GORD Flashcards
Define
GOR = defined as the involuntary passage of gastric contents into the oesophagus
- due to inappropriate relaxation of LOS (functional immaturity) -> most resolve by 12m of age
Baby factors that contribute to reflux:
- Predominantly fluid diet
- Mainly horizontal posture
- Short intra-abdominal length of oesophagus
- Larger ratio of gastric volume to oesophageal volume
- Shorter and lower oesophageal sphincter
- Short narrow oesophagus
EXTREMELY COMMON in infancy but nearly all cases will resolve by 1 year as diet changes, sphincter matures, posture changes.
Symptoms
Most infants with gastro-oesophageal reflux have recurrent regurgitation or vomiting but still put on weight normally and are otherwise well.
- Kinda like a diagnosis of exclusion - only really presents with vomiting in babies
Check if they keep child upright when they feed
Investigations
Usually CLINICAL and NO INVESTIGATIONS are required.
- OBS AND EXAMINATION!
- Hydration status - dry, drowsy, etc.
- Weight
However, possible investigations may include:
* 24-hour oesophageal pH monitoring (should remain mostly above 4)
- 24-hour impedance monitoring (weakly acidic/ nonacidic reflux may cause disease)
- Endoscopy with oesophageal biopsies (identify oesophagitis and exclude other causes)
- Upper GI contrast study (exclude underlying anatomical abnormalities in the oesophagus, stomach and duodenum, identify malrotation)
Red flags
Referral -> SAME DAY referral if haematemesis, melaena or dysphagia present
Assessment by paediatrician if:
Red flag symptoms
1. Faltering growth
2. Unexplained distress
3. Unresponsive to medical therapy
4. Feeding aversion
5. Unexplained IDA
6. No improvement after 1 year of age
7. Suspected Sandifer’s syndrome
Refer if there are complications:
- Recurrent aspiration pneumonia
- Unexplained apnoea
- Unexplained epileptic seizure-like events
- Unexplained upper airway inflammation
- Dental erosion with neurodisability
- Recurrent acute otitis media
Management
Reassure
- It is VERY common, has an excellent prognosis
- Begins early (< 8 weeks) and may be frequent
- It usually becomes less frequent with time
Treatment and investigation is NOT usually needed
Review infant or child if:
- Projectile regurgitation
- Bile-stained vomit or haematemesis
- New concerns e.g. faltering growth, feeding difficulties
- Persistent, frequent regurgitation beyond the first year of life
Initial Management:
If breast fed:
- Carry out breastfeeding assessment
- Going through technique of breastfeeding
- DONE BY HEALTH VISITOR
- If issue persists, consider trial of alginate therapy (i.e. Gaviscon Infant) for 1-2 weeks (stop at intervals to check whether the infant has recovered)
If formula fed:
- Review feeding history
- Reduce feeding volumes for infant’s weight (aim for 150-180mL/kg/day)
- Offer a trial of smaller, more frequent feeds
- Offer a trial of thickened formulas or anti-regurgitant formula
- Offer alginate therapy without feed thickeners if above hasn’t worked
- If unsuccessful then try alginate therapy
Positional:
* Advice about upright positioning during feeds (30o head up) and avoiding overfeeding
* Prone to left-lateral positioning helps but should be used when awake
* Do NOT use positional management in a sleeping infant (they should sleep on their back)
Pharmacological Management:
Consider 4 week trial of PPI or histamine antagonist in children who have ≥ 1 of the following:
* Unexplained feeding difficulties (refusing feeds, choking)
* Distressed behaviour
* Faltering growth
* Consider specialist referral if still no resolution
* Prokinetic agents should only be used with specialist advice e.g. metoclopramide
Mnemonic (order):
G Gaviscon (a form of alginate therapy)
O Omeprazole
M metoclopramide (specialist care)
Last Resort Options
- Enteral feeding (if failure to thrive)
- Nissen fundoplication: The fundus of the stomach is wrapped around the intra-abdominal oesophagus / Abdominal or laparoscopic procedure
- If the child fails to respond to these measures, other diagnoses e.g. cow’s milk protein allergy should be considered
NOTE: surgical management is reserved for children with complications unresponsive to intensive medical treatment or oesophageal stricture
Complications
Faltering growth from severe vomiting
Oesophagitis- haematemesis, discomfort on feeding or heartburn, iron-deficiency anaemia
Recurrent pulmonary aspiration- recurrent pneumonia, cough or wheeze, apnoea in preterm infants
Frequent otitis media
In older children, dental erosion may occur
Dystonic neck posturing (Sandifer syndrome)
- combination of gastro-oesophageal reflux disease with spastic torticollis (a condition in which the head becomes persistently turned to one side) and dystonic body movements with or without hiatal hernia
Apparent life-threatening events
PACES
Name of Diagnosis:
Baby Nidhi Eason has a condition called gastro-oesophageal reflux disease
Briefly explain what it is:
One of the muscles in your son’s food pipe has not fully matured, therefore feeds can come back up as you have noticed
This is very common for children of this age, and usually resolves by 1 year of age
How is it managed:
We will get the health visitor to come and assess your breastfeeding technique and give you some support and advice
If there is improvement with this, we can give you something called alginate therapy for 2 weeks
This will him to hold down his feeds and hopefully he should not get the symptoms
review feeding history à smaller, more frequent feeds à thickeners ± alginate therapy
Risks/Safety net
If you find that this still doesn’t help, then please do come and see us or your GP again, and we can offer you trial of formula feeds specifically designed for GORD
keep an eye on the vomitus (if it’s blood-stained or green seek medical attention)
Leaflets/Offer more information:
Does this all make sense? Do you have any questions?
