Paediatric GORD

ACEM Fellowship

Table of Contents

Introduction

Regurgitation/vomiting need to have alternative diagnoses explored before diagnosing GOR
GOR is a normal physiological phenomenon
- Appear healthy and thriving
- Very few ’crying’ babies will have GORD as the cause
If appears unwell, failing to thrive – Other causes should be considered
Complications can include failure to thrive, reflux oesophagitis, apnoea, aspiration pneumonia and recurrent aspiration with chronic lung disease

Antacids and antisecretory therapies can be helpful
Usually self-resolves in infancy
When complications occur = GORD
Peaks at 4 months of age (2/3 of healthy infants have >1 daily episode of regurgitation
Prevalence decreases from 6-7 months of age
At 12 months, only 5% have any symptoms

In infants, the lower oesophageal sphincter is aboe the diaphragm, rendering the contraction of the diaphragm ineffective in preventing GOR
GOR is unusual over 18 months as this mechanism develops
- Risk factors (Poor oesophageal motility with reduced clearance of refluxed gastric contents leading to complications)
- Premature infants
- Neurological conditions
- Tracheo-oesophageal fistula
- CF
- Down syndrome
- Hiatus hernia
- Pyloric stenosis

Cardinal symptom is regurgitation of milk post-feeds
Usually effortless (as opposed to vomiting)
Careful questioning re:
- Relationship to feeds
- Content e.g. blood/bile
- Associated distress or not
- Feeding behaviour and positioning
Episodic irritability with feeding may be associated with GOR
Screen for poor weight gain, wheezing, apnoea or pulmonary infections
Onset >6 months old is uncommon and suggests an alternative cause

Benign GOR – Appear well
Abdominal distension, abnormal tone, hepatosplenomegaly suggest alternative diagnoses including anatomical abnormalities, neurodevelopmental issues or metabolic disorders
Palpate for pyloric mass in young infants
Respiratory exam to screen for wheeze/creps
Conjunctival pallor suggests anaemia which can be due to reflux oesophagitis
Screen urine for UTI

Infection
Surgical conditions (e.g. malrotation volvulus, pyloric stenosis, intussusception)
Metabolic disorders
Food allergy
Raised ICP

Aspiration with chronic wheeze/cough and pneumonia
Reflux oesophagitis – may have blood in vomitus or anaemia
Failure to thrive
Sandifer syndrome
- Abnormal trunk and neck posturing in response to oesophagitis
- Can be confused with seizures

If well and thriving
- No investigations necessary
If vomiting is predominant
- UTI screen
- VBG – Hypochloraemic metabolic alkalosis from pyloric stenosis
- Pyloric USS
In more severe cases, refer to Paediatrics for consideration of below:
- Barium meal and follow-through to exclude anatomical abnormalities
- Oesophageal pH monitoring over 24 hours
  - Correlation with oesophagitis is weak
  - Good test to confirm severe GOR prior to antireflux surgery
- Radiolabelled milk study to identify aspiration events
- CXR +- CT of chest to assess for chronic lung disease

Reassure that natural history is resolution over months
Unusual to persist beyond 12-15 months
Don’t encourage parents to change formulas
Never change a breastfed child to formula
Simple measures
- Postured feeds (30 degrees head-up)
- Thickening of feeds (reduces vomiting but not total time of oesophageal acidity)
- Partially hydrolysed formula can be trialled for GORD e.g. GOR with FTT
- None of the above are of proven benefit

Pharmacological
- Contraindicated if benign GOR
- If more severe/GORD: PPI have clear evidence of benefit. Omeprazole preferred
- Antacids are less effective and metals/surface agents are unsuitable for infants
- Prokinetics not recommended for infants due to cardiovascular risks
Surgical
- Used in severe GORD with complications
- Nissen fundoplication

Last Updated on November 20, 2021 by Andrew Crofton