In this feature, leading GORD expert and Treasurer of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), Chief of the Department of Translational Medical Science at the University of Naples ‘Federico II’, and Vice-President of the Italian Society for Paediatrics, Professor Annamaria Staiano, answers the key questions surrounding GOR and GORD, including the differences between the two conditions, how the conditions are managed, and the impact the conditions can have on infants and their parents.
WHAT ARE THE MAIN CAUSATIVE FACTORS AND CHARACTERISTICS OF INFANT GOR?
GOR is defined as the passage of gastric contents into the oesophagus with or without regurgitation and / or vomiting. The main characteristics of infant GOR are regurgitation and vomiting which are very common in healthy infants, mostly during the first months of life.
Around 70 per cent of healthy infants physiologically regurgitate several times per day, and in approximately 95 per cent of this group, symptoms disappear without intervention by the time they reach 12-to-14 months of age. These patients are often labelled as ‘happy spitters’ which reflects the benignity of this condition. Infants regurgitate more frequently than adults due to the intake of large volumes of liquid, the prolonged horizontal position of infants, and the limited capacity of both stomach and oesophagus.
HOW IS GOR GENERALLY MANAGED?
Infants with functional GOR should not receive pharmacological treatment. When physiologic GOR is suspected in healthy infants, management largely centres on parental education, reassurance, and advice.
Additional treatment options include the use of thickened feeds, as well as the adjustment of the quantity and frequency of feeds according to age and weight, to avoid overfeeding. Nutritional advice (feeding technique, volume and frequency, and changes in the formula) can be considered and the physician should always stress the benefits of breastfeeding and offer appropriate support to continue breastfeeding.
Special attention should be given to fluid management as many infants drink too much. This leads to overfeeding that, especially in formula-fed infants, is a frequent cause of infant distress. The duration of feeding should also be considered as if this is too fast or too slow it may distress the infant.
Medication and investigations are not required in the management of uncomplicated regurgitation. If the infant is very distressed, mainly after a feeding or between the feeds, treatment with alginate may be considered. If necessary, the use of alginates may slightly improve visible regurgitation and / or vomiting as signs and symptoms of GOR, although there is currently no scientific evidence that supports their use.
The use of the histamine receptor antagonists (H2RA) or proton-pump inhibitors (PPIs) for the treatment of distress in otherwise healthy infants is not recommended.
WHEN DOES THE ESCALATION OF SYMPTOMS RESULT IN A GORD DIAGNOSIS?
GOR is considered to be pathologic and referred to as GORD when the reflux leads to problematic symptoms and / or complications, such as esophagitis or stricturing. In infants, the typical symptoms of GORD vary widely and may include excessive crying, back arching, recurrent regurgitation and / or vomiting, irritability, and weight loss or poor weight gain. However, these symptoms are common in infants and, as such, are not sufficient to diagnose the condition as they are non-specific to GORD.
In addition to these typical symptoms, there are extra-oesophageal, or atypical, symptoms which may occur or may even represent the only clinical picture of GORD, including wheezing, stridor, coughing, hoarseness, and apnoea / apparent life-threatening events. Moreover, GORD may cause other complications or conditions, such as impaired quality of life, food refusal, persisting hiccups, abnormal posturing / Sandifer’s syndrome, anaemia, and bradycardia.
Major symptoms that require further investigation in infants with recurrent regurgitation and / or vomiting include gastrointestinal bleeding, hematemesis, haematochezia, bilious vomiting, consistently forceful vomiting, onset of vomiting after six months of age, failure to thrive, diarrhoea, constipation, fever, lethargy, hepatosplenomegaly, bulging fontanelle, seizures and macrocephaly / microcephaly.
WHAT DO WE KNOW ABOUT THE PREVALENCE AND RISK FACTORS OF GORD?
The prevalence of GOR and GORD vary according to the population, the study design (cross-sectional or longitudinal), and the diagnostic criteria (visible symptoms vs. validated questionnaire).
An Italian study conducted on 2,642 infants aged 0-to-12 months found a GOR prevalence of 12 per cent, while the prevalence of GORD in this cohort was less than one per cent. Being born from atopic parents was found to be a risk factor for GOR. (1)
A recent prospective cohort study conducted in France, which included 272 full-term infants aged 0-to-12 months, found that GOR prevalence peaked at three months of age (59.3 per cent), while GORD prevalence peaked at one month of age (19 per cent). The prevalence of GORD thereafter dropped to nine per cent at three months, and to two per cent at 12 months of age. In this study, two risk factors were identified for GOR and GORD at one month of age: family history of GOR, and exposure to paternal smoking. (2)
TO WHAT EXTENT ARE INFANTS WHO EXPERIENCE GORD DISTRESSED AND WHAT EMOTIONAL BURDEN CAN IT POSE ON THE INFANT’S PARENT(S)?
The impact of the symptoms of GOR / GORD varies from mild to extremely distressing for both the infant and parents. The emotional burdens posed by the symptoms can trigger parental anxiety, poor quality of life, shortened duration of full breastfeeding, numerous changes in the formula, medical consultations, and associated significant healthcare costs. GOR / GORD impact significantly on personal and public healthcare expenses, such as healthcare consultation fees, drug prescriptions, use of special milk formulas and prolonged diet, and the loss of income due to absenteeism from work.
WHAT ARE THE RECOMMENDED CLINICAL INTERVENTIONS AND MANAGEMENT OPTIONS?
In addition to the use of thickened feeds for treating visible regurgitation and / or vomiting, and the modification of feeding volumes and frequency, a two-to-four-week trial of formula with extensively hydrolysed protein (or amino-acid based formula) should be considered in formula-fed infants after optimal non-pharmacological treatment has failed. In fact, symptoms of cow-milk protein allergy and GORD in infants are identical.
In the case of reflux-related erosive esophagitis in infants with GORD, PPIs should be used as the first-line treatment. NASPGHAN / ESPGHAN recommendations for paediatric GORD suggest to use H2RAs if PPIs are not available or contraindicated. However, in April 2020 the FDA requested to remove all forms of ranitidine from the market because unacceptable levels of NDMA, a probable carcinogen (cancer-causing chemical), were found in some ranitidine products.
The use of other treatments, such as massage therapy and complementary therapy (hypnotherapy, homeopathy, acupuncture, and herbal medicine), or prebiotics and probiotics, have not been adequately studied and may pose more risk and cost. Therefore, these treatments can’t be recommended to reduce the symptoms of GORD in infants and children. Moreover, antacids / alginates should not be used for the chronic treatment of infants and children with GORD.
ARE THERE ANY LIFESTYLE MODIFICATIONS WHICH SHOULD BE MADE?
There is a lack of evidence supporting non-pharmacologic interventions. Some interventions (such as tobacco avoidance) are low-to-no cost and risk, and may merit a trial before considering more costly or risky therapies.
1. Campanozzi A, Boccia G, Pensabene L, et al. Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey. Pediatrics. 2009;123(3):779-783. doi:10.1542/peds.2007-3569
2. Curien-Chotard, M., Jantchou, P. Natural history of gastroesophageal reflux in infancy: new data from a prospective cohort. BMC Pediatr 20, 152 (2020). https://doi.org/10.1186/s12887-020-02047-3