgery
The commonest operative intervention is fundoplication done
laparoscopically or via open procedure. Children with co mor-
bidities, particularly neurodisability who have the most severe
GORD are at the highest risk for operative morbidity and post-
operative failure. Before surgery it is essential to rule out non-
GORD causes of symptoms and ensure that the diagnosis of
chronic-relapsing GORD is firmly established.
Indications for surgery include:

Failure of optimal medical therapy

Extra oesophageal manifestation (asthma, cough, chest
pain, recurrent pulmonary aspiration of refluxate)

Complication of GORD (e.g. Barrett’s oesophagus or oeso-
phageal stricture)
It is important to provide families with appropriate education
and a realistic understanding of the potential complications of
PAEDIATRICS AND CHILD HEALTH 29:9
surgery, which include recurrence of reflux (10%), retching,
bloating, dumping and intestinal obstruction.
Some children have a high risk of needing surgery. These
include children with neurodisability, those with respiratory
disease with intractable reflux (e.g. oesophageal atresia, bron-
chopulmonary dysplasia), Children with complication of oeso-
phagitis such as stricture or Barrett’s oesophagus and those who
have had a tracheo-oesophageal fistula repair.
Gastro-oesophageal reflux and neurodisability
Paediatric neurodisability is an umbrella term for conditions
associated with impairment of the nervous system, including
conditions such as cerebral palsy, and epilepsy. Potential cau-
ses of feeding difficulties include bulbar weakness, primary or
secondary aspiration, reflux oesophagitis, widespread gut dys-
motility, mobility and posture problems, poor nutritional state
and constipation. These children require careful multidisci-
plinary assessment by a feeding team including dietetics,
speech and language therapy, occupational therapy and the
neurodevelopmental paediatrician.
Attention to nutrition is of key importance and many children
with feeding difficulties benefit from a feeding gastrostomy. A
fundoplication is required if reflux is severe although in some
cases improved nutritional status will result in improvement of
the reflux.
The motility of the gut is a key factor in feed tolerance in
children with cerebral palsy who may have delayed gastric
emptying which impact significantly on the ability to feed
particularly if nutrition is dependent upon nasogastric or gas-
trostomy feeding. Therapeutic strategies include explanation
and reassurance, trial of anti-reflux therapy, prokinetic agents
such as domperidone and in some cases with marked dysmo-
tility it may be necessary to give feeds by continuous infusion
via gastrostomy or gastro-jejunal route. A milk free diet for a
trial period of 2e4 weeks can be helpful. Hydrolysed protein
formula feeds/MCT predominant feeds may be given as a milk
substitute.
Gastro-oesophageal reflux and respiratory disease
Gastro-oesophageal reflux has been associated with significant
respiratory symptoms in infants and children. There is a complex
relationship between asthma and gastro-oesophageal reflux,
manifested by a bidirectional cause and effect.
One postulated mechanism for gastro-oesophageal reflux
mediated airway disease involves micro-aspiration of gastric
contents that leads to inflammation and bronchospasm.
However, experimental evidence also supports the involve-
ment of oesophageal acideinduced reflex bronchospasm, in
the absence of frank aspiration. In such cases, gastro-
oesophageal reflux therapy using either H2-blockers or pro-
ton pump inhibitors has been shown to benefit patients with
steroid-dependent asthma, nocturnal cough and reflux symp-
toms. Similarly, intrinsic lung disease may through excessive
coughing result in reflux.
The association between gastro-oesophageal reflux and
apparent life-threatening events is somewhat controversial and
probably only relevant if the infant vomits, chokes or goes blue
during or immediately after feeds.
382 Ó 2019 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NUTRITION
Barrett’s oesophagus
This refers to the presence of metaplastic columnar epithelium in
the lower oesophagus thought to be a consequence of long-
standing gastro-oesophageal reflux disease.
There is an increased risk of adenocarcinoma of the
oesophagus.
It is rare in childhood and requires aggressive medical treat-
ment, of the gastro-oesophageal reflux and regular endoscopic
surveillance. Surgery (fundoplication) is often considered.
Case study 1
A 7 week old baby formula fed baby presented with history of
vomiting after most feeds and excessive crying. Vomiting was
variable quantity, non-projectile and non-bilious. The child was
thriving very well. There was no abnormality seen on examina-
tion. A careful feed history revealed he was having nearly
200mlg/kg of formula feed. Parents were reassured and the
volume of feeds was reduced. Symptoms resolved in 3 weeks. He
continued to thrive and was discharged from follow-up. Over
feeding is frequently seen in formula fed infants and a careful
feeding history allows for an accurate diagnosis and helps in
avoiding unnecessary treatments.
Case study 2
An 11 month old with cerebral palsy and seizure disorder pre-
sented with history of poor weight gain, recurrent vomiting and
episodic crying. She was born at 25 weeks of gestation and had
periventricular leukomalacia. She was particularly distressed at
meal times as if she was in pain. Further investigations revealed
significant reflux (reflux index 14% and endoscopic findings of
oesophagitis). She was treated with proton pump inhibitors with
improvement in her symptoms. Her symptoms were secondary
of acid reflux in her oesophagus in response to gastric acid
secretion associated with meal times. Her feeding improved with
treatment of the reflux.
Case study 3
A 4 month old presented with feed refusal, retching, constipation
and eczema. Her symptoms failed to improve with anti-reflux
therapy and her weight was static. She was referred to
specialist clinic and was started on extensively hydrolysed for-
mula. At 6 months she was started on a dairy free diet. Symp-
toms improved and she showed good catch up growth. Cow’s
milk was gradually introduced in her diet from the age of 12
months. Cow’s milk allergy is the commonest food allergy in
infancy and usually resolves by 2 years of life and almost always
by 5 years of age. Gastro-oesophageal reflux can co-exist but
poor a response to anti-reflux therapy should prompt consider-
ation of cow’s milk allergy.
A
FURTHER READING
Beattie RM, Dhawan A, Puntis JWL, Batra A, Kyrana E. Oxford
specialist handbook in paediatric gastroenterology, hepatology
and nutrition. Oxford University Press, 2018.
PAEDIATRICS AND CHILD HEALTH 29:9
Mutalib M, Rawat D, Lindley K, et al. BSPGHAN Motility working
Group position statement: paediatric multichannel intraluminal pH
impedance monitoring eindications, methods and interpretation.
Front Gastroenterol 2017; 8: 156e62.
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of
symptoms of gastroesophageal reflux during infancy. A pediatric
practice-based survey. Pediatric Practice Research Group. Arch
Pediatr Adolesc Med 1997 Jun; 151: 569e72.
Rosen R, Vandenplas Y. Paediatric gastroesophageal reflux clinical
practice guidelines: joint recommendations of the North American
society for paediatric Gastroenterology, Hepatology, and nutrition
and the European society for pediatric gastroenterology, hepatol-
ogy, and nutrition. J Pediatr Gastroenterol Nutr 2018; 66: 516e54.
Rudolph CD, Vandenplas Y. Paediatric gastro-oesophageal reflux
clinical practice guidelines: joint recommendation of NASPGHAN
and ESPGHAN e J Pediatr Gastroenterol Nutr 49;498-547.
Sherman PM, Hassall E, Fagundes-Neto U. A global, evidence-based
consensus on the definition of gastro-oesophageal reflux disease
in the pediatric population. Am J Gastroenterol, 2009; https://doi.
org/10.1038/ajg.2009.129.
Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Phar-
macological treatment of children with gastro-oesophageal reflux.
Cochrane Database Syst Rev 2014 Nov 24; 11.
Tighe MP, Beattie RM. Managing gastro-oesophageal reflux in in-
fancy. Arch Dis Child 2010; 95: 243e4.
Tighe MP, Cullen M, Beattie RM. How to use: a pH study. Arch Dis
Child Educ Pract Ed 2009; 94: 18e23.
Practice points
C Functional reflux is very common in infancy and resolve
spontaneously
C Gastro-oesophageal reflux disease (GORD) is defined as
‘gastro-oesophageal reflux associated with troublesome
symptoms or complications.
C Physiological reflux is a clinical diagnosis and does not
warrant further investigation. It is important to consider
appropriate differential diagnoses during history taking and
examination.
C Most reflux will respond to simple strategies including
reassurance and explanation, feeding advice, feed thick-
eners and anti-reflux milk.
C It is important to carefully consider cow’s milk protein al-
lergy and a trial of 2e4 weeks of extensively hydrolysed or
amino acid based formula can be considered before starting
medical treatment.
C Medical therapy is by a step up approach with use of H2
blockers, prokinetics, proton pump inhibitors and consid-
eration of a trial of hydrolysed formula.
C Surgery is required in cases resistant to medical treatment
and those with extra oesophageal complications such as
recurrent aspiration.
C Children with cerebral palsy are at increased risk of reflux
although many other factors are relevant in the assessment
of feeding problems in children with neurodisability
383 Ó 2019 Elsevier Ltd. All rights reserved.