CKS GORD in children

NHS Patient information reflux in babies

Gastro-oesophageal reflux disease (GORD)

Troublesome symptoms (such as discomfort or pain) or complications (oesophagitis, pulmonary aspiration or failure to thrive) consequent to gastric contents refluxing into the oesophagus.

It may be difficult to differentiate between gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD) as there is no reliable diagnostic test.

Regurgitation

• Regurgitation is the voluntary and involuntary movement of part or all of the stomach contents up the oesophagus at least as far as the mouth and often emerging from the mouth.

• In infants (younger than 1 year of age), it may be considered entirely normal.

• In older children, it may be a symptom of GORD.

• Regurgitation and GORD usually begin before the age of 8 weeks and resolve in 90% of infants before they are 1 year of age.

Diagnosing GORD (regurgitation PLUS distress or other features)

Suspect GORD in an infant (up to 1 year of age) or child if they present with REGURGITATION and one or more of the following:

• Distressed behaviour shown, for example, by excessive crying, crying while feeding, and adopting unusual neck postures

• Hoarseness and/or chronic cough

• A single episode of aspiration pneumonia

• Unexplained feeding difficulties, for example, refusing to feed, gagging, or choking

• Faltering growth

Risk factors for GORD

• Premature birth.

• Parental history of heartburn or acid regurgitation.

• Obesity.

• Hiatus hernia.

• History of congenital diaphragmatic hernia (repaired) or congenital oesophageal atresia (repaired).

• Neurodisability (such as cerebral palsy).

Complications of GORD

• Distressed behaviour shown, for example, by excessive crying, crying while feeding, and adopting unusual neck postures

• Hoarseness and/or chronic cough

• A single episode of pneumonia

• Unexplained feeding difficulties

• Faltering growth

• Heartburn, retrosternal pain, or epigastric pain (reported by children aged >1yr)

Red Flag features suggesting a condition other than GORD

1. Frequent, forceful (projectile) vomiting
   Suggests hypertrophic pyloric stenosis in infants up to 2 months old.

2. Bile-stained (green or yellow-green) vomit and/or abdominal distension, tenderness, or palpable mass
   Suggests intestinal obstruction or another acute surgical condition (e.g. mid‑gut volvulus from intestinal malrotation)
   Hirschsprung's disease (chronic constipation, absence of ganglion cells in the colon, age <2 months)

3. Blood in vomit (haematemesis) not caused by swallowed blood from a nosebleed or ingested from a cracked maternal nipple
   Suggests an important and potentially serious bleed from the oesophagus, stomach, or upper gut.

4. Dysphagia
   Suggests chronic oesophagitis

5. Bulging fontanelle, altered responsiveness (lethargy or irritability), persistent morning headache and vomiting worse in the morning or rapidly increasing head circumference
   Suggests raised intracranial pressure (meningitis, hydrocephalus or brain tumour).

6. Blood in the stool and/or chronic diarrhoea and/or high risk of, atopy

   Suggest a variety of conditions:
   bacterial gastroenteritis
   non‑IgE‑mediated cows' milk protein allergy

7. Dysuria (and/or fever, irritability, lethargy, jaundice, haematuria, and offensive urine)
   Suggests a urinary tract infection (UTI)

8. Appearing unwell or fever
   Suggests infection.

9. Onset of regurgitation and/or vomiting after 6 months of age or persisting after 1 year of age
   Suggests a cause other than reflux, for example UTI.

Intussusception involves invagination of a portion of the small bowel into another portion of bowel.
It is the most common cause of intestinal obstruction in children six to 36 months of age.
Presents with vomiting, intermittent, progressive abdominal pain, red-currant jelly stools and a palpable sausage-like abdominal mass.

Oesophageal atresia and tracheo-oesophageal fistula
Presents with cough, cyanotic episodes with feeding, respiratory distress, or recurrent pneumonia.
Other defects associated with the VACTERL association may be present, such as vertebral anomalies, anal atresia, congenital heart disease, renal or radial anomalies or limb defects.

Common causes of paediatric vomiting by age of presentation

Management of GORD

Reassure parents that symptoms improve over time.

For breastfed infants:

1. 1–2 week trial of alginate therapy (for example Gaviscon® Infant) and given after each feed

2. 4-week trial of a proton pump inhibitor (PPI, such as omeprazole suspension) or a histamine-2 receptor antagonist (H2RAs, oral ranitidine)

3. Referral to a paediatrician

For formula-fed infants

1. 1–2 week trial of smaller volume, more frequent feeds (while maintaining 150ml/kg body weight daily feed over 6-8 feeds)

2. 1–2 week trial of feed thickeners:

   Pre-thickened formula milk (for example Enfamil AR® and SMA Staydown®), both indicated for a maximum of 6 months, normal teat can be used, or

   Adding a thickener to the usual infant formula (for example Instant Carobel®), a teat with a larger hole or a variable flow (split) will be required.

3. Stop the thickened formula and offer a 1–2 week trial of alginate therapy (Gaviscon® Infant) added to formula.

4. 4-week trial of a proton pump inhibitor (PPI, such as omeprazole suspension) or a histamine-2 receptor antagonist (H2RAs, oral ranitidine).

5. Referral to a paediatrician

Thickened (anti-reflux) infant formula suitable from birthThere are several reasons to be cautious about using these milks:

• These formula contain cereal-based thickeners, and infants do not need anything other than milk in the first few months of life.

• Some anti-reflux formulas are made up at <70C, which may be less ‘antibacterial’ than formulas made up >70 C
  [When making conventional formula milk, it is recommended to use boiled water stood<30min so its temperature stays>70C]

For children aged 1–2 years of age with suspected GORD
4–week trial of  PPI (omeprazole) or H2RA (ranitidine)

Referral to a paediatrician or paediatric gastroenterologist

Same-day admission:

• Haematemesis (not caused by swallowed blood from a nosebleed or ingested from a cracked maternal nipple).

• Melaena (black, foul-smelling stool).

• Dysphagia.

Referral to Paediatrician (urgency depending on clinical judgement)

1. An uncertain diagnosis or 'red flag' symptoms which suggest a more serious condition.

2. Persistent faltering growth associated with regurgitation.

3. Unexplained distress in children with communication difficulties

4. Symptoms not responding to medical treatment

5. Feeding aversion and a history of regurgitation 

6. Unexplained iron‑deficiency anaemia

7. No improvement in regurgitation after age 1yr

8. Suspected Sandifer's syndrome (episodic torticollis with neck extension and rotation)

9. Recurrent aspiration pneumonia

10. Unexplained apnoeas (rarely caused by GORD)

11. Unexplained epileptic seizure-like events

12. Unexplained upper airway inflammation

13. Dental erosion in a child with a neurodisability, in particular cerebral palsy

14. Recurrent acute otitis media (more than three episodes in 6 months)