Gastro-Oesophageal Reflux Disease

 

GORD is effortless retrograde movement of gastric contents upward into the esophagus or oropharynx.

Mild ‘spitting up’ in young infants is common, doesn’t affect weight gain or cause respiratory problems. Physiological reflux does not always need treatment.

Differentiate this from ‘Vomiting’, which is a forceful-active movement, with retching, sweating and pallor.

 

Factors contributing to GORD:

– Liquid meals in horizontal position

– Frequent, large volume feeds (or overfeeding)

– Immature lower esophageal sphincter (LES)

 

Most infants grow out of GORD by 9- 12 months of age as they:

– Spend more time upright

– Eat more solid foods & less volume

– Larger and more compliant stomach

 

Clinical presentation

Enquire detailed feeding historyfrom birth

– Breastfed / bottle fed; changes to feed over time

– Current volume offered each time & number of feeds per day

– Estimate daily volume intake, accept 130 – 180ml/kg/day

– Excess feeding volume (e.g. > 200ml/kg/d) and rapid weight gain suggests overfeeding

Behavior during feeding: choking, gagging, cough, arching, discomfort, refusal of feed. Excess crying or becoming unsettled after feeds?

 

Explore reflux symptoms

– Minor ‘spitting up’ or posseting only?

– Refluxing after most feeds? Including overnight? (concern if >4/d)

– Estimate volume of reflux each time

– Is there ‘vomiting’- bilious? Projectile?

 

Is growth affected?

Any constipation / diarrhea / blood in stools

Recurrent respiratory symptoms?

Sandifer’s syndrome- reflux with sudden neck retraction or rotation

Any red flags* or high-risk* features?

 

GORD in older children

– Recurrent upper abdominal pain, heartburn, nausea

– Bad breath / dental enamel issues

– Can sometimes describe regurgitation with foul taste in mouth

– Wheeze/ hoarseness of voice

– Recurrent otitis media

 

Examination

Assess growth, hydration

Alertness, active movements

Inspect palate & tongue movements

Abdominal examination including hernia sites

 

Red flag features

– Unwell: febrile; lethargic; tachypnoeic, non-blanching rash

– Bulging fontanelle, rapidly increasing head size, headaches

– Recurrent LRTI (? Aspiration from silent reflux)

– Apnoeas / Acute Life Threatening Events

– Frequent, forceful (projectile) vomiting

– Bilious vomiting / haematemesis

– Blood in stool

– Dysphagia

– Abdominal distension / palpable mass

– Atopy / Family h/o atopy

– Late onset GORD

 

High-risk group:

– Neuromuscular diseases (with hypertonia / hypotonia)/ chronic disability

– Preterm babies (especially with Chronic lung disease)

– Repaired GI anomalies- Tracheo-oesophageal fistula, Congenital Diaphragmatic hernia

– Obesity

 

Investigations (only if persisting symptoms or complications)

Generally not required, as GORD is a clinical diagnosis

Barium swallow / meal- look for malrotation, hiatus etc

USS abdomen if suspecting pyloric stenosis

24-hour esophageal pH / impedance probe monitoring

Upper GI endoscopy to look for oesophagitis, stricture etc

 

Treatment

Healthy young infants (“well-nourished, happy spitters”) require no medical treatment.

 

Non-drug interventionsinclude

Reduce feeding volume if overfed

Try smaller and frequent feeds

Slight upright position during feeds

Trial of thickener (e.g. rice starch, Carobel, Thick & Easyetc)

Weight management in children with Obesity

 

Antacids– Ranitidine, Omeprazole are the mainstay in managing most infants with GORD

Prokinetic drug like Domperidoneis sometimes helpful

Extensively Hydrolysed Formula, if suspecting Cow’s Milk Protein Intolerance

Surgical interventions like Fundoplication/ Jejunostomy may help, especially in neuromuscular conditions

 

Refer to Specialist if:

– Red-flag or high-risk features

– Unexplained feeding difficulties / swallow incoordination

– Poor weight gain

– Poor response to initial treatment

– Recurrent LRTI / otitis media

– Dental enamel problems due to GORD

– Persisting symptoms beyond 1 year age