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Gastro-Oesophageal Reflux in Children

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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:

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:

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

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