Uncomplicated gastro-oesophageal reflux is common in infancy with regurgitation in at least one episode a day being found in at least half of all infants aged 0-3 months. When this is associated with symptoms it is termed G.O.R.D, gastro-oesophageal reflux disease.
Reflux is probably a combination of a relative immaturity of the Lower Oesophageal Sphincter, the predominantly recumbent position of babies, and a liquid diet. In older children, as in adults it is commonly associated with an inappropriate relaxation of the sphincter.
By 12-18 months, most symptoms have resolved. Most children with G.O.R.D will present in the first year of life, but there are some who present later with symptoms of heartburn, regurgitation, or dysphagia.
Risk factors of G.O.R.D
- Cerebral palsy, and neurodevelopmental conditions
- Congenital oesophageal anomalies such as T.O.F.
- Recurrent regurgitation or vomiting
- Epigastric pain often presenting as distress after feed, behavioural problems, feed aversion,and faltering growth
- Respiratory problems such as chronic cough
- Screaming often with back arching
- Sandifer's syndrome torticollis, or dystonic neck movements
- Faltering growth
- Feeding difficulties
- Cows milk allergy. This can be difficult. Hypoallergenic feeds are often used in management empirically
- Eosinophilic oesophagitits
- Routine bloods
- 24h pH study, often unreliable in babies due to milk feeds. Many now prefer impedance pH manometry
- Barium meal to exclude underlying abnormalities such as malrotation
- Endoscopy when oesophagitis is suspected
- Check for allergy, particularly dairy
- Mild reflux in an otherwise well baby who is growing adequately and free of complications
- Reassurance may be all that is needed
- Simple feeding advice such as avoid overfeeding, try increasing frequency of feeds and decreasing feed volume
- Positioning such as a left lateral position
When simple measures fail. Feed thickening with agents such as carobel.
For older children life style changes such as small frequent volume meals. Low fat foods. Avoid excessive carbonated drinks.
Sleep with a slight head up positioning. Try to avoid more pillows, but better to use blocks beneath the head end of the bed.
For more significant reflux medical treatment, help should be sought by a Paediatrician or Paediatric Gastroenterologist. Currently there is very little evidence based therapy. The ESPGHAN criteria of management gastro-oesophageal provide a very useful guide.
H2 – receptor antagonists relieve symptoms and may help healing.
Pro kinetic agents such as metoclopramide/domperidone / low dose erythromycin may also be helpful in addition in severe cases. These assist in gastric emptying.
The use of proton pump inhibitors has become widespread. These should only be prescribed by paediatricians. Long term use should be reviewed regularly. It is worth noting that in adults it is advisable to gradually reduce the dose rather than stopping abruptly to avoid a rebound effect.
The use of many changes of feed is not recommended. However many guidelines suggest a change of feed to a hypoallergenic one if medical management seems to be failing.
Surgical management such as fundoplication is rarely recommended. This is reserved for those children with severe complications of reflux in spite of adequate medical treatment. The complications of this type of surgery include exacerbation of vomiting and nausea. This is due to delayed gastric emptying and distension.
For severe cases that require tube feeding ijejeunal feeding is becoming more frequently used to avoid fundoplication.