Gastro oesophageal reflux

Introduction

Gastro oesophageal reflux (GOR) is passage of gastric contents from the stomach into the oesophagus with or without regurgitation and/or vomiting. ^1,2,3,4,5

GOR is common and benign in children, ² is self-resolving in large majority and does not need treatment.^1,2,3,4 Onset is generally in first few weeks of life; usually peaks around four months and is far less pronounced after six months of age in neurodevelopmentally normal children as the weaning foods are introduced, infant starts sitting up and spends more time awake.^{1, 2} It usually resolves by 12-18 months of age. ^{1, 2, 3} 

Considerations

Infants with GOR may be difficult to settle ^1,2,3,4. Differential diagnoses for vomiting and irritability should always be considered.^{1, 5} 

In addition to vomiting and irritability, these children may also have behaviours that might suggest GOR.^{1, 2, 3} These include back arching, difficulty feeding including food refusal and restless/disturbed sleep.^{1, 2, 3, 4}

The term Gastro Oesophageal Reflux Disease (GORD) is used when the reflux leads to troublesome symptoms and /or complications such as oesophagitis or recurrent aspirations or failure to thrive.^{1, 2} Symptoms such as hematemesis, chronic cough and wheeze may indicate GORD though other differential diagnoses need to be considered.¹ P

ersistence of GOR beyond infancy is more frequent in children with conditions such as neurodevelopmental disabilities, Down’s syndrome, cystic fibrosis and upper gastrointestinal malformations.^{1, 5} 

General Principles of Management

• Gentle burping for few minutes after breast or bottle feeding is recommended.² 
• Change from breast feeding to formula or change from one formula to another is not necessary in GOR.^{1, 3} 
• If the infant is gaining excessive weight, consider overfeeding as a cause of vomiting rather than GOR. ^{1, 5} 
• Try smaller and more frequent feeds. ^{1, 2}
• Reassure parents. ^{1, 2, 3, 4, 5}
• For irritable and unsettled infants, consider referral to Ngala or similar centres.
• In GOR, antacids such as omeprazole (proton pump inhibitor) and ranitidine (H2 receptor antagonists) are not required as they have side effects.⁴
• Though feed thickeners available across the counter at pharmacy can be tried, ⁵ there is no evidence they are effective and they may cause constipation. ^{1, 2, 3} 
• Consider head elevation or left lateral lying position only when infant is awake.⁵
• Keeping the head elevated while the infant is asleep may be a sleep safety hazard. ^{1, 2} 
• Monitor weight gain and development. ^{4, 5} 

When to refer

Please send growth charts and information on examination findings and developmental status with your referral letter. 

Referral to a paediatrician is recommended if the child is likely to have GORD.^{2, 3, 4} In such cases, a 4-8 week trial of a proton pump inhibitor may be appropriate.⁵

The treating paediatrician may consider referral to a gastroenterologist for opinion and consideration if GORD is refractory to treatment. ^{2, 3, 4} 

References 

1. Gastrooesophageal reflux in infants, RCH guideline. 
2. Reflux in babies-bringing milk up. Parenting and Child Health-Health topics 
3. Reflux (GOR) and GORD. RCH guideline. 
4. Reflux. The Sydney Children’s Hospitals Network. 
5. Paediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), Rosen R et al. Journal of Pediatric Gastroenterology & Nutrition. 2018 March ; 66(3): 516–554. 

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