GORD

Question 1

a 3 month old boy has had recurrent and frequent vomiting from one month of age. Over the last month he has become intermittently irritable, especially when lying flat. He continues to thrive.

Answer 1

Impression
With frequent vomits, notably when lying down, my impression is that this may represent Gastro-oesophageal reflux disease. Of course, reflux is physiological in many infants and typically resolves by one year of age, this may be the case given the child continues to thrive and is mainly irritable when lying flat. Notably, I would want to rule out more sinister causes of this presentation such as pyloric stenosis, other GIT (malrotation, volvulus, intussusception), and other causes for vomiting including infection, raised ICP, and food intolerances (CMPI/FPIEs).

DDx
- intolerance: CMPI/FPIES
- obstructive:
- non-GIT: raised ICP

Goals
- Conduct Hx/Ex/Ix to rule out serious differentials and distinguish GORD from physiological reflux, and to assess for evidence of complications of vomiting including dehydration
- Engage in parent education about normal reflux, refer to paeds gastro if evidence of GORD for definitive management.

Question 2

GORD - History

Answer 2

History
- vomiting: frequency, volume, colour and consistency, projectile vs posits? Chronic cough/wheeze? relieved when upright?
- sx: irritability, grizzly, dehydration, neuro signs (tone, floppy)
- REDS: slow weight gain, haematemesis, FTT, sleeping disturbance
- feeding hx: amount, type, frequency, volume
- paeds hx: growth, blue book, obstetric details, development since birth, any other issues?
- fam hx

Question 3

GORD - Examination

Answer 3

Examination
- General appearance + vitals
- abdominal examination: tenderness/discomfort/distension, REDS (olive-mass in RUQ, visible peristalsis)
- Hydration status assessment

Question 4

GORD - Investigations

Answer 4

Investigations
Nil required for phsyiological/GORD, clinical diagnosis.

Consider bloods if concern for malnutrition/dehydration and electrolyte derangements
- labs: UEC, LFT, FBC
- Imaging: abdo US for pyloric stenosis if concerned

Referral to paeds gastro for further GORD workup;
- endoscopy
- barium swallow

Question 5

GORD - Management

Answer 5

Management
Given likely gastro-oesophageal reflux, mainstay of treatment is conservative management and parent education.

Supportive
- parent education: normal, physiological, typically completely resolves by one year
- safety netting: when to return: FTT, haematemesis, non-resolving, etc
- smaller, more regular feeds, keep upright where possible esp after meals, not proning during sleep, provide thickened feeds (anti-reflux formula) or add thickening agent to breast milk

Definitive (if GORD)
- referral to paediatrics
- further investigation for CMPI/other food interolerances
- trial of PPI (omeprazole). if no benefit, cease at 4 weeks