Regurgitation and reflux are benign and self-limiting functional gastrointestinal disorders that often occur interconnected. Both are common and normal physiological processes that usually resolve over time and need no intervention. Nevertheless, symptoms can stress parents and lead to decreased quality of life, making therapy with conservative interventions necessary.
Gastro-oesophageal reflux (GOR, also called gastroesophageal reflux GER) describes the involuntary movement of stomach content into the oesophagus. It does not necessarily result in regurgitation, which is the re-entry of stomach content into the oral pharynx or mouth (i.e. spitting-up) (Vandenplas et al., 2009, Benninga et al., 2016). If regurgitation or GOR cause troublesome symptoms (e.g. complications, tissue damage or inflammation), it is classified as gastroesophageal reflux disease (GORD/GERD) (Benninga et al., 2016, Zeevenhooven et al., 2017, Vandenplas et al., 2009).
According to the Rome criteria, infant regurgitation is diagnosed if both of the following criteria are displayed in otherwise healthy infants between three weeks and 12 months (Benninga et al., 2016):
GOR and regurgitation are frequent and normal physiological processes most commonly caused by a temporary relaxation of the lower oesophageal sphincter resulting from distention after feeding (Baird et al., 2015). GOR can also occur because of increased intraabdominal pressure following delayed gastric emptying (Leung & Hon, 2019) About 50% of healthy infants younger than three months regurgitate at least once per day, making it the most common functional gastrointestinal disorder (FGID) (→) in infants below 12 months of age (Baird et al., 2015, Benninga et al., 2016). Preterm infants are particularly affected because of the immaturity of their lower oesophageal sphincter, uncoordinated oesophageal and intestinal peristalsis, slow(er) gastric emptying times and high milk intake in relation to stomach size. Regurgitation occurs in nearly all cases of GOR and is usually harmless. As long as the infant thrives and has no other symptoms it is considered a "happy spitter" (Leung & Hon, 2019).
Even though regurgitation and GOR are benign and self-limiting disorders, parents are often anxious and stress over the symptoms, which leads to a decrease in quality of their life. In general, no treatment is necessary but parents' concerns should be addressed and reassured (Leung & Hon, 2019, Benninga et al., 2016). If regurgitation occurs often or becomes problematic, several management options are available:
Changes in posture
Breastfeeding is recommended because breastfed infants are less likely to exhibit GOR. Breastfeeding mothers can try a low allergenic diet (e.g. avoidance of cow's milk) when intolerance or allergic reactions are suspected, whereas for formula-fed infants hydrolysed protein formulas can be tested. Other recommendations include weight reduction in overweight infants and avoidance of overfeeding (Leung & Hon, 2019, Baird et al., 2015, Benninga et al., 2016).
Usually pharmacological treatment is unnecessary because GOR most often resolves itself within the first 12 month of life. If infants display GORD, which does not resolve with conservative (non-pharmacological) measures, pharmacological options (e.g. H2-receptor antagonists and proton pump inhibitors) are available (Leung & Hon, 2019, Baird et al., 2015, Benninga et al., 2016).
Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler: in Rome IV. Functional gastrointestinal disorders: Disorders of gut-brain interaction [SECTION II: FGIDs: Diagnostic groups _15]. Gastroenterology 2016; 150(6):1443–55. at: pubmed.ncbi.nlm.nih.gov/27144631
Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, Gottrand F, Hegar B, Lifschitz C, Ludwig T, Shah N, Staiano A, Szajewska H, Treepongkaruna S, Vandenplas Y. Review shows that parental reassurance and nutritional advice help to optimise the management of functional gastrointestinal disorders in infants. Acta paediatrica (Oslo, Norway : 1992) 2018a; 107(9):1512–20. at: pubmed.ncbi.nlm.nih.gov/29710375
Salvatore S, Savino F, Singendonk M, Tabbers M, Benninga MA, Staiano A, Vandenplas Y. Thickened infant formula: What to know. Nutrition (Burbank, Los Angeles County, Calif.) 2018b; 49:51–6. at: pubmed.ncbi.nlm.nih.gov/29495000
September C, Nicholson TM, Cichero JAY. Implications of changing the amount of thickener in thickened infant formula for infants with dysphagia. Dysphagia 2014; 29(4):432–7. at: pubmed.ncbi.nlm.nih.gov/24658846/
Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenzl TG, North American Society for Pediatric Gastroenterology Hepatology and, Nutrition, European Society for Pediatric Gastroenterology Hepatology and, Nutrition. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of pediatric gastroenterology and nutrition 2009; 49(4):498–547. at: pubmed.ncbi.nlm.nih.gov/19745761
WHO. Infant and Young Child Feeding. Model Chapter for textbooks for medical students and allied health professionals. Geneva, Switzerland: World Health Organization (WHO) press; 2009. at: www.who.int/maternal_child_adolescent/documents/9789241597494/en/
Zeevenhooven J, Koppen IJN, Benninga MA. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric gastroenterology, hepatology & nutrition 2017; 20(1):1–13. at: pubmed.ncbi.nlm.nih.gov/28401050back