Functional gastrointestinal disorders (FGIDs) are common, self-limiting, non-organic conditions in infancy, with an incidence of about 50% (National Institute for Health and Care Excellence (NICE), 2015). The digestive, circulatory and nervous systems are all maturing and the lower esophageal sphincter is quite lax, allowing gastric contents to flow back. The Angle of His (the angle created between the cardia at the entrance to the stomach and the oesophagus) is also obtuse at first, increasing the likelihood of the passage of milk back up to the pharynx. This guide will focus primarily on reflux and regurgitation, but it is common for babies to experience other conditions affecting the gastrointestinal tract, like colic and constipation.
Definitions point to general signs and symptoms. Often a combination of conditions are evident, so obtaining a clear diagnosis can be difficult (NICE, 2019a; 2019b). Reflux and regurgitation tend to peak at 4–6 months of age and generally resolve from 6–12 months of age (Iacono et al, 2005). FGIDs result in significant financial and emotional costs to the family and the health service (Mahon et al, 2017). They increase the stress on family life and the mother is more likely to stop breastfeeding. Thus, it is important that health professionals are equipped to support families with these difficulties and are well informed of the most effective management techniques.
Reassurance and nutritional management, using empathy and warmth are important, and motivational interviewing techniques are a valuable tool, adopting an approach with open questioning and listening skills (Miller and Rollnick, 2002). It is important to avoid medicalising a normal physiological stage of development, where all the organs are still maturing and the stomach is undergoing normal development. The aim of this guide is to:
- Provide an evidence-based resource for the practitioner
- Reduce the rate of inappropriate prescribing and wasted cost
- Increase the confidence of the practitioner
- Increase the confidence of the care giver and reduce anxiety.
Definitions
The Rome IV criteria are a useful basis to assist with differential diagnosis. There are seven conditions that come under the definition of FGIDs (Benninga et al, 2016; Rome Foundation, 2020).
Regurgitation is when the gastric contents pass back into the pharynx and may be expelled from the mouth. Gastro-oesophageal reflux (GOR) is where the gastric contents pass back into the oesophagus, with or without regurgitation and vomiting. Reflux can start after 2 weeks, generally peaks at 4–6 months of age and resolves by 12–14 months. It is equally common in both breast- and formula-fed infants and occurs equally in boys and girls (NHS Choices, 2020). It is normal for milk to be posseted several times a day initially. By the end of the first week, a baby’s tummy is about the size of an apricot. The stomach has the capacity for only 30–60 ml of milk (1–2 oz) at this time.
Idiopathic constipation is defined as the inability to pass stools regularly or to empty the bowel completely, with no evidence of anatomical or physiological abnormalities. Identifying constipation in babies is difficult, as infrequent bowel action can be quite normal, particularly in breastfed infants. Guidelines recommend nutritional management of the condition (NICE, 2020).
Infantile colic is a self-limiting condition that is defined clinically as repeated episodes of excessive and inconsolable crying in an infant who otherwise appears to be healthy and thriving (NICE, 2017). A specific definition that may be used for research purposes is ‘paroxysms of irritability, fussing or crying lasting for a total of 3 hours a day and occurring on more than 3 days in any 1 week for a period of 3 weeks in an infant who is otherwise healthy and well fed (Wessel et al, 1954). Typically, an infant with colic presents with the following (Wall and Bogle, 2018):
- Excessive, inconsolable crying, which starts in the first weeks of life and resolves by around 3–4 months of age
- Crying that most often occurs in the late afternoon or evening
- Drawing its knees up to its abdomen or arching its back when crying.
Risks of inadequate management of FGIDs
It is important for health professionals from a broad range of service areas to offer consistent and evidence-based advice. An unsettled baby will increase stress and anxiety for the immediate family and the extended family members. If a baby does not settle, there is an increased risk of child maltreatment (NICE, 2019c). It is important to ensure that parents know never to shake their baby during these crying episodes as tiny blood vessels in the brain can rupture, and shaking conveys distress and lack of control, which will only exaggerate the stressful situation. As Mahon’s research demonstrates, FGIDs generate substantial unnecessary expense for the parents and the health system if the guidelines are not followed and implemented (Mahon et al, 2017).
Warning ‘red flags’
It is important that a detailed description is given to ensure that a medical condition is not overlooked and is simply inappropriately attributed to FGIDs. These conditions include projectile vomiting, which is more common in boys from 3 weeks of age. Gastric contents in this case are forcefully vomited after feeds with accompanying loss of weight. Other areas of concern are when the baby is generally unwell, has haematemesis, aspiration or apnoea, is failing to thrive or has swallowing difficulties. FGIDs also need to be differentiated from conditions like cow’s milk protein allergy.
We need to distinguish between gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD). The latter requires a medical referral and intervention (NICE, 2019a).
Management
Drug treatment is not recommended for gastrointestinal disorders. A stepped approach is advocated, as described in detail in the literature (NICE, 2015).
Ideally, the health professional should observe feeding episodes and give the appropriate advice about positioning during a feed, amount
of feed taken and winding techniques. If formula feeding, the teat size can be considered to see if the milk flow is too fast or slow. Smaller, more frequent feeds may help to reduce reflux and regurgitation.
After a feed it is advisable to hold the baby upright to avoid the back flow of milk. Gentle tapping of the back and keeping the back at a 90 degree angle will help the bringing up of wind. Other helpful strategies include giving a warm bath and baby massage. Touch helps to stimulate maturity of all the organs, particularly as the skin is the largest organ of the human body. Ensure that clothing is not restrictive, especially around the tummy. Background or white noise, such as a hoover or washing machine, can be soothing and help to relax the baby after a feed.
If reflux and regurgitation persist, a thickened anti-reflux formula may be effective for formula-fed babies. A Cochrane review found that thickened feeds appear to be beneficial, although only eight clinical studies were reviewed (Kwok et al, 2017). Studies that have been undertaken have involved the addition of corn starch, rice starch and carob bean gum to the milk. After 6 months, when the rate of regurgitation drops significantly, anti-reflux formula may be continued or the parents can elect to resume use of a standard formula.
There is some evidence that products containing alginic acid work, such as Gaviscon, but these should only be suggested if regurgitation and reflux persist. Alginic acid is derived from seaweed, and in Infant Gaviscon the alginates combine with the stomach contents to form a gel. This prevents stomach acid from backtracking into the oesophagus (NICE, 2015; 2019a). One note of caution is that alginates and thickened formula should not be used together due to the risk of bezoar formation (Konstantinos et al, 2019). This is the formation of a solid mass of indigestible material, which can cause bowel blockage.
Proton pump inhibitors (PPIs) are not recommended and may have adverse effects. Vandenplas is one of the main researchers in this field and warns against use of PPIs (Vandenplas et al, 2009; 2015). They cause overgrowth of bacteria in the small intestine. This results in the increased risk of iron deficiency, vitamin B12 deficiency, calcium malabsorption, respiratory tract infections and gastric infections. If PPIs are used they should be strictly trialled on a 2-week basis and then stopped to monitor their effects.
Medication has not been found to be effective in clinical trials (Headley and Northstone, 2007). Remedies such as lactase drops (Colief), simeticone (Infacol) and herbal remedies do not have sufficient clinical evidence to support their use. Gripe water contains sodium bicarbonate and dill seed oil. The only support for its use is anecdotal and it may be due to its sweet taste. Probiotics have no robust evidence following clinical trials of their use. The mother should be reassured that any manipulative techniques, for example, cranial osteopathy, have no scientific proof of efficacy. Finally, if all the options available result in no improvement, the infant can be referred by their GP to a specialist.
Motivational interviewing
Research undertaken has found that less than 10% parents knew that FGIDs were the normal symptoms of a developing gut and more
than 85% felt anxious about the condition (see Box 1).
Communication is important when giving reassurance (Miller and Rollnick, 2002). Parents and carers will not feel reassured if they believe their difficulties have not been heard and appreciated, with the likely result that the parents will make repeated consultations and make high use of healthcare resources. Parents want reassurance that they are good parents and they need to gain confidence in their role as parents and that they are doing all the right things. The health professional can ask the carer what a typical day is like coping with the digestive difficulties. This provides an opportunity to discuss and have a clear picture of the baby’s behaviour and milk intake over the whole day.
It is easy to make sweeping statements about providing reassurance to anxious parents. There are tools available to assist the practitioner to become more skilled in this role. One tool is that of motivational interviewing (Miller and Rollnick, 2002). Role play between professionals may help to refine skills in this field.
Economics
There are a high percentage of medical consultations for FGIDs and statistics highlight that as many as 26% mothers see their GP for advice about FGIDs. The economic considerations are also relevant, as functional gastrointestinal disorders are costly to both families and the NHS (Mahon et al, 2017). Mahon’s research involved a systematic review, with 34 studies identified as being appropriate for inclusion. The researchers discovered that the total costs for managing these disorders were estimated at £72.3 million per year in 2014/2015. £49.1 million was NHS expenditure, with parents incurring £23.2 million through over the counter remedies. This estimate is likely to be lower than the actual costs, due to missing data and evidence.
This wasted cost may be because of parental demands for a prescription when they see their health professional. The number and kind of products purchased suggest there is a gap between what happens in practice and what treatment guidelines advocate, which is primarily reassurance and nutritional advice.
Conclusions
Health professionals need to be aware of the distress that FGIDs cause to the family. They are common and often difficult to define precisely, as conditions merge and overlap. The cornerstone of managing FGIDs is nutritional management and reassurance from a well informed practitioner (Salvatore et al, 2018). A consistent approach from all primary care professionals is necessary and all service areas need to be knowledgeable of the NICE guidance and latest research. Those primary care practitioners include practice nurses and pharmacists, in addition to the health visiting team and GP staff.
Alison Wall, Independent Public Health Strategist and Health Visitor
This guide was produced with a financial grant from Danone Nutricia
This guide can be downloaded as an A5 PDF here
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Important notice: Anti-reflux formulas are foods for special medical purposes and must be used under medical supervision.
HCP658 Oct 2020