Infant gastro-oesophageal reflux

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Considered pretty normal for neonates, most babies regurgitate milk at some point or another. Becomes a problem if baby vomits so much that they fail to gain weight, or if associated with another symptom, esp distress, apnoea, choking, abnormal movements (so called Sandifer syndrome, typically dystonic movements eg arching, posturing of head/limbs).

Becomes less of an issue as the baby gets older, with most children being asymptomatic by 6 months of age, but can persist to 1yr or longer.

Diagnosis can be helped by pH study, but this is only really sensitive for acid reflux, rather than milk reflux. Barium swallow can confirm reflux but depends on whether the baby can ingest the barium and whether any reflux occurs during the study or not.

Conservative measures are to raise the head of the cot, position the baby in a seat during/after feeds. Infant Gaviscon sachets thicken the feed and have an antacid effect, but are associated with constipation. Ranitidine/omeprazole may have additional benefit where acid reflux prominent.

Cisapride and Metoclopramide have prokinetic actions but associated with cardiac and neurological side effects respectively. Domperidone is licensed for nausea and vomiting but some evidence of arrhythmias in adults. Hence MHRA advice (2014):

  • Children with congenital heart disease - Consider stopping domperidone therapy or discuss with parents/carers andensure that cardiac monitoring is regularly performed. Consider offering an alternative treatment where appropriate.
  • Other children with established reflux or nausea and vomiting - Take no immediate action in patients already established on domperidone. Consider reducing the dose (where appropriate) to 250microgram/kg three times a day at the next convenient review. Consider routine cardiac monitoring where there are concerns (e.g. cardiovascular instability, concomitant CYP3A4 inhibitors prescribed).
  • In new patients, always give a proper trial of feed thickeners before considering pharmacological intervention - at least two weeks. In more serious cases, and after the introduction of thickeners then consider the benefits and risks of medical anti-reflux/anti-acid secretion treatment.

If domperidone is to be used, give an initial maximum of 250micrograms/kg three times a day. Where reflux or nausea is refractory to this then give increased doses to a maximum of 400micrograms/kg (max 20mg) three times a day and recommend regular cardiac monitoring. A Patient Information Leaflet is available from Medicines for Children.

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