Gastro_Oesophageal_Reflux_in_Children_Flashcards
What is the commonest cause of vomiting in infancy?
Gastro-oesophageal reflux.
What percentage of infants regurgitate their feeds to a certain extent?
Around 40% of infants.
What are the risk factors for gastro-oesophageal reflux in children?
Preterm delivery, neurological disorders.
When does gastro-oesophageal reflux typically develop?
Before 8 weeks.
What are the features of gastro-oesophageal reflux in children?
Vomiting/regurgitation, milky vomits after feeds, may occur after being laid flat, excessive crying especially while feeding.
How is gastro-oesophageal reflux in children diagnosed?
Diagnosis is usually made clinically.
What are the management steps for gastro-oesophageal reflux in children based on the 2015 NICE guidelines?
Advise regarding position during feeds - 30 degree head-up, infants should sleep on their backs to reduce the risk of cot death, ensure infant is not being overfed and consider a trial of smaller and more frequent feeds, trial of thickened formula, trial of alginate therapy (e.g., Gaviscon).
When should a proton pump inhibitor (PPI) be considered for treating gastro-oesophageal reflux in children?
If there are unexplained feeding difficulties, distressed behaviour, or faltering growth.
What was previously used as an alternative to a PPI for gastro-oesophageal reflux and why was it withdrawn?
Ranitidine was previously used but was withdrawn in 2020 due to small amounts of the carcinogen N-nitrosodimethylamine (NDMA) being discovered in products from a number of manufacturers.
When should prokinetic agents (e.g., metoclopramide) be used for gastro-oesophageal reflux in children?
Only with specialist advice.
What are the complications of gastro-oesophageal reflux in children?
Distress, failure to thrive, aspiration, frequent otitis media, dental erosion in older children.
What may be considered if there are severe complications of gastro-oesophageal reflux and medical treatment is ineffective?
Fundoplication.
A woman brings her six-week-old son to see his general practitioner. The boy has been vomiting white ‘stuff’ after feeds, and also often cries whilst being breastfed. He has no diarrhoea or bloody stools. He was born at 35 weeks by ventouse delivery.
What is the most likely diagnosis?
Coeliac disease
Cow’s milk protein intolerance/allergy
Duodenal atresia
Gastro-oesophageal reflux
Gastroenteritis
Gastro-oesophageal reflux
Infant < 8 weeks, presents with milky vomits after feeds, often after being laid flat, excessive crying → ? GORD
Gastro-oesophageal reflux is the most likely diagnosis. This is indicated by the combination of milky vomits after feeds and crying with feeds, in an infant under eight weeks. Risk factors include preterm delivery, which is seen in this case.
Coeliac disease is incorrect as this usually presents when children are introduced to cereals. However, this child is being exclusively breastfed. It would also be more likely to present with diarrhoea and failure to thrive.
Cow’s milk protein intolerance/allergy is incorrect. This can lead to regurgitation, vomiting and irritability but this is not the most likely diagnosis because it is typically seen in formula-fed infants. Although it can rarely be seen in exclusively breastfed infants, you would expect it to be accompanied by other features such as diarrhoea and atopy. Gastro-oesophageal reflux is therefore the more likely diagnosis.
Duodenal atresia is incorrect as it causes bilious vomiting in neonates, a few hours after birth. This child is six-weeks-old and has white vomitus, and therefore unlikely to have duodenal atresia.
Gastroenteritis is unlikely as the mother has not reported any diarrhoea. Additionally, the timing of the vomits straight after feeds points to gastro-oesophageal reflux.
summarise GORD in children
Gastro-oesophageal reflux in children
Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes.
Risk factors
preterm delivery
neurological disorders
Features
typically develops before 8 weeks
vomiting/regurgitation
milky vomits after feeds
may occur after being laid flat
excessive crying, especially while feeding
Diagnosis is usually made clinically
Management (partly based on the 2015 NICE guidelines)
advise regarding position during feeds - 30 degree head-up
infants should sleep on their backs as per standard guidance to reduce the risk of cot death
ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
ranitidine was previously used as an alternative to a PPI but was withdrawn from the market in 2020 as small amounts of the carcinogen N-nitrosodimethylamine (NDMA) were discovered in products from a number of manufacturers.
prokinetic agents e.g. metoclopramide should only be used with specialist advice
Complications
distress
failure to thrive
aspiration
frequent otitis media
in older children dental erosion may occur
If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered
