What is reflux?

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. This occurs normally in all infants, children and adults during and immediately after meals. It is considered physiological when symptoms are absent or not troublesome, and in most cases resolves spontaneously.

Gastro-oesophageal reflux disease (GORD) is present when there are symptoms that are troublesome, severe or chronic, or when there are complications arising from GOR. The most common complication is tissue damage or inflammation to the oesophagus (oesophagitis).

What causes reflux?

GOR occurs as a result of transient lower oesophageal sphincter relaxation. There are several anatomical and physiological features that make infants (younger than 1 year of age) more prone to GOR than older children and adults: having a short narrow oesophagus; delayed gastric emptying; shorter lower oesophageal sphincter that is slightly above the diaphragm; having a liquid diet and high calorie requirement which can put a strain on gastric capacity; and having a larger ratio of gastric volume to oesophageal volume.

It is also important to consider that GOR and GORD may be caused by an allergy to cow’s milk protein.

How is reflux diagnosed?

In the first instance, reflux is usually diagnosed by symptoms alone. The main symptoms identified are frequent and troublesome vomiting or regurgitation (this may occur up to 2 hours after feeding), as well as frequent and troublesome crying, irritability or back-arching during or after feeding. This may also be accompanied by refusing feed.

In order to confirm and assess the severity of reflux, and to rule out any abnormalities that could be at the root of the reflux symptoms, specialists may consider conducting diagnostic investigations.

Multichannel intraluminal impedance (MII) PH/impedance test is one of the most commonly used of investigations. The test is conducted by passing a tube with multichannel sensors through the nostril of the child. The tube has a sensor that sits in the stomach and one that sits just above the lower oesophageal sphincter. The advantage of this test is that it is able to detect both acid and alkaline reflux travels, and investigates the correlation between symptom association, meal times and patient position (e.g. nocturnal symptoms which may be exacerbated when lying down flat).

Treatments for GOR and GORD

Non-medical therapies for GOR have been proven to be effective in many cases. Thickened feeds, the elimination of cow’s milk and cow’s milk protein (from the mother’s diet in the case of breastfed infants) as well as other recommended methods should be trialled for 2–3 weeks. If successful, these should be continued for 3 months or until weaning.

Medical treatments include Infant Gaviscon which helps thicken the milk; histamine-2-receptor antagonists (H2-blockers), such as ranitidine, work by blocking or preventing the production of gastric acid; proton pump inhibitors (PPI), such as omeprazole or lansoprazole, work by stopping gastric acid production at its source. Prokinetic agents, such as domperidone, work by speeding up the emptying stomach and helping close the lower oesophageal sphincter.

Do infants grow out of GOR?

Most infants showing signs of GOR will grow out of it between the ages of 12 and 15 months. As young children grow, most cases of reflux will settle when mixed feeding is introduced and when there is an increased effect of gravity on infants as they become more upright and ambulant.