Written by Registered Dietitian Nishti
Gastro-oesophageal Reflux (GOR), also known as reflux, is when the stomach’s contents come back up into the food pipe. It is very common in babies, especially during the first 12 months of life, and tends to start before the baby is 8 weeks old. If GOR negatively affects the daily life of both the baby and the family, it is referred to as Gastro-oesophageal Reflux Disease (GORD). In babies who are preterm, GORD can be extremely common.
Why food allergy?
Cow’s milk protein allergy is the most common food allergy in the world and is recognised to play a possible role in babies with GORD. In fact, some research suggests that an allergy to cow’s milk may play a role in 40% of children with GORD and that eliminating cow’s milk can improve symptoms.
This suggests that it is likely that children with GORD may have an allergy to cow’s milk.
What are the symptoms of cow’s milk protein-related GORD?
The following may suggest that it could be cow’s milk protein allergy (or any other food allergy for that instance): Recurrent regurgitation and vomiting together with or without excessive crying, distress, discomfort, irritability, feeding difficulties, food refusal, rash, atopic dermatitis, and poor growth. Therefore, if your baby is struggling with eczema and tummy issues, it most likely could be cow’s milk protein allergy.
How we manage a baby with GORD:
This is what happens in our clinic when we see babies with reflux.
- Step 1 – The dietitian takes a detailed clinical history.
If a baby has GI symptoms (constipation, loose poo, colic, wind, etc.) or even eczema it most likely could suggest an allergy to cow’s milk protein. If an allergy to cow’s milk is suspected, the dietitian will take the necessary steps to diagnose this (more about this later).
- Step 2 – Feeding Assessment
Breastfed babies: The dietitian will ask your health visitor to carry out a breastfeeding assessment and observe breastfeeding.
Formula-fed babies: Avoid fast-flowing teats to prevent your baby from choking or gulping too quickly. Your dietitian may suggest feeding smaller amounts more frequently.
Other suggestions include: not bouncing your baby after feeding and keeping your baby upright after feeding for as long as possible (at least 30 minutes).
- Step 3 – Your dietitian may suggest trying a thickened feed or to add thicker to a feed. Some feeds contain a thickening agent already whilst Carobel is a thickener that may be added to both breast or formula.
There is no evidence that one thickener is clinically better than another. However, anti-reflux formulas offer the advantage of a balanced composition, controlled viscosity, and calories compared with adding thickening agents to a standard formula.
Below is a table listening common anti-reflux formulas and thickeners:
|Brand Name||Thickening Agent|
|Aptamil Anti Reflux||Carob Bean Gum|
|C&G Anti Reflux||Carob Bean Gum|
|SMA Pro Anti Reflux||Potato starch|
|Enfamil AR||Rice starch|
|SMA Staydown||Corn starch|
|Carobel||Carob bean gum|
- Step 4 – If a baby has been unresponsive to all of the above, a 2-6 week elimination diet of cow’s milk protein will take place followed by a reintroduction of cow’s milk protein.
Elimination of cow’s milk protein from the infant’s or mother’s diet and challenges are the gold standard for diagnosis. Your dietitian may even suggest limiting other foods if multiple food allergies are suspected.
How about medication?
Recent guidelines suggest that pharmacological treatment of GORD should only be used AFTER an elimination diet has been trialed. Unfortunately, babies are put on anti-reflux medication too quickly, and most often, an elimination diet was never suggested.
The use of medication in babies with reflux is extremely common and often it is needed to help manage symptoms of reflux. However, it is extremely important to ensure a less invasive strategy is trialed first given that proton pump inhibitors used in treating reflux in babies may disrupt the microbiome causing dysbiosis in the gut, mouth, and lungs.
Many babies who present with GORD may indeed have cow’s milk protein allergy and therefore the management of such patients may require a cow’s milk protein elimination diet. It is highly recommended that babies with suspected cow’s milk protein allergy are managed by a paediatric dietitian.
If this blog post was helpful, please leave a comment below and share it with a parent who you may think could benefit from reading this. If you are interested to watch educational videos on reflux in babies and more videos on cow’s milk protein allergy please visit Nishti’s Choice on Youtube
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Omari, T. et al. (2020) ‘Characterization of Upper Gastrointestinal Motility in Infants With Persistent Distress and Non-IgE-mediated Cow’s Milk Protein Allergy’, Journal of pediatric gastroenterology and nutrition. J Pediatr Gastroenterol Nutr, 70(4), pp. 489–496.
Salvatore, S. et al. (2018) ‘Thickened infant formula: What to know’, Nutrition. Elsevier, 49, pp. 51–56.
Meyer, R. et al. (2022) ‘Diagnosis and management of food allergy-associated gastroesophageal reflux disease in young children—EAACI position paper’, Pediatric Allergy and Immunology. John Wiley & Sons, Ltd, 33(10), p. e13856.
Meyer, R. et al. (2018) ‘Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition’, JPGN, 66, pp. 516–554.
Levy, E. I., Hoang, D. M. and Vandenplas, Y. (2020) ‘The effects of proton pump inhibitors on the microbiome in young children’, Acta paediatrica (Oslo, Norway : 1992). Acta Paediatr, 109(8), pp. 1531–1538.