Paediatric Gastro-oesophageal Reflux Disease

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Introduction

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is considered physiological when asymptomatic or not troublesome to the patient.1

Gastro-oesophageal reflux disease (GORD) is when the passage of gastric contents into the oesophagus causes symptoms (e.g. discomfort or pain) or complications.1

Regurgitation of feeds is common and occurs in at least 40% of infants.2 It usually begins before 8 weeks old and will resolve before they turn one year old.2

You might also be interested in our medical flashcard collection which contains over 1000 flashcards that cover key medical topics.

Aetiology

There is no singular cause for GORD. However, patients may be more likely to have the condition due to anatomical and physiological differences.3

Anatomical conditions may include where the oesophagus is shorter or narrower than average or if the lower oesophageal sphincter is slightly above the diaphragm rather than below it.

The most common physiological cause involves the natural weakness of the lower oesophageal sphincter, allowing the passage of stomach contents involuntarily. It typically resolves by 1-year-old as the sphincter naturally strengthens.


Risk factors

Risk factors for GORD in infants include:

  • Prematurity: the incidence of GORD is even higher in preterm infants, particularly if the infant has a feeding tube
  • History of congenital diaphragmatic hernia or oesophageal atresia
  • Hiatus hernia
  • Neurodisability (e.g. cerebral palsy)
  • Parental history of heartburn or acid regurgitation

Clinical features

History

GORD is a clinical diagnosis. It is essential to distinguish between typical symptoms and red flags that may suggest an alternative diagnosis.3

Typical symptoms of GORD if the child is <1 include:

  • Time taken to feed >30 minutes
  • Distressed behaviour during meal times (e.g. crying while feeding or refusing to feed)
  • Hoarseness and/or chronic cough
  • Faltering growth

Typical symptoms of GORD if the child is >1 include:

  • Retrosternal pain
  • Epigastric pain
Red flags

Red flag features which may suggest an alternative diagnosis and require urgent specialist assessment include:

  • Persistent symptoms despite management of GORD or age above >1
  • Non-bilious, projective vomiting in children 2- 6 weeks: suggests hypertrophic pyloric stenosis
  • Abdominal distension/pain: may indicate intestinal obstruction, tinkling bowel sounds may be heard when auscultating.

For more information, see the Geeky Medics guide to paediatric history taking.

Clinical examination

In the context of suspected GORD, it is important to perform a thorough examination of the child, including:

  • Basic observations (vital signs): in particular, the child’s temperature will help to exclude other acute differentials (e.g. infection).
  • Head circumference: Using a Lasso-O, the child’s head circumference should be measured and plotted to help exclude other worrying patterns (e.g. faltering growth)
  • Respiratory examination: respiratory symptoms or signs. Children may have a single episode of pneumonia with GORD, but recurrent episodes should prompt further investigations.
  • Abdominal examination: usually normal. If any positive examination findings are found, other differentials should be considered.

Differential diagnoses

Differential diagnoses to consider in the context of suspected GORD include:

  • Anatomical disorders: cleft lip/palate and ankyloglossia (tongue tie)
  • Gastrointestinal disorders: cow’s milk protein allergy (CMPA), coeliac disease and lactose intolerance.

If there is a sudden change in feeding habits, an acute cause (e.g. infection) should be excluded.


Investigations

GORD is a clinical diagnosis and does not usually require further investigations.1

If the child is breastfed, a feeding assessment by a health visitor is beneficial. Health visitors can advise on breastfeeding techniques and attachment.

A feeding history, exploring the history and examination above, should be taken to exclude red flags which require specialist assessment.

Children should be charted on a growth chart to exclude other causes of faltering growth.


Management

It is important to explain the diagnosis of GORD to the parents or carers of the child.

Subsequent feed alterations will depend on whether they are breastfed or formula-fed.

If the child is breastfed, alginate therapy (e.g. Gaviscon infant) can be used for 1-2 weeks.Β 

If the child is formula fed, then a stepwise approach is used:

  • Reduce the volume of feed if excessive for the child’s weight
  • Keep infant upright after feeding for up to 30 minutes
  • Raising the head of the infant’s cot: positioning the child in this position allows the use of gravity as the stomach contents remain below the chest rather than refluxing upwards
  • A 1-2 week trial of smaller, more frequent feeds
  • A 1-2 week trial of adding Gaviscon to the usual feed
  • A 4-week trial of a proton pump inhibitor (e.g. omeprazole) or a histamine-2 receptor antagonist (e.g. ranitidine)

Referral to a paediatrician should be made if there are any red-flag features or if the child remains symptomatic >1 year old.


Complications

Most children who have GORD will not develop complications. However, complications may include:

  • Reflux oesophagitis
  • Recurrent aspiration pneumonia
  • Recurrent acute otitis media (more than three episodes in 6 months)

Key points

  • GORD involves the passage of gastric contents into the oesophagus causing problematic symptoms and/or complications.
  • It typically resolves in most infants by one year old and is more common in premature infants.
  • GORD is a clinical diagnosis, with feeding histories and clinical assessments helping to determine management.
  • Management of GORD includes reassurance, adjusting the child’s feed and using thickeners.
  • Complications are rare but may include oesophagitis, aspiration pneumonia and recurrent otitis media.

Reviewer

Dr Shakirat Balogun

Paediatric Registrar


Editor

Dr Chris Jefferies


References

  1. NICE CKS. Management of gastro-oesophageal reflux disease in children. Published February 2019. Available from: [LINK]
  2. BMJ Best Practice (2022). Disorders of infant feeding. Available from: [LINK]
  3. Dogra H, Bhavini L, Sirisena D. Paediatric Gastric-Oesophageal Reflux Disease. British Journal of Medical Practitioners. BJMP 2011;4(2):a412.

 

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