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Scenario

Melanie Woolcott comes to the counter. Technician Vicky sees that she has a prescription in her hand.

“Oh hi, Melanie,” says Vicky. “How’s that gorgeous boy of yours? Not poorly, I hope?”

“He’s OK, I think,” replies Melanie. “I’d get him out to say hello, but he’s just dropped off on the walk from the doctor’s, so I think I’ll leave him. Nights are pretty awful at the moment, to be honest. Thank goodness for coffee, I don’t know how I’d get through the days without it.”

“Broken nights are a killer,” agrees Vicky, sympathetically. “What’s going on? I thought you were doing quite well with getting him into a routine?”

“I thought that too, and for the first couple of months – while I was feeding – it definitely felt like we were heading in the right direction,” sighs Melanie. “But then my milk seemed to dry up when he was around six weeks so I moved onto formula. It wasn’t long after that that he started kicking off during the night. He’s fine for the first few hours, but then he wakes up increasingly often and it’s like he’s in pain. He draws his legs right up to his chest, and the only way I can soothe him is to lay him on me while I sit in the chair next to his cot. I’ve seen the health visitor about it a few times, but none of the things she suggested, like giving smaller feeds more often and being super-careful about burping him, have really helped. And he seems OK during the day, so I can’t see how he can be allergic to the formula. The doctor said he has reflux and has switched him on to a trial of thickened infant formula milk, but will that really help?”

Answer

Although there is no accurate data available, reflux in infants up to the age of one year is remarkably common. There is a spectrum of severity, with regurgitation – part or all of the stomach contents moving up the oesophagus into the mouth, also known as posseting – at the mild ‘completely normal’ end, and gastro-oesophageal reflux disease (GORD) which features troublesome symptoms such as discomfort or complications such as oesophagitis, aspiration pneumonia and recurrent otitis media, at the other extreme.

The condition usually begins before the age of eight weeks, and 90 per cent of cases resolve before the child’s first birthday, which may provide a level of reassurance to Melanie. Given that the baby is distressed, a stepped-care approach is sensible, which is what the healthcare visitor and GP have been advising. Melanie is now at the stage of trying a thickened formula milk containing either rice starch, cornstarch, locust bean gum or carob bean gum.

If this is unsuccessful, Melanie will be advised to stop the thickened formula and offer alginate therapy for a trial period of one to two weeks. If the alginate therapy is successful, Melanie should continue with it, but try stopping it at intervals to see if the baby has recovered. If the alginate therapy does not work, Melanie should return to the GP who may prescribe a four week trial of a proton pump inhibitor or histamine-2 receptor antagonist.

The bigger picture

Reflux is common in infants because of several factors:

• A shorter, more narrow oesophagus than in older children and adults
• A lower oesophageal sphincter that is slightly above, rather than just below, the diaphragm
• Delayed gastric emptying
• The high calorie, liquid diet that babies need putting the stomach under strain
• The fact that babies are often lying down, which means gravity can’t exert its usual effect.

Certain factors increase the risk of a baby developing reflux, including premature birth, parental history of heartburn or similar, obesity, anatomical abnormalities of the GI tract or surrounding muscles, and neurodisability disorders such as cerebral palsy.

Extend your learning

• The scenario above refers to proton pump inhibitors and ranitidine-2 receptor antagonist. Can you give three examples of each? Use the British National Formulary to check your answers
• Would you know when to refer a baby with reflux? Read the guidance published by the National Institute for Health and Care Excellence (NICE)
• Remind yourself of the anatomy that relates to infant GORD by viewing the image from Anatomy Medicine.