Gastro-esophageal reflux in a child

Question 1

Define gastro-oesophageal reflux.

Answer 1

Involuntary passage of gastric contents into the oesophagus.

Question 2

How common is GOR?

Answer 2

Extremely common in infants

Question 3

What are the reasons for GOR in infancy?

Answer 3

1. inappropriate relaxation of the LOS as a result of functional immaturity
2. predominantly fluid diet
3. mainly horizontal posture
4. short intra-abdominal length of the oesophagus

Question 4

When should GOR resolve in infants?

Answer 4

Resolves sopontaneously by 12 months of age - due to maturation of the LOS, assumption of an upright posture and more solids in the diet

Question 5

What is a typical presentation of GOR?

Answer 5

• Recurrent regurgitation or vomiting (5% of those affected can have 6 or more episodes each day)
• Putting on weight normally
• Otherwise well
• Parents frustrated by frequent changes in clothes, smell, mess.

Question 6

What are the complications of GOR making it GORD?

Answer 6

1. Faltering growth - from severe vomiting
2. Oesophagitis - haematemesis, discomfort on feeding or heartburn, iron-deficiency anaemia
3. Recurrent pulmonary aspiration - recurrent pneumonia, cough or wheeze, aponea in preterm infants
4. Dystonic neck posturing (Sandifer syndrome)
5. Apparent life-threatening events

Question 7

In which children is GOR more common?

Answer 7

• Cerebral palsy/neurodevelopmental disorders
• Preterm infants, especially with bronchopulmonary dysplasia
• Following surgery for oesophageal atresia or diaphragmatic hernia

Question 8

What investigations are done for GOR?

Answer 8

Usually clinical diagnosis but if there is atypical history, complications or treatment resistance consider:

• 24hr oesophageal pH monitoring
• 24hr impedance monitoring
• endoscopy with oesophageal biopsies - identify oesophagitis/exclude other causes
• contrast studies - ?anatomical abnormality

Question 9

What is the management of uncomplicated GOR and prognosis?

Answer 9

Excellent prognosis

Management:

• Parental reassurance
• Add inert thickening agents to feeds e.g. Carobel
• Smaller, more frequent meals

Question 10

What is the management of complicated GOR?

Answer 10

• Acid suppression - hydrogen receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole).
• Consider other diagnoses e.g. CMPA and further investigations
• Surgical (e.g. Nissen fundoplication) - if unresponsive to treatment or oesophageal stricture

Question 11

Is there evidence for use of drugs that enhance gastric emptying in GOR in children?

Answer 11

E.g. domperidone; no evidence and associated with significant side-effects

Question 12

What does Nissen fundoplication involve?

Answer 12

Fundus of stomach is wrapped around the intra-abdominal oesophagus - performed laparoscopically or as an abdominal procedure