GOR and GORD in infants: an overview of clinical and dietary management of GOR and GORD in infants and children.
Article Type: Report
Subject: Ranitidine (Dosage and administration)
Proton pump inhibitors (Dosage and administration)
Prokinetic agents (Dosage and administration)
Surgery (Methods)
Diet (Methods)
Infants (Health aspects)
Gastroesophageal reflux in children (Development and progression)
Gastroesophageal reflux in children (Complications and side effects)
Gastroesophageal reflux in children (Care and treatment)
Author: Falconer, Jackie
Pub Date: 10/01/2009
Publication: Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Ten Alps Publishing ISSN: 1462-2815
Issue: Date: Oct, 2009 Source Volume: 82 Source Issue: 10
Product: Product Code: 8000410 Surgical Procedures; 8000141 Nutrition & Diet Programs NAICS Code: 62 Health Care and Social Assistance; 621498 All Other Outpatient Care Centers
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 209163265
Full Text: Gastro-oesophageal reflux (GOR) refers to the inappropriate opening of the lower oesophageal sphincter, releasing gastric contents into the oesophagus. In a large percentage of infants it can be considered an uncomplicated self-limiting condition, with up to 70% of healthy infants between the ages of three and seven months regurgitating once or more per day. In most infants, reflux resolves spontaneously by 12 to 18 months of age. In fact by the age of 12 to 15 months, only about 5% of infants regurgitate with an even smaller percentage continuing to have problems beyond two years. However in the more severe presentation of the condition, when an infant does not respond to simple treatment, acid-induced inflammation in the oesophagus leading to oesophagitis may develop. This can be associated with other symptoms such as faltering growth, apnoea, irritability, feeding difficulties, haematemesis and iron deficiency anaemia. It is commonly associated with neurological and cardiac conditions.

For uncomplicated GOR, initial management involves parental reassurance and simple feeding measures such as reviewing volumes and frequency of feeds along with postural advice (keeping the baby upright after feeds for at least 30 minutes) and avoiding exposure to tobacco smoke. Small frequent feeds are often recommended, though these may be difficult to manage practically and the baby may become distressed with a reduction in feeds. Frequent winding is also recommended before, during and after feeding. The prone elevated position of 30[degrees] cannot be recommended anymore, due to the studies showing an increased risk of sudden infant death syndrome if infants are placed in the prone position for sleeping. A systematic review concluded that raising the head of the cot was not beneficial to infants lying in the supine position. (1)

For the small percentage of infants that do not respond to the above measures, further investigations and management can be undertaken.

Investigations

The gold standard investigation for reflux remains pH monitoring, and the amount of time in which the pH is less than four over a 24-hour period is a useful indicator of GOR. A newer procedure--impedence--measures both acid and non-acid reflux, and is particularly useful for children on a continuous nasogastric (NG) feed or who are unable to come off medications due to the severity of their condition. Upper endoscopy can determine the presence of oesophagitis and may be used in infants who continue to display significant symptoms despite full medical and dietary management. A barium study is helpful to detect the presence or absence of anatomical abnormalities, but is not a procedure that helps to determine reflux severity.

Medical management

Medications used to treat GOR include acid-reducing agents such as ranitidine, proton-pump inhibitors such as omeprazole, and prokinetic agents such as domperidone, which elevate the lower oesophageal sphincter pressure and increase gastric emptying. A combination of these is often given to control symptoms. In extreme circumstances where symptoms have failed to respond to all treatments, medical and dietary surgery may be required. The procedure undertaken is a Nissen fundoplication, which wraps the fundus of the stomach around the lower oesophageal sphincter to create an artificial valve and hence preventing GOR. A gastrostomy is often inserted at the same time to allow for the venting of excess wind from the stomach. If the child may need nutritional support, the gastrostomy can be used for supplementary feeding.

Thickeners and thickened feeds

Dietetic management focuses on resolution of symptoms such as vomiting and irritability, with feeding and also on correction of faltering growth where applicable. Feed thickeners such as Thick and Easy, Resource ThickenUp, Carobel or thickened feeds (which have starch added to 2g/100mls of infant formula), Enfamil AR (anti-regurgitation) and SMA Staydown decrease regurgitation episodes, but there is no evidence of benefit with respect to acid exposure of the oesophageal mucosa. (2) The European Society for Pediatric Gastroenterology, Hepatology and Nutrition states they should only be used in infants with faltering growth and not in those who are healthy and thriving. (2) In infants with faltering growth, high-energy formulas such as SMA High Energy and Infatrini could help meet nutritional requirements in a smaller volume of feed.

Food allergy

In more complicated GOR or gastro-oesophageal reflux disease (GORD) that fails to respond to simple feeding measures and medical management, a therapeutic trial of a hypoallergenic formula for one to two weeks should be considered--using formulas such as Nutramigen, Pepti-Junior-as GOR can be secondary to food allergy. (3) In those failing a hydrolysate feed, an amino acid-based formula such as Neocate, Nutramigen AA can be used. (4) Soya and partially hydolysed formula should not be used, due to the high incidence of cross-reactions of proteins. (5) Infants should be selected to trial hypoallergenic formula if they have a positive atopic history, positive allergy tests, persistent reflux that has not responded to reflux medications or mucosal changes on biopsy such as oesophagitis.

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Two studies have found significant improvement in symptoms in 30% to 40% of infants using a hypoallergenic formula, and concluded that a high frequency of cow's milk allergy was associated with GORD. (6,7) In food sensitive patients, cow's milk has been shown to cause gastric dysrhythmia and delayed gastric emptying, which in turn may exacerbate GOR and induce reflux vomiting. If the cow's milk-free trial is successful, then the infant should stay on the exclusion until their first birthday with milk-free weaning solids introduced at the appropriate time.

Associated feeding problems

Feeding problems are common in infants with GOR/GORD and are often associated with negative feeding experiences along with carer anxiety. Extreme texture aversion can be a major problem, with infants failing to progress from puree foods onto lumps and finger foods. Feed refusal and consequently faltering growth can also be a consequence of GOR. Infants with GOR can be more demanding and difficult to feed, and have been shown to ingest significantly fewer calories than in matched infants without GOR. (8)

Infants and children with feeding difficulties should be managed by a multidisciplinary team comprising a speech and language therapist, psychologist, dietitian, and paediatrician or gastroenterologist. This team can provide support and management strategies to relieve carer anxiety. If possible, managing them in a specific feeding clinic gives a consistent approach across the professions

Management of infants and children with feeding difficulties should address growth and nutritional assessment, feed changes and behavioural advice.

Growth and nutritional assessment

Overall, growth is of paramount importance and a percentage of the infants will present with faltering growth. A full dietary history should be undertaken, along with weight and height. Calorie intake should be optimised by discussing food fortification and the use of high calorie milks and supplements.

Feed changes

Where allergy is suspected or the infant has failed to respond to medical management, a hydrolysate or amino acid-based formula can be tried for a one- to two-week trial period. If dietary exclusion is successful, then the nutritional adequacy of the diet must be monitored and vitamin and mineral supplements provided if necessary, such as for calcium.

In infants where allergy is not suspected, high calorie feeds (SMA High Energy and Infatrini) or thickeners added to standard formulas are often used, especially if they are showing faltering growth.

Behavioural advice

Behavioural advice should include:

* Limit meal duration to 20 to 30 minutes

* Make use of positive praise and avoid negative behaviour

* Provide regular mealtimes and snacks--three meals and two to three snacks

* Avoid force feeding

* Psychological support for parent or carer to break the cycle of anxiety or distress around mealtimes

* Use resources such as stickers or charts for the older child

* Consider texture of diet and information on appropriate finger foods

* Eat together whenever possible

* Avoid distractions such as TV and toys

* Encourage self-feeding where appropriate

* Avoid giving alternative food if a meal is not eaten

* Get advice from support groups such as Living With Reflux, Allergy UK.

Enteral feeding

With severe feeding difficulties, NG tube feeding may need to be instigated. In infants and children with on-going feeding difficulties, gastrostomy placement may be an option. However, gastrostomy tubes can worsen symptoms of GOR and the severity of the reflux should therefore be quantified prior to percutaneous endoscopic gastrostomy (PEG) placement. The use of enteral feeding via NG or PEG can help with reversing faltering growth, and with relieving parental or carer anxiety around mealtimes. An oral intake should be continued wherever possible, however small. Ideally, the feed can be administered overnight, leaving the day free to establish oral feeding. The overall feed volume may need to be reduced below that expected or desired for the child's requirements to ensure tolerance, and feeds can be fortified by adding extra calories or changed to high energy formulas to ensure that catch-up growth occurs.

Summary

In most infants, GOR is a normal occurrence that is self-limiting and they will outgrow it. However, in those who experience more severe symptoms, a combination of medical and dietetic management under the care of a multidisciplinary team is important. Where feeding problems exist, input should include behavioural and psychological support.

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References

(1) Craig WR, Hanlon-Dearman A, Sinclair C, Taback S, Moffatt M. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database of Systematic Reviews, 2004; (4): CD003502.

(2) Aggett PJ, Agostoni C, Goulet O, Hernell O, Koletzko B, Lafeber HL, Michaelsen KF, Milla P, Rigo J, Weaver LT. Antireflux or Antiregurgitation milk products for infants and young children: a commentary by the ESPGHAN Committee on Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 2002; 34(5): 496-8.

(3) Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, Gerson WT, Werlin SL; North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 2001; 32(S2): S1-31.

(4) Kelly KJ, Lazenby AJ, Rowe PC, Yardley JH, Perman JA, Sampson HA. Eosinophilic oesophagitis attributed to gastro-oesophageal reflux: improvement with an amino acid based formula. Gastroenterology, 1995; 109(5): 1503-12.

(5) Host A, Koletzko B, Dreborg S, Muraro A, Wahn U, Aggett P, Bresson JL, Hernell O, Lafeber H, Michaelsen KF, Micheli JL, Rigo J, Weaver L, Heymans H, Strobel S, Vandenplas Y. Dietary products used in infants for treatment and prevention of food allergy: joint statement of the European Society for Paediatric Allergology and Clinical Immunology Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. Archives of Disease in Childhood, 1999; 81(1): 80-4.

(6) Iacono G, Carroccio A, Cavataio F, Montaltoo G, Kazmierska I, Lorello D, Soresi M, Notarbartolo A. Gastroesophageal reflux and cow's milk allergy in infants: a prospective study. Journal of Allergy and Clinical Immunology, 1996; 97(3): 822-7.

(7) Cavataio F, Iacono G, Montalto G, Soresi M, Tumminello M, Carroccio A. Clinical and pH-metric characteristics of gastro-oesophageal reflux secondary to cows' milk protein allergy. Archives of Disease in Childhood, 1996; 75(1): 51-6.

(8) Mathisen B, Worrall L, Masel J, Wall C, Shepherd RW. Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study. Journal of Paediatrics and Child Health, 1999; 35(2): 163-9.

Jackie Falconer

Lead paediatric dietitian, Chelsea and Westminster Hospital NHS Foundation Trust
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