Management of infants with gastroesophageal reflux and constipation

Key Messages
• Although we all know that functional gastrointestinal disorders (FGIDs) in infants are        transient problems, parents sometimes want more than just words.

• Breastfeeding should never be discontinued as a form of treatment of a FGID.

• Dietary management if necessary, is the recommended treatment of regurgitation
  while medications can be used for treatment of constipation.

We will discuss here two of the three more frequent functional gastrointestinal disorders (FGIDs) in infants.

Gastroesophageal reflux

Although regurgitation can occur at any age, it peaks around 4 months of age, tapering from 6 months and declining in frequency until 12–15 months1 (Figure 1).[2] When correctly identified, unnecessary doctor visits and investigations and therapy will be avoided. Treatment goals are to provide symptom relief, prevent complications and effective reassurance. In order to improve the caregiver-child interaction relieving the caregiver’s fears about the condition may lead to reduction of parents’ anxiety and consequently demand for medications, as management guidelines do not recommend their use. Multiple trials showed a lack of benefit of proton pump inhibitors in infants with regurgitation.[3]  Discontinuation of breastfeeding is not recommended but alginates can be used to thicken breastmilk in the stomach. Early administration of Limosilactobacillus (L) reuteri (previously known as Lactobacillus reuteri*) DSM17938 has been shown to control regurgitation episodes in full-term breastfed infants.[4] Thickened feedings and antiregurgitation formulas can decrease regurgitation in healthy formula fed infants and are part of the treatment guidelines, as well as an empirical trial of an extensively hydrolyzed protein formula. A study with a partially hydrolyzed whey formula (PHWF) supplemented with starch and L. reuteri DSM 17938 significantly reduced regurgitation compared to controls.[5] Overall, PHWF may offer a useful alternative to intact protein in the dietary management of common functional gastrointestinal symptoms.[6] 



Constipation

Diagnosis of constipation in infants is relatively simple; it must include 1 month of at least 2 of the following: 1) two or fewer defecations per week 2) history of excessive stool retention, painful or hard bowel movements, 3) large-diameter stools and/or presence of a large fecal mass in the rectum.[7] This is the only infantile FGID for which treatment recommendations include medications: lactulose 1–2 g/kg, once or twice/day or polyethylenglycol 3350 0.2– 0.8 g/kg/day. However, parents usually don’t like their infants to be on long term medication despite their lack of side effects, generally good results, palatability, ease of administration and cost. In the first year of life, dietary manipulation is almost impossible except for changing the formula type in non-breastfed infants. Prebiotics, small non digestible and non-absorbable carbohydrates, have been shown to prevent or relief constipation in formula fed infants.[8] In addition, in a 2010 study,[9] the authors concluded that the administration of L reuteri (DSM 17938), a probiotic (live beneficial bacteria), administered to infants with chronic constipation had a positive effect on bowel frequency, even when there was no improvement in stool consistency. Because of their safety profile, probiotics may be an attractive option in the treatment of functional constipation.



1. Hegar B, Dewanti NR, Kadim M, et al. Natural evolution of regurgitation in healthy infants. Acta Paediatr 2009; 98:1189–1193
2. James Martin A. Natural History and Familial Relationships of Infant Spilling to 9 Years of Age. Pediatrics. 2002; 109:1061
3. Orenstein SR, Hassall E, Furmaga-Jablonska W, et al. Multicenter, double-blind, randomized, placebo controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr 2009; 154:514–520 e4.
4. Garofoli F, Civardi E, Indrio F, et al. The early administration of Lactobacillus reuteri DSM 17938 controls regurgitation episodes in full-term breastfed infants. Int J Food Sci Nutr. 201465:646– 8
5. Indrio F, Riezzo G, Giordano P, et al. Effect of a partially hydrolysed whey infant formula supplemented with starch and Lactobacillus reuteri DSM 17938 on regurgitation and gastric motility. Nutrients 2017. 9; 1181
6. Vandenplas Y , Cruchet S, C Faure, et al. When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention? Acta Paediatr. 2014;103, 689–95
7. Benninga MA, Nurko S, Faure C, et al. Childhood Functional Gastrointestinal Disorders: Neonate/ Toddler. Gastroenterology 2016;150:1443–1455
8. ESPGHAN Committee on Nutrition: Braegger C, Chmielewska A, Decsi T, et al. Supplementation of Infant Formula with Probiotics and/or Prebiotics: A systematic review and comment by the ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr 2011;52: 238–250
9. Coccorullo P, Strisciuglio C, Martinelli M, et al. Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation: a double- blind, randomized, placebo-controlled study. J Pediatr. 2010;157:598– 602