Reflux in infants is a common condition, yet research indicates that it is often over diagnosed and poorly managed. Nurses are among the first contacts for parents/carers when concerns about a child's feeding arise. In order to ensure that they are provided with appropriate access to education and management options, it is essential that professionals are equipped with knowledge on the differences between reflux and gastro-oesophageal reflux disease (GORD) and what interventions are in the best interests of the child and family.
This article discusses the common symptoms of reflux and GORD and what strategies can be developed to ensure effective nursing care is delivered from the outset.
Pathophysiology
In reflux and GORD the stomach contents (feeds) and acid are expelled upwards from the stomach through the lower oesophageal sphincter (cardiac sphincter) into the oesophagus and mouth (Terblanche, 2010; Douglas, 2013; Kirby et al, 2016).
There are defined differences between reflux and GORD. Reflux is common in infants under 1 year of age and can be a characteristic of a normal gastric function in young infants where the gastrointestinal system is still immature (Douglas, 2013; Bell et al, 2018). Reflux presents as regurgitation of milk feeds with little or no distress or discomfort. It is expected to resolve independently by the time the child is around 1 year old, with no need for medical intervention (Omari et al, 2002; National Institute for Health and Care Excellence (NICE), 2015).
GORD is described as reflux that is associated with some degree of oesophageal damage and can impair quality of life. GORD presents with the physiological symptoms of pain or discomfort, with crying and feed aversion, and may result in faltering growth, oesophagitis, aspiration and associated respiratory conditions (Omari et al, 2002; Hua et al, 2015; NICE, 2015).
Reflux is reported to affect almost half of all babies under 3 months of age. The regurgitation of feeds in newborns is not unusual and should not raise professional alarm (Hua et al, 2015; Kirby et al, 2016). However, when reflux is associated with crying and perceived pain, parents will be understandably anxious about their child. Parents often present in community baby clinics, GP surgeries, walk-in centres and accident and emergency departments with concerns that their child is in pain and regurgitating or vomiting feeds.
Nurses and health visitors are most commonly the first health professionals to be presented with these babies and children. Therefore it is essential that all nurses are equipped with skills to complete efficient holistic assessments and are able to differentiate between reflux and GORD or other conditions that affect the comfort and feeding of infants and children. Premature babies are more at risk of reflux and GORD, due to health complexities that could be affecting feeding (Omari et al, 2002; Psaila et al, 2014). Children with neurological conditions, cystic fibrosis and oesophageal atresia are at increased risk of severe GORD (Omari et al, 2002). Children and young people can also be affected by a combination of reflux and GORD, although this is less common and more often attributed to physical illness, medication or obesity.
Assessment
As with all nursing assessments, a complete and comprehensive approach is required. It is important to ascertain presenting symptoms, feeding patterns, the medical history and social circumstances, alongside parental concerns and ideas.
Where some degree of postprandial regurgitation and non-forceful vomiting is common in babies and children, the frequency and volume need clarification:
Red flags for GORD
The following symptoms are ‘red flags’ and need to be assessed to ensure other health complications are excluded and GORD is established as the only possible diagnosis:
Premature infants, children with cystic fibrosis, oesophageal atresia or neurological impairment are at heightened risk of developing severe GORD (Omari et al, 2002; Terblanche, 2010; NICE, 2015).
The root cause of any reflux or GORD needs to be established as part of the assessment process in order to ensure appropriate management can be initiated (Terblanche, 2010; NICE, 2015). Further investigations are rarely required unless other alarming factors are identified through assessment and examination (Omari et al, 2002; Terblanche, 2010; NICE, 2015; Kirby et al, 2016). If this process indicates a need for investigations due to severe GORD or to eliminate other health complexities, pH monitoring, gastric motility tests and endoscopy are the first actions that are recommended by NICE (2015).
When other health complications are eliminated, it its then important that the nurse is able to recognise where reflux and GORD differ and is able to support a suitable therapeutic approach in the management of the presenting symptoms (Table 1).
| Reflux | Gastro-oesophageal disease |
|---|---|
| Postprandial regurgitation (can last 3–5 minutes) up to 3 times a day in infants | More frequent postprandial regurgitation in infants |
| Infant settles after feed | Back arching during and after feeds in infants |
| Completes feed in infants | Feed aversion in infants and children |
| Attaches to breast or bottle with little distress in infants | Excessive crying during feed in infants |
| Comfortable in supine position in infancy | Wriggles and cries in supine position in infants |
| Strange taste in mouth in children and young people (acid backflow) | Haematemesis |
| Heartburn in young people | Irritability in infancy |
| Earache in children and young people | |
| Worsening asthma in children and young people (or respiratory problems) | |
| Aspiration and/or sleep apnoea in infants | |
| Faltering growth and/or weight loss in infants and children | |
| Chest pain in children and young people | |
| Hoarseness in children and young people | |
| Abdominal pain in children and young people |
Management of reflux
Reflux alone—with the only presenting symptom being postprandial regurgitation or low-volume non-forceful vomiting—should be managed with education and support for parents and the avoidance of medication (Douglas, 2013; Hua et al, 2015; NICE, 2015; Kirby et al, 2016).
Non-nutritive sucking
There is some research that suggests non-nutritive sucking (the use of a dummy) may help inhibit acid production and settle a baby if used directly before feeds. Corvaglia et al (2014) studied 19 premature infants with reflux to identify whether the use of a pacifier (dummy) after a feed would reduce acid build up and postprandial regurgitation. The newborns in the study received eight feeds—four followed by the use of a dummy and four without. Results indicated that there was no significant effect on reflux but there was a slight acid reduction when the dummy was used (Corvaglia et al, 2014). However, the research for non-nutritive sucking is limited and must be considered in relation to the controversial use of a dummy.
Positioning
Holding an infant in an upright supine position (upright, facing the parent's/carer's chest, with head resting on their shoulder, with parent/carer sitting or standing) is often recommended (Bargaoui et al, 2014; NICE, 2015) to help reduce postprandial regurgitation. It is suggested that keeping the infant in this position for 20–30 minutes post feed will allow the stomach contents to settle, reducing the risk of feed and acidic backflow up the oesophagus. To facilitate this position safely, parents and carers need advice on the optimal position and to be educated so that they are aware that this is only safe for infants when awake and in parents/carers arms, and is not a safe position for feeding or sleeping positions. It is essential to ensure that parents and carers are supported to maintain safe sleeping guidelines in order to minimise risk of sudden infant death syndrome (Bargaoui et al, 2014; Hua et al, 2015; NHS website, 2018).
Volume and frequency of feeds
NICE (2015) advises that small frequent feeding will help reduce stomach distension and over-full stomachs and therefore reduce postprandial regurgitation and discomfort in infants and young children. Feeding patterns need to be clarified and parents of formulafed infants encouraged to offer the same total volume of daily feeds in smaller amounts with increased frequency. For example, if a formula-fed infant is usually fed 120 ml every 4 hours, changing to 60 ml every 2 hours can help reduce symptoms of reflux such as regurgitation and post-feed discomfort. More frequent breastfeeding is also encouraged to help breastfed infants regulate their feeds, ensure an adequate milk supply and minimise symptoms. Parents often hold the misguided belief that infants and children should be fed 4-hourly; education around the stomach capacity of babies and the benefits of feeding more regularly can help change these perceptions and provide support to parents in managing their child's feeding behaviours, enabling a reduction in symptoms of reflux (Carroll et al, 2002). Similar feeding behaviours for children and young people are recommended to minimise overfilling the stomach and avoid increased acid production, stomach distension and associated pain or vomiting (Ruigómez et al, 2010).
Use of feed-thickening agents
NICE (2015) advises that if feeding regimens do not make significant improvements and reflux symptoms continue, the use of feed thickeners should be trialled for an initial period of 1-2 weeks. There are some thickened formula milk preparations available or a thickening agent could be added to expressed breast milk for breastfed babies. If symptoms improve, the use of feed thickener can be continued. Use of the feed thickener can be stopped occasionally to see if symptoms have resolved and, if so, the thickening agent can be discontinued.
A study by Kwok et al (2017) reviewed 637 infants who were using feed thickeners to manage reflux and GORD symptoms; 95% of the sample were reported as having 2 fewer episodes of regurgitation each day and were 2.5 times more likely to be asymptomatic when on feeds containing thickening agents. No side effects of the thickening agents were reported in any of the sample participants; pH studies were performed on the sample and supported the results, representing a reduction in stomach acid by 5% in babies who received feed thickeners (Kwok et al, 2017).
Use of sodium alginate products
NICE (2015) advises that, as a last-line treatment for reflux, a trial of a sodium alginate product such as Gaviscon can be tested. It advises a short trial of 1–2 weeks to assess efficacy and to discontinue use if no improvement is symptoms is apparent. Where significant reduction of symptoms occurs, NICE (2015) recommends continued use with regular trials off-treatment to reassess whether symptoms persist or the child has outgrown the reflux. Sodium alginate products work by providing a barrier on the surface of the gastric contents and forming a raft, preventing the gastric contents from entering the oesophasgus (Malcolm et al, 2008).
Clinical studies report that the use of sodium alginate products merely offer a placebo effect and their use should be limited (Douglas, 2013; Hua et al, 2015; Kirby et al, 2016; Bell et al, 2018). These products have potential side effects such as increased respiratory infections. As they have a high sodium content there is also an increased risk of renal complications such as hypernatraemia (Zentilin et al, 2005).
Corvaglia et al (2011) researched 32 infants who were all symptomatic with reflux. Management with a sodium alginate product decreased reflux in the whole sample and pH monitoring found that infants treated with this product had reduced stomach acidity and less regurgitation that reached the proximal oesophagus, therefore showing significant reduction in signs of reflux. This study offers promising results on the use of sodium alginate products; however, clinical assessment and education strategies should guide their short-term use.
Managing GORD
GORD differs from reflux in the severity of its symptoms and its impact on the gastrointestinal tract. GORD affects an infant, child or young person's quality of life and can present with serious complications, such as apnoea, aspiration, oesophageal inflammation and damage (oesophagitis) and faltering growth. GORD in infancy is often associated with excessive crying due to perceived pain, which has a negative effect on continued breastfeeding, infant and parent attachment and mental health (Douglas, 2013).
Management of GORD requires intervention from the outset. Similar strategies for the education and support of parents and carers to those recommended in reflux are guided by NICE (2015) in the first instance. Where these are not seen to be effective, further medical management can be initiated, a trial for each treatment of 4 weeks is advised to ascertain efficacy, prior to reassessment and controlled periods of no treatment to establish the need for continued medication.
H2 receptor blockers
H2 receptor blockers or antagonists such as ranitidine (Joint Formulary Committee, 2019a) are prescribed for extreme symptoms of GORD. These medications block the reaction of histamine within the parietal cells in the stomach. This mechanism decreases the production of acid and reduces symptoms of GORD that are caused by excessive acid production. Studies such as those by Zentilin et al (2005) and Corvaglia et al (2011) highlight that these drugs can increase the risk of necrotising enterocolitis in low-birthweight infants and may increase the risk of sepsis in infancy, and should be used with extreme caution and monitoring in infants, children and young people.
Proton pump inhibitors
The effect of proton pump inhibitors (PPIs) such as omeprazole and lansoprazole (Joint Formulary Committee, 2019b), is the pronounced and long-lasting reduction of stomach acid. PPIs are classed as the most beneficial inhibitor of gastric acid secretions. PPIs are prescribed for the prevention and treatment of acid-related conditions such as severe GORD. They are generally well tolerated, although they have recognisable side effects such as abdominal pain, nausea and vomiting that could be misinterpreted as the treatment being ineffective in managing all symptoms of GORD. PPIs increase the risk of infection of the colon with Clostridiodes difficile and long-term use may increase risk of osteoporosis and bone fractures. Their use in children is rare and would be directed by medical assessment for severe and potentially life-limiting GORD (Davies et al, 2015; NICE, 2015).
Surgical intervention
In extreme cases where medical management has not resulted in satisfactory weight gain and serious concerns continue over a child's ability to grow, maintain adequate nutrition and a healthy life, surgery is considered. Nissen fundoplications are rare and often only required in infants or children with complications of GORD due to chronic health needs or faltering growth. Investigations will be completed prior to surgical intervention and directed by surgical teams within acute care. In a Nissen fundoplication the lower oesophageal sphincter is surgically tightened to reduce the risk of any regurgitation from feeds, acid or vomiting. In extreme cases of GORD this provides infants and children with the opportunity to be more permanently asymptomatic (Rothenberg, 2005), with improvements to health and quality of life.
Supporting parents/carers
Parents and carers need to be equipped with the knowledge and techniques to manage their child's crying and possible feed aversion (Scherer et al, 2013). The strategies mentioned above such as positional adaptations and changes to feed patterns, alongside listening and professional reassurance, may help parents to feel supported and maintain infant-parent/carer attachment (Hua et al, 2015). Excessive crying that is associated with challenging feed behaviours can increase parental anxiety, with a negative effect on how their child responds and settles (Khoshoo et al, 2007). Professional reassurance and guidance must be at the centre of all interventions (NICE, 2015).
Summary
Research suggests that the incidence of diagnosed reflux and GORD is increasing exponentially (Bell et al, 2018). An Australian study of 400 cases of infantile reflux and GORD found that over-diagnosis is possibly occurring, with heath professionals feeling the need to medically manage rather than treat with a conservative approach (Kirby et al, 2016).
In order to ensure that infants, children and young people are provided with the best possible nursing care, it is essential that all health professionals who have contact with this group are able to complete holistic assessments, differentiate between reflux and GORD and initiate effective education and management plans that support both the child and family, reducing the risk of over-treatment for reflux or worsening health in ill-managed GORD (Terblanche, 2010; Kirby et al, 2016; Bell et al, 2018).