Explaining paediatric GORD

Question 1

How would you explain GORD to a parent?

Answer 1

When you swallow, food goes down the food pipe, called the oesophagus, and 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, which means milk can easily move from the stomach back up into the food pipe and mouth.
Babies also spend a lot of time lying flat, which also makes it easier for milk to travel from the stomach back into the food pipe and mouth.

By the age of 1, reflux will have resolved in approximately 90% of infants. This spontaneous resolution occurs because the ring of muscle above the stomach becomes increasingly stronger, preventing the backflow of milk into the food pipe.
After the age of 1, children also typically spend more time upright and eat a diet that consists of solid, both of which reduce the likelihood of reflux occurring.

Question 2

What is the typical management of GORD in breastfed infants?

Answer 2

• 1-2 week trial of alginate therapy (Gaviscon Infant)
• If symptoms improve periodically stop treatment (every 2 weeks) to see if symptoms have improved and if it is possible to stop treatment completely

Question 3

What is the typical management of GORD in formula-fed infants?

Answer 3

• Reduce the volume of feeds if they are excessive for the child’s weight (~150 ml/kg over 24h is recommended)
• Offer a 1-2 week trial of smaller, more frequent feeds whilst maintaining an appropriate total daily amount of milk
• Offer a 1-2 week trial of feed thickeners
• If previous steps are unsuccessful, stop the thickener and offer a 1-2 week trial of alginate therapy. If symptoms improve after the trial continue with the treatment and suggest stopping the treatment at regular intervals to see if symptoms have improved

Question 4

How do you manage infants unresponsive to first-line treatments?

Answer 4

• Consider a 4-week trial of a PPI (omeprazole) to reduce stomach acid production
• If symptoms persist despite all of the above steps, refer to paediatrics

Question 5

How would you explain the management of paediatric GORD to a parent?

Answer 5

“The first thing I’d suggest we try is a 1-2 week trial of smaller, more frequent feeds of around 6-8 times a day, still making sure that your baby gets an appropriate total amount of milk over a 24 hour period.”

“If we don’t see any improvement, we could try a 1-2 week trial of adding a thickening agent to the formula milk which makes the milk heavier and more likely to stay in the stomach.”

“If we still don’t see much of an improvement, we could consider a 1-2 week trial of Gaviscon which is a medication that neutralises stomach acid.”

“If the Gaviscon medication doesn’t seem to be improving symptoms, we could consider a 4 week trial of a medication that reduces the amount of acid the stomach produces.”

“If despite all of these options, the reflux was still troublesome, I would refer you to a paediatrician to consider some further tests and treatment.”

“Although in most cases reflux resolves on its own over time, it’s important to be aware of some rare but serious symptoms that, if present, would require your baby to be reviewed urgently in hospital. These symptoms include your baby’s stools turning black or the presence of blood in their vomit. If either of these symptoms were to develop, we would need to arrange same-day admission to the hospital.”