Gastro-oesophageal reflux disease is a when the gastro-oesophageal reflux leads to symptoms that are severe enough to warrant treatment. The gastro-oesophageal reflux itself is a normal physiological mechanism that occurs in infants and adults like. It starts prior to 8 weeks in around 40% of infants due to immaturity of the lower oesophageal sphincter (LES). This allows stomach contents to be regurgitated back into the oesophagus. With maturation of the oesophagus, around 90% of infants stop having reflux by 1 year.
Pathophysiology
In infants less than 1-year-old, there are certain factors that make them more susceptible to reflux, such as:
- Delayed gastric emptying
- Shorter and lower LES that is above the diaphragm
- Large quantities of liquid feeds
- Gastric volume much higher than oesophageal volume
- Infants tend to be lying down a lot
⚠️ Risk factors
- Prematurity
- Parental history of GORD
- Obesity
- Hiatus hernia
- Congenital diaphragmatic hernia or oesophageal atresia
- Neurodisability (such as cerebral palsy)
😷 Presentation
Signs and symptoms that the child is distressed and that the reflux is problematic are:
- Chronic cough
- Hoarse cry or distress and crying after feeding.
- Reluctance to feed
- Pneumonia
- Failure to thrive
Children over 1 year may experience symptoms similar to that of an adult (heartburn, acid regurgitation, epigastric/retrosternal chest pain, bloating and nocturnal cough).
🔍 Investigations
⭐️ It is a clinical diagnosis based on history from parent/carers. We do not need to do invasive testing at this stage.
In infants, it should be suspected in those who have regurgitation + at least 1 of the following:
- Distressed behaviour (excessive crying, crying while feeding, abnormal neck posturing)
- Hoarseness and/or chronic cough
- Pneumonia (a single episode is sufficient)
- Unexplained feeding difficulties
- Faltering growth
In children over 1 year it should be suspected if they have:
- Heartburn
- Retrosternal or epigastric pain
🧰 Management
Infants with GORD:
- Breastfed → 1-2 week trial of Gaviscon Infant
- Formula-fed → 1-2 week trial of the following options (sequentially if they don’t work):
- Reduction of volume of feeds
- More frequent feeds
- Thickened feeds such as Instant Carobel (a thickening agent)
- Gaviscon Infant
- If treatment is successful, continue treatment for 2 weeks and stop it every 2 weeks to see if symptoms improve.
- If, in both cases, treatment with Gaviscon Infant is not successful, we can do a 4-week trial of omeprazole or an H2 antagonist (such as cimetidine or ranitidine).
- If still unsuccessful → refer for specialist assessment.
Children aged 1-2 years old with GORD:
- 4 week trial of omeprazole or an H2 antagonist (such as cimetidine or ranitidine).
- If unsuccessful → refer for specialist assessment.