Gastro-oesophageal Reflux in a Child (GORD in a child)

Question 1

Define GORD in a child.

Answer 1

Abnormal retrograde flow of gastric contents from stomach into oesophagus.

Question 2

Explain the aetiology/risk factors of gasto-oesophaegeal reflux.

Answer 2

Normal in infants (60–70% have physiological reflux), predisposing factors include:

• Supine position
• Short + straight intra-abdominal length of oesophagus (affecting angle of His = angle between gastric cardia + distal end of oesophagus)
• Immature lower oesophageal sphincter (LES) function with multiple transient relaxations
• Primarily milk diet

Question 3

Explain the aetiology/risk factors for gasto-oesophageal reflux.

Answer 3

When reflux frequency + duration produce Sx. Common mechanisms:

• Delay in neurological maturation (e.g. preterm infants)
• Neurological impairment (CP, hypoxic ischaemic encephalopathy, trisomy 21)
• Excessive frequent spontaneous reductions in sphincter pressure (crying, coughing or defecating)

Question 4

What is GORD associated with?

Answer 4

Cow’s milk intolerance

Hiatus hernia

Oesophageal atresia

Question 5

Summarise the epidemiology of GORD.

Answer 5

1 in 3000 infants

Often overdiagnosed due to difficulty differentiating physiological from pathological reflux.

Question 6

What are the general signs and symptoms of GORD?

Answer 6

Wide range of clinical presentations, ranging from mild irritation to severe disease depending on degree of reflux. Respiratory symptoms may be the first complaint.

General: Feeding avoidance (associating feeding with discomfort) or constant eating/ drinking (milk is alkali), irritability (discomfort of acid indigestion), failure to thrive, tooth enamel decay, may present with ALTEs.

Question 7

What are the gastrointestinal signs and symptoms of GORD in a child?

Answer 7

Difficulty/pain on swallowing

Frequent spitting up or vomiting hours after feed

Haematemesis

Gastric/ abdo/ retrosternal pain.

Question 8

What are the respiratory signs and symptoms of GORD?

Answer 8

Apnoea

Intermittent stridor

Recurrent chest infections

Question 9

What are some appropriate investigations for GORD?

Answer 9

24-hour pH monitoring of the oesophagus: Calculated reflux index (time at which the lower oesophagus is pH < 4).

Impedance testing: More sensitive technique for testing small changes in pH levels by measuring resistance to electrical currents within oesophagus. Detects non-acid reflux

Contrast studies: Upper GI tract to exclude anatomical abnormalities, reflux can be demonstrated.

Endoscopy: Confirms oesophagitis, biopsies of the lower oesophagus, fundus and the duodenum.

Question 10

What is a management plan for GORD?

Answer 10

Conservative: Time + reassurance unless child is exhibiting failure to thrive. Thickened feeds, reduced volume, increased frequency of feeds, position infant upright for 30 minutes after feeding.

Medical: H2-antagonists with prokinetic (ranitidine + domperidone) used with symptomatic infants or confirmed GORD with 24-h pH study/contrast/OGD.

Surgical

Question 11

What is the surgical management for GORD in children?

Answer 11

Only with children who have failed conservative/medical management. Fundoplication performed is either complete (Nissen 360) or partial (Toupet 180 or Belsey/Thal 270).

May involve the placement of a gastrostomy and the laparoscopic approach can be used. In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter.

Question 12

What are the possible complications associated with GORD?

Answer 12

General: FTT, Sandifier Syndrome (GORD + dystonic torticollis) GI: Oesophagitis, peptic stricture, Barrett’s oesophagus

Respiratory: Aspiration that can lead to infection

Question 13

What is the prognosis for GORD?

Answer 13

As the lower sphincter matures with age, 60% resolve by 6m