Paediatric Gastro-Oesophageal Reflux Disease

Harween Dogra, Bhavini Lad and Dinesh Sirisena

Definition

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus.  In most infants with GOR the outcome is benign & self-limiting. ⁽¹⁾

Incidence/Prevalence

Peak incidence of GOR is around 4 months of age, and it resolves spontaneously by 1-2 years of age in most patients. ⁽²⁾

Regurgitation (possetting or spitting up) is the most common presentation in infants with GOR.  Regurgitation of at least one episode a day is seen in:

• 50% of infants 0-3 months
• 67% of infants at 4 months
• 5% at 10 to 12 months of age ⁽³⁾

It is important to note that in infants (younger than 1 year of age) who are otherwise well and symptomatic, regurgitation may be considered entirely normal. ⁽⁴⁾

Causes/Risks

GOR occurs due to the transient, inappropriate relaxation of the lower oesophageal sphincter, which allows the stomach contents to pass into the oesophagus.

GOR can be physiological or pathological:

• Physiological GOR – when the infant has normal weight gain and experiences no complications and is generally well.
• Pathological GOR – also known as gastro-oesophageal reflux disease (GORD) is when reflux is associated with other symptoms like failure to thrive or weight loss, feeding or sleeping problems, chronic respiratory disorders, oesophagitis, haematemesis etc ⁽³⁾

Several anatomical and physiological conditions make infants (younger than 1 year of age) more prone to GORD than older children and adults:

• Short, narrow oesophagus
• Delayed gastric emptying
• Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm
• Liquid diet and high calorie requirements, putting a strain on gastric capacity
• Larger ratio of gastric volume to oesophageal volume⁽⁴⁾

Most children have no specific risk factors for GORD.  Children with the following conditions are at increased risk for developing GORD and for progressing to severe GORD:

• Severe neurological impairment
• Prematurity
• Cystic fibrosis
• Gastro-oesophageal abnormalities (even after surgical repair), e.g. Oesophageal atresia, diaphragmatic hernia, pyloric stenosis
• Bronchopulmonary dysplasia (preterm infants with lung disease)
• Hiatus hernia
• Oesophageal sphincter disorders
• Raised intra-abdominal pressure⁽⁵⁾

Symptoms

GORD in infants and children can present with a variety of symptoms many of which can be relatively non-specific.  Equally, other pathologies may lead to the development of reflux.  Those in the early years tend to be based on observations by parents, while older, more vocal children express symptoms more akin to adult presentations. 

As such, the history/symptoms will be broadly divided into those expected for infants (<1yr), young children (1-5yrs) and older children (>5yrs).

Infants^(6-10)

1. Excessive possetting/regurgitation
   1. Possetting is a normal phenomenon in infants
   2. Frequent episodes, together with vomiting may indicate underlying GORD
   3. Projectile vomiting may indicate an obstructive pathology
2. Difficult/rapid cessation of feeds
   1. There may be difficulty initiating feeds and latching
   2. Early cessation may be precipitated with the onset of reflux
3. Failure to thrive
   1. No weight loss can be expected
   2. Weight loss crossing centiles on the growth chart must be addressed urgently
4. Sleep disturbance
   1. Particularly after an evening feed
   2. This is often associated with irritability and inconsolable crying
5. Irritability and inconsolable crying
   1. One of the commonest presentations to the GP
   2. This may occur during feeds or shortly afterwards
6. Apnoeic episodes
   1. A witnessed pausing in respiratory effort
   2. Occurring at night, it can mimic obstructive sleep apnoea
   3. This may indicate a more serious underlying pathology and requires urgent assessment
   4. It is likely to be more prevalent in this age group

Young Children^(6-10)

1. Regurgitation/vomiting
   1. Beating/rubbing the chest may be an early sign of this pathology
   2. Reflux symptoms can be typical of those in adults
2. Failure to thrive
3. Refusing food
   1. Similar to the infant, however, the younger child can be more vocal in their refusal
4. Abdominal/chest pain
   1. With increasing age, children may demonstrate gastric irritation with abdominal pain
   2. Acid reflux producing oesophagitis may present as chest discomfort
   3. Both are similar to symptoms adults experience
5. Irritability
6. Persistent/nocturnal cough/wheezing
   1. There may be a dry, non productive cough
   2. Secondary to pharyngeal irritation
   3. There may be no co-morbidities or underlying pathologies
   4. Symptoms can be mistaken for asthma by parents

Older Children ⁽⁹⁾

1. Dyspepsia/vomiting
   1. These symptoms in older children are thought to have a similar reliability in diagnosis as in adults
2. Dysphagia/odynophagia
   1. As children become more articulate they may be able to describe these symptoms in relation to meals
   2. Particularly with chronic GORD and the development of a Barrett’s Oesophagus
3. Abdominal/chest pains
4. Persistent/nocturnal coughing/wheezing

Other Symptoms

Symptoms which can be identified but which maybe considered less life-threatening include:

1. Dental erosions
2. Hiccups
3. Halitosis

Those deserving urgent investigation and intervention include:

1. Forceful/Bilious vomiting
2. Suggesting a possible obstructive pathology
3. This requires urgent surgical referral
4. Force of vomiting may not always indicate the severity of the problem
5. Upper gastrointestinal bleeding/hematemesis
6. This may be a consequence of increased pressure from vomiting
7. Similar to a Mallory-Weiss pathology
8. An urgent review by local Paediatric Gastroenterologists is warranted
9. Profuse diarrhoea or constipation
10. Failure to thrive/weight loss
11. Lethargy
12. Apnoeic episodes

Physical Signs

As with the previous section, physical signs will be considered for each age range as above: infants (<1yr), young children (1-5yrs) and older children (>5yrs).

Infants⁽⁹⁾

1. Irritability when lying flat
   1. Particularly following feeds
   2. Especially when supine
2. Weight loss
   1. Regular monitoring with repeat measurements
   2. A single weight cannot imply loss
   3. This is usually a late sign
3. Arching of the back
   1. Secondary to oesophageal irritation
   2. Can be associated with increased tone and crying
4. Dehydration
   1. Loss of fluid through vomiting
   2. Look for
5. Dry mouth
6. Sunken fontanelle
7. Prolonged capillary refill time
8. Reduced skin turgor
9. Reduced urine output
10. Crying without tears
11. Apnoeas
    1. Periods of reduced respiratory effort
    2. Noted by parents as pauses in breathing

Young Children ⁽⁹⁾

1. Weight loss
2. Dehydration
3. Anaemia
   1. Associated with chronic symptoms and gradual loss of iron
   2. Look for Pallor/pale conjunctivae, Glossitis, Angular stomatits, Pica
4. Dysphagia/choking with food
   1. Particularly with prolonged GOR and development of stricturing
5. Difficulty in breathing/wheezing/lower respiratory tract infection (LRTI)
   1. Similar to asthma on examination
   2. Signs of LRTI on auscultation
   3. Possibly stridor

Older Children ⁽⁹⁾

1. Weight loss
2. Dehydration
3. Anaemia
4. Dysphagia/Choking with food
5. Difficulty in breathing/Wheezing/LRTI
6. Persistent sinusitis

Signs requiring urgent intervention include ⁽⁹⁾:

1. Hematochezia
   1. Unaltered blood in stool
   2. Stools take on a red appearance
2. Onset of vomiting after 6 months of life
3. Fever
   1. Uncommon with GOR
   2. Indicating an infective pathology
4. Hepatosplenomegaly
   1. An underlying condition other than GOR is likely
   2. Important pathologies must not be missed
5. Bulging fontanelle
   1. Indicating increased intracranial pressure and an alternative pathology underlying the reflux
6. Macro/microcephaly
   1. Suggestive of hydrocephalus or a congenital malformation
7. Seizures
   1. Related to a number of other problems
   2. Metabolic pathologies should figure highly in any differential diagnosis
8. Abdominal distension with reduced bowel sounds
   1. Tinkling bowel sounds and an pain may suggest bowel obstruction

Differential diagnoses

Common differential diagnoses have been noted in Table 1, however, this is by no means a definitive list of conditions or presentations.  It should be taken as an indication to the diverse presentations that can mimic or precipitate GOR (adapted from ⁽⁹⁾ and ⁽¹⁰⁾).

Table 1

Investigations and management of infants (<1 yr old)

Complicated cases of GORD (not gaining weight/faltering growth or non-GI symptoms e.g. cough), should be referred to a Paediatrician while investigating for causes and instituting simple management.

Simple investigations to do in primary care:

1. Abdominal examination for hernias/pyloric stenosis (test feed)
2. Urine dip to rule out UTI
3. Blood tests for electrolyte abnormalities, coeliac screen (if weaned)

Referral to a Paediatrician will result in imaging investigations such as Abdominal x-ray and upper GI contrast study to rule out malrotation/hiatus hernia/achalasia in older children, sometimes GORD can be seen on contrast studies.   The Paediatrician may go on to arrange a pH/impedance study, upper GI endoscopy or allergy testing.

Management

1. Calculate feed requirements, parents may be over feeding, e.g. approximate fluid requirement 100-120ml/kg/day every 3-6hrs (depending on age and whether weaned on to solids)
2. In thriving infants there is no evidence that pharmacological therapy will make a significant difference to symptoms.
3. Therefore the mainstay of management is reassurance. Simple pharmacological intervention can be tried with feed thickener (in formula fed babies) or Alginates e.g. Gaviscon (can be mixed with water for breast fed babies)
4. If there are continued concerns refer to Paediatrician for on going investigations and management.
5. Recent evidence shows that some infants may have cow’s milk protein intolerance ⁽⁹⁾.  Therefore for breast fed babies the mother could try cutting out dairy from her diet (important to have supervision from dietician re: nutritional requirements while breast feeding).  Formula fed babies can have a 2 week trial of hydrolysed/amino acid based formula e.g. Progestimil, Nutramigen, Neocate.  
6. Reviews from ESPGHAN ⁽⁹⁾ and DTB ⁽¹¹⁾ recommend H2RA (H2 receptor antagonists eg. Ranitidine) may help, though there is little evidence – these could be commenced while waiting for an appointment with the Paediatrician.
7. (Currently there is no role for Domperidone.  The next medication a Paediatrician may try is Omeprazole ± omission of cow’s milk protein) ⁽¹¹⁾

Investigation and management of older children (>18mths)

As before, complicated cases of GORD (not gaining weight/faltering growth or non-GI symptoms e.g. cough), should be referred to a Paediatrician while investigating for causes and instituting simple management.

Investigations

1. Urine dip, if there are symptoms of vomiting
2. Stool H. Pyloti antigen test
3. Bloods tests inc. inflammatory markers, H. Pylori antigen, celiac screen

Management

1. If main symptom heartburn with no evidence of H. Pylori:
2. Reassurance and lifestyle changes (weight loss, dietary changes, timing of meals), up to 4 week trial of PPI (Proton pump inhibitor e.g. lansoprazole, omeprazole).
3. If symptoms improve then continue PPI for up to 6 months, then wean off over 4 weeks (evidence that if stopped suddenly patients may get rebound symptoms) ⁽¹⁰⁾.
4. If PPI doesn’t help or symptoms recur after stopping the PPI, then refer to a Paediatrician.
5. The Paediatrician may investigate with more blood tests e.g. Autoimmune screen, allergy testing, imaging, pH/impedance study, endoscopy.

References

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