Gastro-esophageal reflux in a child

Question 1

Define gastro-oesophageal reflux.

Answer 1

Involuntary passage of gastric contents into the oesophagus.

Question 2

How common is GOR?

Answer 2

Extremely common in infants

Question 3

What are the reasons for GOR in infancy?

Answer 3

1. inappropriate relaxation of the LOS as a result of functional immaturity
2. predominantly fluid diet
3. mainly horizontal posture
4. short intra-abdominal length of the oesophagus

Question 4

When should GOR resolve in infants?

Answer 4

Resolves sopontaneously by 12 months of age - due to maturation of the LOS, assumption of an upright posture and more solids in the diet

Question 5

What is a typical presentation of GOR?

Answer 5

• Recurrent regurgitation or vomiting (5% of those affected can have 6 or more episodes each day)
• Putting on weight normally
• Otherwise well
• Parents frustrated by frequent changes in clothes, smell, mess.

Question 6

What are the complications of GOR making it GORD?

Answer 6

1. Faltering growth - from severe vomiting
2. Oesophagitis - haematemesis, discomfort on feeding or heartburn, iron-deficiency anaemia
3. Recurrent pulmonary aspiration - recurrent pneumonia, cough or wheeze, aponea in preterm infants
4. Dystonic neck posturing (Sandifer syndrome)
5. Apparent life-threatening events

Question 7

In which children is GOR more common?

Answer 7

• Cerebral palsy/neurodevelopmental disorders
• Preterm infants, especially with bronchopulmonary dysplasia
• Following surgery for oesophageal atresia or diaphragmatic hernia

Question 8

What investigations are done for GOR?

Answer 8

Usually clinical diagnosis but if there is atypical history, complications or treatment resistance consider:

• 24hr oesophageal pH monitoring
• 24hr impedance monitoring
• endoscopy with oesophageal biopsies - identify oesophagitis/exclude other causes
• contrast studies - ?anatomical abnormality

Question 9

What is the management of uncomplicated GOR and prognosis?

Answer 9

Excellent prognosis

Management:

• Parental reassurance
• Add inert thickening agents to feeds e.g. Carobel
• Smaller, more frequent meals

Question 10

What is the management of complicated GOR?

Answer 10

• Acid suppression - proton pump inhibitors (e.g. omeprazole).
• Consider other diagnoses e.g. CMPA and further investigations
• Surgical (e.g. Nissen fundoplication) - if unresponsive to treatment or oesophageal stricture

Question 11

Is there evidence for use of drugs that enhance gastric emptying in GOR in children?

Answer 11

E.g. domperidone; no evidence and associated with significant side-effects

Question 12

What does Nissen fundoplication involve?

Answer 12

Fundus of stomach is wrapped around the intra-abdominal oesophagus - performed laparoscopically or as an abdominal procedure

Question 13

How do you diagnose colic?

Answer 13

Colic is not a diagnosis but rather a description of a fussy baby. It is defined as >3 hours total crying, for >3 days in any week for >3 weeks. The crying usually occurs in the evenings, without any identifiable cause.

During these episodes, an otherwise healthy infant aged 2 weeks to 4 months is difficult to console, stiffens, draws up their legs and passes flatus. Colic is not usually associated with vomiting. Medical causes (e.g. GOR or CMPA) should be ruled out first.