GORD Flashcards
what is GORD?
Passage of gastric contents into the oesophagus
When is GORD physiological in infants?
when symptoms are absent or not troublesome
When is GORD a problem ininfants?
it is the presence of troublesome symptoms (discomfort or pain) or complications (oesophagitis or pulmonary aspiration) arising from GORD
adults: GORD refers specifically to reflux oesophagitis
what is regurgitation?
it is the voluntary and involuntary movement of part or all of the stomach contents up the oesophagus at least as far as the mouth and often emerging from the mouth
when is regurgitation considered normal in infants?
infants younger than 1
when is regurgitation a symptom of GOR?
in older children
why does GOR occur?
as a result of transient lower oesophageal sphincter relaxation
what anatomical and physiological features make GOR more common in infants younger than 1 than older children and adults?
short, narrow oesophagus
delayed gastric emptying
shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm
liquid diet and high caloric requirement putting strain on gastric capacity
larger ratio of gastric volume to oesophageal volume
infants frequently recumbent
relatively large quantities of liquid feeds
what are the risk factors for GORD?
premature birth
parental history of heart burn or acid regurgitation
obesity
hiatus hernia
history of congenital diaphragmatic hernia
history of congenital oesophageal atresia
neurodisability (cerebral palsy)
what is the estimated prevalence of GORD in children?
UK cross sectional study conducted in primary care estimated the incidence of GORD to be 0.9% in children younger than 13 years of age
what are the complications that occur in children with GORD?
reflux oesophagitis
recurrent aspiration pneumonia
recurrent acute otitis media (more than 3 episodes in 6 months)
dental erosion in a child with neurodisability (cerebral palsy)
rarely apnoea orapparent life threatening events (episodes of combinations of apnoea, colour change, change in muscle tone, choking, and gagging that are sometimes considered missed sudden infant death syndrome)
MOST CHILDREN WITH REGURGITATION DO NOT DEVELOP COMPLICATIONS
What is the prognosis of GORD?
usually begins before the age of 8 weeks and resolve before 1 year of age in 90% of infants
what is the cause of improvement in regurgitation and GORD?
an increase in length of oesophagus
increase in tone of lower oesophageal sphincter
more upright posture
more solid diet
why is it difficult to differentiate between GOR and GORD?
no reliable diagnostic test
when should you suspect GORD in infant (up to1 year of age or if child presents with regurgitation and one more of…
distressed behaviour: excessive crying, crying whilst feeding and adopting unusual neck postures
hoarseness and/or chronic cough
single episode of pneumonia
unexplained feeding difficulties: refusing to feed, gagging or choking
faltering growth
what can children over 1 year of age present with?
heart burn
retrosternal pain
epigastric pain
when should you consider sandifer’s syndrome in children with GORD symptoms?
episodic torticollis with neck extension and rotation
what should you assess the presence of in a child suspected of GORD?
red flag features: suggest condition other than GOR or GORD
risk factors (premature birth) or complications ( recurrent aspiration pneumonia) increasing likelihood of GORD
what should you do after suspecting child of GORD?
feeding history
ensure a person with appropriate expertise and training (health visitor) conducts feeding assessment
breastfeeding: advice given to mother with regards to breastfeeding technique, positioning and attachment
bottle fed: ask about type of formula used, how it is prepared, frequency of feeding and volume consumed
any resistance or refusal to feed should be noted
what should you enquire about when suspecting GORD in children?
age of infant or child when symptoms started -
crying whilst feeding
any respirations symptoms or signs
any episodes of apnoea or any apparent life-threatening events (RARE)
frequency and estimated volume of regurgitation and vomiting
characterstics of vomit : effortless spitting up to1 or 2 mouthfuls of stomach contents normal
what are red flag features that suggest a condition other than GORD?
frequent, forceful (projectile) vomiting suggesting hypertrophic pyloric stenosis in infants up to 2 months
bile stained (green or yellow-green) vomit suggests intestinal obstruction
abdominal distension, tenderness or palpable mass suggests intestinal obstruction or another acute surgical condition
blood in vomit (not caused by swallowed blood from nose bleed or ingested from a cracked maternal nipple) suggests important and potentially serious bleed from the oesophagus, stomach or upper gut
bulging fontanelle or altered responsiveness(lethargy) suggests raised intracranial pressure
rapidly increasing head circumference suggests raised intracranial pressure
blood in stool
chronic diarrhoea
dysuria
appearing unwell or fever suggests infection
dysuria suggests UTI
what management for breast fed child with GORD in primary care?
frequent regurgitation and marked distress: consider prescribing 1-2 week trial of alginate therapy (gaviscon infant)
if symptoms improve, continue with treatment, advise parent to stop treatment at regular intervals to see if symptoms have improved
what management for formula-fed child with GORD in primary care?
review feeding history then reduce volume of feeds only if excessive for childs weight
offer 1-2 week trial of smaller, more frequent feeds
offer 1-2 week trial of feed thickeners
what should you prescribe if symptoms remain troublesome despite 1-2 week trial of alginate therapy
consider prescribing 4 week trial of PPI
