GORD - Children
Definition: Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is considered physiological in infants when symptoms are absent or not troublesome. GORD in children is the presence of troublesome symptoms or complications.
Risk factors
Parental history of heartburn or acid regurgitation
Obesity
Premature birth
Hiatus hernia
History of congenital diaphragmatic hernia
History of congenital oesophageal atresia
Neurodisability
When to suspect
single episode of pneumonia
Unexplained feeding difficulties eg refusing to feed, gagging or choking
hoarseness and/or chronic cough
Faltering growth
Distressed behaviour eg excessive crying, Crying while feeding or adopting unusual neck posture
Assessment
Examination if usually normal and largely guided by working diagnosis.
Examine chest, check temperature, palpate abdomen, review head circumference measurements to exclude alternative diagnosis including intercranial pathology. Assess growth using centile charts.
Ask about: age when symptoms started, crying when feeding, frequency/estimated volume of regurgitation and vomiting, any respiratory symptoms or signs, episodes of apnoea, persistent back arching.
Take a feeding history, and ensure that a person with appropriate expertise and training (for example a health visitor) conducts a feeding assessment.
Assess for red flags, risk factors/complications
Red flags
Bulging fontanelle or altered responsiveness - raised intracranial pressure
Rapidly increasing head circumference, persistent morning headache and vomitting worse in the morning - raised intracranial pressure
Blood in vomit - important/potentially serious bleed
Blood in stool - variety of conditions.
Abdominal distention, tenderness or palpable mass - intestinal obstruction
Chronic diarrhoea - cows milk protein allergy
Bile-stained vomit - suggests intestinal obstruction
Frequent, forceful vomiting - hypertrophic pyloric stenosis in infants up to two months
With, or at high risk, atophy - cows milk protein allergy
Onset of regurgitation and/or vomiting after 6 months of age or persisting after 1 year of age - cause other than reflux.
Appearing unwell or fever - suggests infection
Management
Reassure parents and carers that in well infants, effortless regurgitation of feeds: is common, usually begins before the infant is 8 weeks old, usually becomes less frequent with time, does not usually require further investigation.
Provide sources of additional infromation.
Refer to paediatrician is suspected recurrent aspiration pneumonia, unexplained apnoeas, unexplained epileptic seizure like events, unexplained upper airway inflammation, recurrent acute otitis media.
Review if regugitation becomes persistent, bile-stained vomiting, new concerns, persistent, frequent regurgitation beyond the first year of life.
Arrange specialist assessment - uncertain diagnosis, red flag symptoms which suggest more serious cause, persistent faltering growth, unexplained distress, symptoms suggesting GORD not responding to treatment, feeding aversion and a history of regurgitation, no improvement after 1 year of age.
Treatment dependant on age and breastfeed/not breast fed.
Arrange same day admission for haematemesis, melaena or dysphagia.