GORD

Question 1

what is GORD?

Answer 1

Passage of gastric contents into the oesophagus

Question 2

When is GORD physiological in infants?

Answer 2

when symptoms are absent or not troublesome

Question 3

When is GORD a problem ininfants?

Answer 3

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

Question 4

what is regurgitation?

Answer 4

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

Question 5

when is regurgitation considered normal in infants?

Answer 5

infants younger than 1

Question 6

when is regurgitation a symptom of GOR?

Answer 6

in older children

Question 7

why does GOR occur?

Answer 7

as a result of transient lower oesophageal sphincter relaxation

Question 8

what anatomical and physiological features make GOR more common in infants younger than 1 than older children and adults?

Answer 8

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

Question 9

what are the risk factors for GORD?

Answer 9

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)

Question 10

what is the estimated prevalence of GORD in children?

Answer 10

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

Question 11

what are the complications that occur in children with GORD?

Answer 11

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

Question 12

What is the prognosis of GORD?

Answer 12

usually begins before the age of 8 weeks and resolve before 1 year of age in 90% of infants

Question 13

what is the cause of improvement in regurgitation and GORD?

Answer 13

an increase in length of oesophagus

increase in tone of lower oesophageal sphincter

more upright posture

more solid diet

Question 14

why is it difficult to differentiate between GOR and GORD?

Answer 14

no reliable diagnostic test

Question 15

when should you suspect GORD in infant (up to1 year of age or if child presents with regurgitation and one more of…

Answer 15

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

Question 16

what can children over 1 year of age present with?

Answer 16

heart burn

retrosternal pain

epigastric pain

Question 17

when should you consider sandifer’s syndrome in children with GORD symptoms?

Answer 17

episodic torticollis with neck extension and rotation

Question 18

what should you assess the presence of in a child suspected of GORD?

Answer 18

red flag features: suggest condition other than GOR or GORD

risk factors (premature birth) or complications ( recurrent aspiration pneumonia) increasing likelihood of GORD

Question 19

what should you do after suspecting child of GORD?

Answer 19

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

Question 20

what should you enquire about when suspecting GORD in children?

Answer 20

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

Question 21

what are red flag features that suggest a condition other than GORD?

Answer 21

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

Question 22

what management for breast fed child with GORD in primary care?

Answer 22

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

Question 23

what management for formula-fed child with GORD in primary care?

Answer 23

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

Question 24

what should you prescribe if symptoms remain troublesome despite 1-2 week trial of alginate therapy

Answer 24

consider prescribing 4 week trial of PPI