Gastro-oesophageal reflux is the commonest cause of vomiting in infancy

Aetiology

Risk factors

• Preterm delivery
• Neurological disorders

Clinical presentation

• Typically develops before 8 weeks
• Vomiting/regurgitation
  • Milky vomits after feeds
  • May occur after being laid flat
• Excessive crying, especially while feeding

Investigations

• Diagnosis is usually clinical

Management

• Advise regarding position during feeds - 30 degree head-up
• Infants should sleep on their backs as per standard guidance to reduce the risk of cot death
• Ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
• A trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum) is first line in bottle-fed infants
• A trial of alginate therapy e.g. Gaviscon is first line in breast-fed infants
  • Alginates should not be used at the same time as thickening agents
• NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom; a trial of one of these agents should be considered if 1 or more of the following apply:
  • Unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
  • Distressed behaviour
  • Faltering growth
• Ranitidine was previously used as an alternative to a PPI but was withdrawn from the market in 2020 as small amounts of the carcinogen N-nitrosodimethylamine (NDMA) were discovered in products from a number of manufacturers
• Prokinetic agents e.g. metoclopramide should only be used with specialist advice