Gastro-Oesophageal Reflux

Question 1

What is gastro-oesophageal reflux (GORD)?

Answer 1

Gastro-oesophageal reflux is where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.

Question 2

Why are babies susceptible to GORD?

Answer 2

In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents. This usually improves as they grow and 90% of infants stop having reflux by 1 year.

Question 3

What are the clinical features of GORD?

Answer 3

It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:

• Chronic cough
• Hoarse cry
• Distress, crying or unsettled after feeding
• Reluctance to feed
• Pneumonia
• Poor weight gain

Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.

Question 4

Give examples of causes of vomiting in children

Answer 4

Vomiting is very non-specific and is often not indicative of underlying pathology. Some of the possible causes of vomiting include:

• Overfeeding
• Gastro-oesophageal reflux
• Pyloric stenosis (projective vomiting)
• Gastritis or gastroenteritis
• Appendicitis
• Infections such as UTI, tonsillitis or meningitis
• Intestinal obstruction
• Bulimia

Question 5

What are the clinical features of GORD?

Answer 5

• Not keeping down any feed
• Projectile or forceful vomiting
• Bile stained vomit
• Haematemesis or melaena
• Abdominal distention
• Reduced consciousness, bulging fontanelle or neurological signs
• Respiratory symptoms
• Blood in the stools
• Signs of infection
• Rash, angioedema and other signs of allergy
• Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment

Question 6

What may not keeping down any feed indicate?

Answer 6

Pyloric stenosis or intestinal obstruction.

Question 7

What may projectile or forceful vomiting indicate?

Answer 7

Pyloric stenosis or intestinal obstruction.

Question 8

What may bile stained vomit indicate?

Answer 8

Intestinal obstruction.

Question 9

What may haematemesis or melaena indicate?

Answer 9

Peptic ulcer, oesophagitis or varices.

Question 10

What may abdominal distention indicate?

Answer 10

Intestinal obstruction.

Question 11

What may reduced consciousness, bulging fontanelle or neurological signs indicate?

Answer 11

Meningitis or raised intracranial pressure.

Question 12

What may respiratory symptoms indicate?

Answer 12

Aspiration and infection.

Question 13

What may blood in the stools indicate?

Answer 13

Gastroenteritis or cows milk protein allergy.

Question 14

What may signs of infection indicate?

Answer 14

Pneumonia, UTI, tonsillitis, otitis or meningitis.

Question 15

What may rash, angioedema and other signs of allergy indicate?

Answer 15

Cows milk protein allergy.

Question 16

Briefly describe the management of GORD in children

Answer 16

In simple cases some explanation, reassurance and practical advice is all that is needed. Advise:

• Small, frequent meals
• Burping regularly to help milk settle
• Not over-feeding
• Keep the baby upright after feeding (i.e. not lying flat)

More problematic cases can justify treatment with

• Gaviscon mixed with feeds
• Thickened milk or formula (specific anti-reflux formulas are available)
• Ranitidine
• Omeprazole where ranitidine is inadequate

Rarely in severe cases they may need further investigation with a barium meal and endoscopy. Surgical fundoplication can be considered in very severe cases, however this is very rarely required or performed.

Question 17

Briefly describe Sandifer’s Syndrome

Answer 17

This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:

• Torticollis
  
  • Forceful contraction of the neck muscles causing twisting of the neck
• Dystonia
  
  • Abnormal muscle contractions causing twisting movements, arching of the back or unusual postures

The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good. It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.