1. Paediatric Gastroesophageal Reflux
INTRODUCTION
Definitions: Gastro-oesophageal reflux (GOR) is the physiologic passage of gastric contents into the oesophagus and gastro-oesophageal reflux disease (GORD) as reflux associated with troublesome symptoms or complications.
GOR occurs at least two thirds1 of infants and is considered a normal process with regurgitation or spitting up occurring in 50%2 of all infants.
GORD has been shown to be less common in breastfed infants and incidence peaks at 4 months (50%) declining over time with 5-10% affected by 12 months2.
GORD RISK FACTORS
Preterm
Neurologic Impairment
Oesophageal Atresia
Hiatus Hernia
Achalasia
Respiratory Disorders
Cystic Fibrosis
Bronchopulmonary Dysplasia
Interstitial Fibrosis
PRESENTATION & WARNING SIGNS
Table 1 outlines presentation by different ages
Extraoesophageal symptoms are seen and can include: cough, wheeze, recurrent pneumonia, sore throat and dental erosions
Concerning signs in a vomiting child:
Bilious Vomit, Haematemesis, Projectile Vomiting, Bulging Fontanelle, Seizures, Tender/Distended abdomen.
These indicate a more serious underlying primary cause for vomiting and suggest GORD is less likely in a differential diagnosis.
TABLE 1: Common symptoms seen in GORD
Infant
Ages 1-5
Older Children
Regurgitation
Irritability
Anorexia
Heart Burn
Feed Refusal
Abdominal Pain
Dysphagia
Sleep Disturbance
Epigastric Pain
Poor Weight Gain
Sour Burps
Arching of Back
Respiratory
MANAGEMENT4
Breastfed Infant: Expert assessment of feeding and advise
Consider 4 Week Trial of H2 antihistamine/PPI if:
Presence of other troublesome symptoms unclear e.g. in infants.
Unexplained feeding difficulties such as gagging or choking.
Distressed behavior/ Faltering growth
Heartburn/epigastric pain
If H2/PPI Unsuccessful:
Refer to a specialist if paediatrician is concerned.
Surgical interventions are rarely required.
Formula Fed Infant: Consider altering feeds; reducing volume, small volume with increased frequency, or thickened formula
Unsuccessful
= Lifestyle Management
Unsuccessful
= Medical Management
Alginate Trial – 1/2
Unsuccessful
Unsuccessful
Refer to specialist – possible endoscopy and restart H2/PPI if reflux oesophagitis confirmed
= Surgical Management
Successful
Continue with alginate, stop at intervals to see if infant has recovered
N.B. Do not use positional management for sleeping infants, keep them on back
TAKE HOME MESSAGES
Regurgitation is common in infants and usually resolves by the age of 1. Reassurance to parents is key as there are no specific diagnostic tests to determine the presence of GORD vs GOR.
Always look out for the more concerning signs in an infant who presents with regurgitation/vomiting.
Inexpensive interventions such as lifestyle modifications as initial treatment. Do not prescribe acid suppressing drugs in regurgitation alone.
Upper gastrointestinal radiology is not to be used in the diagnosis or severity assessment of GORD.
REFERENCES
Nelson SP, Chen EH, Syniar GM, Christoffel KK; Pediatric Practice Research Group. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Arch Pediatr Adolesc Med. 2000;154(2):150–154.
Rudolph CD, Mazur LJ, Liptak GS, et al; North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32:S1–S31.
Sherman PM, Hassall E, Fagundes-Neto U, et al. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol. 2009;104(5):1278–1295.
Davies I, Burman-Roy S, Murphy MS, Guideline Development Group. Gastro-oesophageal reflux disease in children: NICE guidance. BMJ. 2015; 350: 7703.