Reflux and GORD

Reflux

“Posseting” after feeds is completely normal. In some babies milk may flow readily back from the oesophagus in the early weeks/months because of low muscle tone in the sphincter between the stomach and oesophagus, which takes time to mature. The stomach content of babies is less acidic than adults and therefore, whilst gastro-oesophageal reflux is common, true "GORD" is rare. 

Signs and Symptoms:

• Vomiting milk shortly after feeding
• Coughing/hiccupping during feeds
• Signs of discomfort after feeds
• Swallowing or “Gulping” after feeds or when winded

Breastfed babies with these symptoms should be referred to the infant feeding team for a full breastfeeding assessment.

Treatment:

For breastfed babies, this involves:

• Upright or laid back feeding positions
• Responsive feeding
• Keep baby upright after feeds for 30 min 
• Safe and correct use of wrap/sling/carrier after or between feeds (speeds gut transit and keeps baby upright) See https://www.babywearing.co.uk for more information (social enterprise with information and resources)

For bottle-fed babies:

• Responsive bottle feeding – looking for “full up” cues as well as feeding cues (overfeeding is a common issue)
• Positioning baby semi-upright for feeds
• Slow flow teat
• Feed preparation – avoid use of “perfect prep” machine, use boiled kettle of water
• Upright after feeds (as above)
• Use of sling (as above)
• Adjusting feed volumes – smaller, more frequent feeds may be better than larger volumes

Breastfed babies feed responsively and cannot be “overfed”. When thinking about feed volumes for bottle-fed babies (expressed milk or formula), it can be helpful to remember their small stomach sizes.

GORD (Gastro-oesophageal reflux disease)

Signs/symptoms:

• Vomiting (although this is not always present)
• Very unhappy, distressed, “unsettled” baby – pain during and after feeds
• Possible suboptimal weight gain
• Choking/coughing during feeds
• Possible apnoea/bradycardia attacks
• Frequent ear infections
• Sounds like baby has a sore throat
• Feeding aversion

Red flag symptoms suggesting other disorders include frequent projectile vomiting, bile stained vomit, haematemesis, onset after 6 months or persisting after 1 year, blood in stool, abdominal distension / tenderness /  mass, chronic diarrhoea. See NICE guidelines for more detail about Red Flags.

Treatment:

If conservative measures listed (for reflux) above have failed:

• Formula fed infants should trial a thickened formula
• For breastfed infants: 
  • 1-2 week trial of alginate therapy e.g. Gaviscon – continue if symptoms improve, and try withdrawing every two weeks to see if symptoms have resolved
•  Consider 4 week trial of PPI e.g. omeprazole may be considered(off licence in under 1yo). It is also worth being mindful of evidence that PPI use in infants has been linked to an increased risk of fractures in early childhood, as well as respiratory and GI infections, allergies and obesity in later life. More information on PPI use can be found in this recent BMJ article 

The Breastfeeding Network has more information on reflux and GORD. 

The GP infant feeding network has information on management of GORD for both breast and formula fed babies. 

For prescribing advice re Gaviscon, thickeners, PPIs ect, consult the relevant NICE guidelines on gastro-oesophageal reflux disease.

Primary Care Knowledge Boost has a useful podcast on this topic for further CPD