Overview
Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus and is physiological in infants when symptoms are absent and not troublesome. Gastro-oesophageal reflux disease (GORD) is where there are troublesome symptoms (such as discomfort or pain), and complications.
Epidemiology
- GOR is common and occurs in at least 40% of infants
- The number of children affected by GORD is thought to be small
Risk Factors
- Prematurity – due to an underdeveloped lower oesophageal sphincter
- Neurological disorders
- Developmental delay
Presentation
Reflux after larger feeds is normal in infants (GOR), however, troublesome features or features of distress suggest GORD:
- Distressed behaviour (e.g. excessive crying, crying when feeding, unusual neck postures)
- Unexplained difficulties feeding:
- Reluctance to feed
- Gagging
- Choking
- Chronic cough
- Hoarseness
- Pneumonia
- Poor weight gain
Sandifer’s syndrome
Sandifer’s syndrome describes abnormal movements associated with GOR in children characterised by the following occurring with reflux:
- Torticollis – forceful contraction of the neck causing neck twisting
- Dystonia – muscle contraction leading to arching of the back and twisting movements
If Sandifer’s syndrome is suspected, refer to a paediatrician.
Red flags
The following red flags suggest a condition other than GORD:
- Forceful and frequent projectile vomiting – suggests pyloric stenosis
- Bile-stained (green/yellow-green) vomit – suggests intestinal obstruction
- Abdominal distention, tenderness, or palpable masses – suggests intestinal obstruction
- Blood in vomit – suggests gastrointestinal bleed
- Bulging fontanelle or altered responsiveness (lethargy/irritability) – suggests raised intracranial pressure
- Rapidly increasing head circumference (>1 cm/week), persistent morning headache and vomiting worse in the morning – suggests raised intracranial pressure
- Blood in the stool – suggests gastroenteritis or cows’ milk protein allergy
- Appearing unwell, fever, or dysuria – suggests infection (e.g. pneumonia, UTI)
- Symptom onset after 6 months or persisting after 1 year, suggests a cause other than GOR
Diagnosis and Referral
Overview
- Clinical diagnosis in most cases
Referral
Arrange same-day admission if any of the following are present:
- Haematemesis
- Melaena
- Dysphagia
Refer to a paediatrician or paediatric gastroenterologist if any of the following are present (urgency depends on clinical judgement):
- Uncertain diagnosis or red flag features
- Persistent, faltering growth associated with regurgitation
- Symptoms of GORD not responding to or needing ongoing medical treatment
- Feeding aversion and a history of regurgitation
- Unexplained iron deficiency anaemia
- No improvement in regurgitation after 1 year of age
- Suspected Sandifer’s syndrome
- The presence of any complications (discussed below)
Differential Diagnoses
Physiological gastro-oesophageal reflux (GOR)
- Reflux onset within the first 6 months of life and does not persist after 1 year of life
- No other symptoms are present, no distress, and normal growth
- Regurgitation more commonly occurs after meals and when the infant is lying down horizontally
Pyloric stenosis
- Vomiting is forceful, ‘projectile’-like, and non-bilious
- Usually seen in the first 6 weeks of life
- A palpable upper abdominal mass may be felt
Hirschsprung’s disease
- Abdominal distention and constipation are more prominent and often precede vomiting
- There is usually a history of delayed meconium passage (>48 hours of life)
Intussusception
- Intermittent colicky abdominal pain
- During episodes of pain, the infant may draw their knees up and turn pale
- A sausage-shaped mass may be felt in the upper abdomen
- There may be passage of ‘redcurrant jelly’ stools – usually a late sign
Gastroenteritis
- Reflux occurs more acutely and may be associated with changes in bowel habits
- There may be associated fever
- There may be a history of exposure to people with similar symptoms or foreign travel
Intestinal malrotation
- Presents with bilious vomiting within the first year of life
- Severe abdominal pain out of proportion to examination findings may be present
- The infant may be severely unwell and in shock
Increased intracranial pressure
- Altered consciousness and alertness (e.g. lethargy/difficult to rouse)
- Bulging fontanelles
- Increasing head circumference
- ‘Sun setting’ of eyes
Management
Overview
Provided there are no features warranting referral:
- Small, frequent meals, avoiding overfeeding, and keeping the baby upright after feeding
- Trial alginate therapy (e.g. Gaviscon) or thickened milk or formula
- Consider proton pump inhibitors if any of the following apply:
- Distressed behaviour (e.g. excessive crying, crying when feeding, unusual neck postures)
- Unexplained difficulties feeding:
- Reluctance to feed
- Gagging
- Choking
- Poor weight gain
- If medical treatment is ineffective/symptoms or complications are severe, then surgery via fundoplication may be considered.
Patient Advice
Effortless and non-problematic regurgitation is:
- Very common (40% of infants)
- Usually starts before the infant is 8 weeks old
- May be frequent and usually becomes less frequent with time (up to 6 episodes per day. 90% of cases resolve by 1 year of age) and does not require further investigation or treatment
Complications
Most children with regurgitation do not develop complications, however, GORD is associated with:
- Reflux oesophagitis
- Recurrent aspiration pneumonia
- Recurrent otitis media (>3 episodes in 6 months)
- Dental erosion in a child with neurodisability (e.g. cerebral palsy)
- Apnoea, gagging, epilepsy-like symptoms
Prognosis
- GOR and GORD usually start before 8 weeks of life and resolve in 90% of cases by 1 year
- Symptoms are thought to improve due to an increase in oesophageal length, an increase in lower oesophageal sphincter tone, a more upright posture, and a more solid diet