Explaining gastro-oesophageal reflux disease (GORD) to parents is a common OSCE scenario and therefore it’s worth practicing the salient points you need to convey. Below is a general guide to this station, with the key points and communication skills you should demonstrate.
Establish why present, check understanding and ask what they want to find out
Take history if required.
“First of all try not to worry, this is common in infants…the majority of cases will resolve on their own given time, and can be easily helped in the meantime.“
Gastro-oesophageal reflux: non-forceful regurgitation of milk into the oesophagus.
In children under 1 year of age
Oesophageal sphincter not yet fully developed (allows stomach contents to reflux)
Made worse by posture –lying down most of the time
Short oesophageal length
Even more common in Cerebral palsy, Down’s syndrome and premature infants
Older than 1 year of age
Usually grow out of it.
Lower oesophageal sphincter strengthens
Child spends more time upright
Eats more solid food
“When you swallow, food goes down the food pipe (oesophagus) into the stomach. At the bottom of the food pipe there is a ring of muscle which opens and closes to let food into the stomach. In young babies this muscle is not fully developed and sometimes may not completely close off, which means milk can come back up, especially as baby is often lying down.”
“By the age of 1, this usually stops happening – this is for a variety of reasons – because the muscle has had chance to develop, the baby spends more time sat up/upright, and they are eating rather than just drinking.”
If mild (growth ok, no LRTIs/oesophagitis):
No further investigation
Reassure – consider thickening, earlier introduction of solids, 95% resolve by 18 months
Avoid overfeeding – consider increasing frequency and decreasing quantity
Avoid fizzy drinks, caffeine and orange juice
Feed upright then place baby 30 degrees head up prone position after feed
If above steps are unsuccessful
Add thickening agents (Nestargel or Carobel)
Can also give antacids (e.g. Gaviscon Infant)
If more severe/no improvement:
Domperidone – speed up passage of food through stomach
Ranitidine – to reduce stomach acid production
Oesophagitis– Proton pump inhibitor (PPI) – e.g. omeprazole
If severe – aspiration (chest infections) / FTT / oesophagitis (vomit with blood)
Further investigation required – e.g. endoscopy
“As I mentioned at the beginning, this is common and baby is managing to maintain a healthy weight and growing well. To reduce their symptoms, there are a few simple changes we can add in. To begin with, we prefer to avoid medication and would suggest that when you feed baby, you do so at a more upright angle, so they are half-sat up; and to keep them resting at this angle for half an hour or so to help encourage the milk to go down. Feeding them smaller amounts, more regularly may help, too.”
“If you find these methods do not seem to help, and you are still concerned we can discuss using thickeners in baby’s milk –these just help to make the milk a little heavier, and stay in the stomach – or consider some medication such as gaviscon. If baby starts to lose weight, or gets more distressed by the sickness we can consider other medication and doing some investigations, to check everything is okay with their tummy.”
Blood tests – Hb/ Urea / WCC / CRP
24 hr oesophageal pH monitoring test – a thin wire is passed down the nose into the lower oesophagus – gives indication of severity of regurgitation
Barium studies – looks for structural abnormalities
Endoscopy – allows direct visualisation of structural abnormalities / oesophagitis
If failing to thrive it is important to seek further help.
Recurrent chest infections (aspiration) or bringing up blood (oesophagitis) needs further investigation.
Closing the consultation
“In summary – the symptoms that your baby is getting at the moment are due to milk coming back up from the stomach after they have had a feed, and is something which is quite common in young babies. This should reduce as time goes on and as baby grows, but in the meantime you may find it useful to sit baby up after feeds for a little while to help the milk go down, to give smaller and more regular feeds, and to try a thickener or adding baby rice to the milk.”
“If this doesn’t seem to be helping, we can give baby some medication – Gaviscon – to help ease any discomfort that they get from the acid. We can do some investigations and there are a few medications that we can try, and if necessary or if baby is struggling we can consider surgery – but this is very rarely required.”
Establish parental understanding, any questions?
“Does everything I’ve said so far make sense?”
“Do you have any questions for me?”
Provide an information leaflet if possible
“This condition is quite common, and as baby is still growing well it is not something to be too concerned about. However if things don’t seem to be settling, or baby starts losing weight, coughing blood or getting chesty, it is important to bring them back in as we will need to do some further tests.”
“I would like to see you again in a few weeks to see how you and baby are doing with some of the changes we have discussed. In the meantime, if you have any concerns or further questions, please feel free to contact me or the GP practice.”