Dear Ros,

I hope the following is of some help.

I recently attended the 'launch' of the new Enfalac AR modified cows milk
in Brisbane.

There was a guest speaker a paed. called Ross Shepherd from the Royal
Children's Hospital in Brisbane (Australia). Shepherd according to other
nurses at the launch, was THEE authority on reflux.

Here are some of the notes that I took down from his overhead on the night,
not all are complete as he went very quickly, and unfortunately question
time was limited.  As yet I have not come accross any nurses, paeds or
mothers that have used this formula.  If and when I do I will let you know.

Treatment of reflux.

* about 50% of infants aged 2 months regurgitate at least twice/day.

* reflux (GOR - gastric oesophogeal reflux or reguritation) iscaused by
spontaneous relaxation of the lower oesophageal sphincter (LOS)

* LOS improveswith time andmost resolve by 12 months

* approx. 1% develop gastro-oesophageal reflux disease (GORD) with
morbidity/chronic persistant symptoms

Distingusihing features.

Physiological reflux 2-3% >20 episodes - does not need medical treatment.
This is not common in very young babies before 2-3 months.

Only 1% endsup as PAATHOLOGICAL reflux which needs treatment.

Symptoms.

Oesophagitis occurs, crying, may be blood in vomiting and back arching can
occur, SIGNIFICANT sleep disturbance.

What effects 'reflux'.

Frequencey, type and amount of feeds (particularly large volume feeds) plus
posture (especially how the baby is postured during a feed).

Advice to clients regarding reflux.

Affects.

* no long term effects
* most reflux disappears within the first year.
* advice (simple reflux) check position - upright - gravity (approx. 30
degrees upright for cot), small frequent feeds, thicken feeds, change and
loosen nappy prior to feed, position of babe left lateral to prone (yes
prone) with head up (he added after a question about SIDS) prone maybe
under supervision then turn babe onto side/back.

Advice regarding thickened formula.

Reducesinfant regurgitation but not so much with disease (as discussed
above).  Use pre thickened formula or add thickener (e.g. enfalac AR for
infants 3-6 months), small or more frequent feeds on younger babies.  On a
larger child increase the distance between each feed.

Refer client when:

* large amounts of vomiting
* excessive irritability
* weight loss or poor weight gain
* poor feeding
* poor sleep patterns - can go to sleep but wakes within 1-1 1/2 hrs may
then have had a vomit on sheet and crying, may wake 5-7 times/night
(particularly over 6 months of age).

Medication.

Zantac is for oesophagitis and is not suitable for < 8 weeks, and can cause
cause cardiac arrhythmias.

Use a mostility agent such as Cisapride or Motilium (15-20 minutes pre
feed) speeds up oesophageal peristalsis but can give runny stools.

Losec - actson enzyme receptors acts as an antagonist, given as a trial for
3 months.  This medication is given after an endoscopy investigation (but
not always!)

The above recommendations were regardless of breast or bottle feeding with
modified cows milk.

The handout given to the Child Health Nurses on the night, to give to
parents mainly reflected the above adivce.

However, the quote "approx. 50% of infants aged two months regurgitate at
least twice a day" is from a paper by Hyman PJ. Pediatrics 1995 125: S103-8
this quote is a little out of context as it does not say this is 'abnormal'
just that statistically 50% of infants regurgitate this much.

Ross Shepherd does state that thickening the formula will sometimes help
those infants under 3-6 months of age, but he did not state to use
EnfalacAR in particular.  The old use of thickeners that some the the child
health nurses are still recommending are: 1/2 teasp corn flour per bottle
or with a little water prior to a feed

Other handouts from the night from MJ stated:

When using EngalacAR studies showed:

Reflux episodes decreased (by 2.7%)
Infant Crying time decreased (by 6%)
Infant Sleep time increased (by 8%)

References quoted by MJ:

Shepherd RW,Modern Medicine 1991: vol 34/4: 80-86
Orenstein SR in: Wyllie R., Hyams JS eds Pediatric Gastrointestinal
diseases, Pathophysiology, Diagnosis Management, Philadelphia, WB Saunders
Company. 1993 pp 337-369.
Hyman PJ Pediatr 1995: 125(6): S103-S108.
Carre U Arch Dis Child 1985; 60: 71-75
Vandenplas Y et. al Dur J Pediatr 1993; 152: 704-711
Prenstein S et al J Pediatr 1987; 110(2): 181-186
Vanderplas  et. al. Acta Paediatr 85:531-4, 1996

Anne Clarke RN Midwife, IBCLC
Brisbane, Australia
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