Top tips for easing reflux

To avoid reflux, advise parents to:

• Try to make each feed as calm and relaxing as possible
• Feed the baby little and often
• Feed as slowly as possible with regular pauses
• Use the correct sized teat for the baby
• Avoid letting the baby get too hungry so that air isn’t gulped down during a feed
• Wind the baby during as well as after a feed, ensuring there is at least one good burp!
• Keep the baby upright during and after feeding and avoid bouncing or active play immediately after a feed.

Clinical summary

For infants experiencing symptoms of reflux and regurgitation, a feeding assessment is the first line of approach for both breastfed and formula-fed babies. In formula-fed infants with frequent regurgitation associated with marked distress, NICE recommends that after a review of the feeding history, the following steps should be followed:

1. Reduce the feed volumes, if excessive for the infant’s weight
2. Offer a trial of smaller, more frequent feeds, while maintaining an appropriate total daily amount of milk (unless feeds are already small and frequent)
3. Offer a trial of thickened formula.

If this is unsuccessful, thickened feeds should be stopped and the infant should be offered alginate therapy for a trial period of one to two weeks. Breastfed babies whose symptoms do not improve despite the mother following the recommendations of an expert should be given a trial of one to two weeks of alginate therapy. Alginates should only be continued if they appear effective, though they should be stopped at intervals to see if the infant has recovered.

Acid-suppressing drugs (proton pump inhibitors such as omeprazole or H2-receptor antagonists such as ranitidine) should only be prescribed for infants with overt regurgitation and either unexplained feeding difficulties (such as refusing feeds, gagging or choking), distressed behaviour or faltering growth. Metoclopramide, domperidone or erythromycin should not be offered without specialist advice.

Gastro-oesophageal reflux disease (GORD) differs from the common and normal regurgitation of feeds that affects many infants in that the symptoms (usually pain or discomfort) are either severe enough to warrant medical treatment, or are causing complications such as oesophagitis or pulmonary aspiration. NICE clinical guidance states that premature infants and children with complex, severe neurodisabilities, both of whom have a high incidence of GORD, should be under specialist care, which will include management of this condition. Red flag symptoms to be aware of include:

• Frequent projectile vomiting (which suggests hypertrophic pyloric stenosis)
• Bile-stained vomit (intestinal obstruction)
• Haematemesis (upper GI blood)
• Blood in stool or diarrhoea (bacterial gastroenteritis or infant cows’ milk protein allergy)
• Abdominal distension or tenderness (intestinal obstruction).

Symptoms that start after six months of age or persist after the child’s first birthday also warrant investigation, as do systemic symptoms such as fever, altered responsiveness and dysuria.

Useful websites

• SMA: bringing up milk
• Aptamil Professional: managing reflux.

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