Reflux: problems in infants, children and young people

Reflux in infants is a common condition, yet research indicates that it is often over diagnosed and poorly managed. Nurses are among the first contacts for parents/carers when concerns about a child's feeding arise. In order to ensure that they are provided with appropriate access to education and management options, it is essential that professionals are equipped with knowledge on the differences between reflux and gastro-oesophageal reflux disease (GORD) and what interventions are in the best interests of the child and family.

This article discusses the common symptoms of reflux and GORD and what strategies can be developed to ensure effective nursing care is delivered from the outset.

Pathophysiology

In reflux and GORD the stomach contents (food) and acid are expelled upwards from the stomach through the lower oesophageal sphincter (cardiac sphincter) into the oesophagus and mouth (Terblanche, 2010; Douglas, 2013; Kirby et al, 2016).

There are defined differences between reflux and GORD:

• Reflux is common in infants under 1 year of age and can be a characteristic of a normal gastric function in young infants where the gastrointestinal system is still immature (Douglas, 2013; Bell et al, 2018).
• Reflux presents as regurgitation of milk feeds with little or no distress or discomfort. It is expected to resolve independently by the time the child is around 1 year old, with no need for medical intervention (Omari et al, 2002; National Institute for Health and Care Excellence (NICE), 2015).
• GORD is described as reflux that is associated with some degree of oesophageal damage and can impair quality of life.

A complete and comprehensive assessment is initially required. It is important to ascertain presenting symptoms, feeding patterns, the medical history and social circumstances, alongside parental concerns and ideas.

Where some degree of postprandial regurgitation and non-forceful vomiting is common in babies and children, the frequency and volume need clarification:

• Is this affecting growth and weight gain?

• Are any other symptoms present that could indicate more complex health issues?

Red flags for GORD

The following symptoms are ‘red flags’ and need to be assessed to ensure other health complications are excluded and GORD is established as the only possible diagnosis:

• aversion to feeding
• weight loss
• choking
• apnoea
• irritability
• perceived indicators of pain
• sleeping difficulties
• any life-threatening occurrences

Premature infants, children with cystic fibrosis, oesophageal atresia or neurological impairment are at heightened risk of developing severe GORD (Omari et al, 2002; Terblanche, 2010; NICE, 2015).

The root cause of any reflux or GORD needs to be established as part of the assessment process in order to ensure appropriate management can be initiated (Terblanche, 2010; NICE, 2015). Further investigations are rarely required unless other alarming factors are identified through assessment and examination (Omari et al, 2002; Terblanche, 2010; NICE, 2015; Kirby et al, 2016). If this process indicates a need for investigations due to severe GORD or to eliminate other health

Management of reflux

Reflux alone—with the only presenting symptom being postprandial regurgitation or low-volume non-forceful vomiting—should be managed with education and support for parents and the avoidance of medication (Douglas, 2013; Hua et al, 2015; NICE, 2015; Kirby et al, 2016).