Functional gastrointestinal disorders

Re­gur­gi­ta­tion, con­sti­pa­tion and colic are the most com­mon func­tional gas­troin­testi­nal dis­or­ders. They often cause parental anx­i­ety and avoid­able feed­ing changes (1, 2, 3). Stud­ies prove that 55% of in­fants under six months of age suf­fer from gas­troin­testi­nal dis­com­fort and 39% of these in­fants ex­pe­ri­ence a com­bi­na­tion of symp­toms.

Re­gur­gi­ta­tion

Al­most all in­fants bring up small amounts of milk after a feed, whether they are breast fed or bot­tle fed. Re­flux, re­gur­gi­ta­tion, pos­set­ing or spit­ting up is com­mon in in­fants; as long as the baby is oth­er­wise happy, healthy and gain­ing weight, there’s gen­er­ally no cause for con­cern. Daily re­gur­gi­ta­tion has a preva­lence of about 87% at two months of age (4). These in­fants are re­ferred to as ‘happy spit­ters’ – a tem­po­rary, non-se­ri­ous prob­lem that usu­ally gets bet­ter as the baby’s di­ges­tive sys­tem ma­tures.

Non-clo­sure of the pro­tec­tive one-way valve at the ­upper end of the stom­ach (known as the lower esophageal sphinc­ter or LES) is re­spon­si­ble for regur­gitation. In in­fants, this LES is not yet fully ma­ture, which al­lows stom­ach con­tents to flow back­ward via the oe­soph­a­gus (the con­nect­ing tube) to the mouth. Dur­ing the first year of life, the sphinc­ter ac­tion ­gradually gets stronger and the chance of re­gur­gi­ta­tion ­decreases. The terms re­flux and re­gur­gi­ta­tion are often used in­ter­change­ably. In med­ical terms, how­ever, this con­di­tion is called Gas­tro-Oe­sophageal Re­flux (GOR). GOR can also be caused by the method of feed­ing. An ex­ces­sive amount of food in the stom­ach or swal­low­ing of air, caused by ex­ces­sive drink­ing, can lead to in­creased stom­ach pres­sure. This can re­sult in cramps or back­flow of food in the stom­ach. GOR is com­mon in young in­fants be­cause their gas­troin­testi­nal tract is still de­vel­op­ing.

"The re­duc­tion in episodes and vol­ume of re­gur­gi­ta­tion is a wel­come im­prove­ment in qual­ity of life for in­fants and care­givers."

Com­plaints of re­gur­gi­ta­tion are known to peak at the age of three to four months. Dur­ing this pe­riod they occur in 50% to 70% of in­fants. Re­gur­gi­ta­tion re­solves spon­ta­neously in most healthy in­fants by 12 to 14 months (5, 6). Par­ents view the symp­tom as a prob­lem more often than med­ical in­ter­ven­tion is given. About 25% of the par­ents seek med­ical help be­cause of in­fant re­gur­gi­ta­tion (2, 5).

Re­gur­gi­ta­tion oc­curs as often in breast-fed as bottle-­fed chil­dren. Be­cause it fre­quently leads to parental anx­i­ety, re­as­sur­ing the par­ents and of­fer­ing prac­ti­cal ad­vice on the cor­rect drink­ing tech­nique and the dis­tri­b­u­tion of feeds over the day (offer small amounts reg­u­larly) can help. Sev­eral stud­ies show that in for­mula-fed in­fants, an AR for­mula de­creases the fre­quency and vol­ume of re­gur­gi­ta­tion (9). AR for­mula con­tains carob bean gum, which thick­ens the for­mula and sub­sequently re­duces re­gur­gi­ta­tion, along with added pre­bi­otics (GOS) – mak­ing it safe and ef­fec­tive.

Hard stools and/or associated cramps

Like regurgitation, hard stools (mild constipation) and cramps (colics) are a common complaint in infants.

Hard stools or mild constipation are defined as difficult defaecation, lasting for two or more weeks. It occurs in 15% of the infants younger than 12 months. In infants younger than four months, the type of feeding has a key role in the stool pattern. Every infant has its own bowel pattern; the baby’s individual pattern depends on what it eats and drinks, how active it is, and how quickly it digests food. It seldom occurs with breast feeding and is more common with forumla feeding (8).

Any extreme changes affecting the infant may cause a decreased frequency of stools or may harden stools. Firm or hard stools are often seen when changing from breast milk to an infant formula or after the introduction of solid food. It takes some time for the infant’s bowel to get used to new food. Another cause can be illness with fever or a reduced food/fluid intake, which produces a disturbed fluid balance. As with regurgitation, the first step in treatment is always parental education. It should be pointed out that hard stools are a common and non-dangerous problem in infancy that usually disappears. For bottle feeding, it is important that the formula is prepared correctly (right amount of powder and water) and the daily fluid intake is appropriate.

Hard stools may occur in combination with colic. Colic and colic pains or cramps are characterised by stomach pain and often accompanied by excessive crying. Infants usually communicate and express themselves by crying. By the time parents visit the doctor with their crying child, they are often anxious, frustrated, and sleep-deprived. The crying and fussiness can last for hours at a stretch, followed by periods when the baby acts and seems perfectly comfortable. The crying episodes tend to increase at six weeks of age and occur mostly in the late afternoon. The cause of infantile colic is generally unknown but there is increased evidence that it is related to a food allergy, an altered gastro-intestinal function, microflora imbalance, GOR or cow’s milk allergy (9). Colic affects 20% of babies worldwide and impacts breast-fed and bottle-fed infants equally (2, 8). The condition usually resolves spontaneously by the age of about four months.

Carob bean gum: safe & effective

In addition to thickening properties that reduce regurgitation, AR formula with carob bean gum also has prebiotic properties that have a relieving effect on hard stools and/or associated colic. Added galacto-oligosaccharides (GOS) are prebiotics in the form of a fermentable fibre that stimulates the growth of ‘good bacteria’ (bifidobacteria and lactobacilli) in the gut. This results in an increased stool volume and softness. In general, it creates a better gut motility. That’s why this formula is also well suited to infants who suffer from hard stools and/or associated cramps.

Further information

• Short article "Regurgitation Olivias Story"
• Overview "Carob bean gum"
• Article "Prebiotics in infant formula – part 1"
• Article "Prebiotics in follow-on foods – part 2"
• Overview "Specialist formula"

Sources
1) Iacono G., et al. The Pediatric Study Group on Gastrointestinal Symptoms in Infancy. Gastrointestinal symptoms in infancy: a population-based prospective study. Dig Liver Dis 2005;37:432-438.
2) Vandenplas Y., et al. Prevalence and health outcomes of functional gastrointestinal symptoms in infants from birth to 12 months of age. J Pediatr Gastroenterol Nutr 2015;61:5:531-37.
3) Zeevenhooven J., et al. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatr Gastroenterol Hepatol Nutr 2017;20(1):1-13.
4) Vandenplas Y., et al. Practical algorithms for managing common gastrointestinal symptoms in infants. Nutrition 2013;29(1):184-194.
5) Dupont C., et al. Efficacy and tolerance of a new anti-regurgitation formula. Pediatr Gastroenterol Hepatol Nutr 2016;19(2):104-109.
6) Vandenplas Y., et al. 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). J Pediatr Gastroenterol Nutr 2009;49(4):498-547.
7) Nelson S.P., et al. Prevalence of symptoms of gastro-esophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med; 1997;151: 569-572.
8) Vandenplas Y., et al. Updated algorithms for managing frequent gastro-intestinal symptoms in infants. Beneficial Microbes 2015;6(2):199-208.
9) Miranda, A. Early life stress and pain: an important link to functional bowel disorders. Pediatric Annals 2009;38:279-282.