Synonyms: childhood GORD, GERD, reflux oesophagitis

Definition

Gastro-oesophageal reflux is the non-forceful regurgitation of milk and other gastric contents into the oesophagus.
It should be distinguished from vomiting which is an active process, requiring the forceful contraction of diaphragm and abdominal muscles. It occurs where there is incompetence of sphincter of the gastro-oesophageal junction or where raised intragastric or intra-abdominal pressures exist sufficient to overcome this mechanism.

Physiological, asymptomatic reflux occurs in all adults and children but is infrequent (<5% of any 24-hour period, mostly occurring postprandially). Gastro-oesophageal reflux disease (GORD) is said to occur when reflux is persistent, more frequent and gives rise to troublesome symptoms or complications.¹

Epidemiology

Approximately 85% of infants reflux and vomit during the first week of life and another 10% have symptoms by six weeks of age. Reflux is most common between one and four months old, but sometimes it persists in teenagers.

• Uncomplicated gastro-oesophageal reflux is common in infancy, with regurgitation of at least one episode a day found in half of all infants aged 0-3 months, in a cross-sectional study.² Peak "problematic" regurgitation occurs at about six months and is reported in approximately a quarter of infants this age. This is due to the functional immaturity of the lower oesophageal sphincter.
• By 12-18 months, most symptomatic reflux will spontaneously resolve as the sphincter matures, the infant adopts an upright posture and begins having a more solid diet.³ Most children with GORD will present in the first year but there are some who present later with symptoms of heartburn, acid regurgitation or dysphagia.

Other sources report the prevalence of pathological GORD in infants as being between 2-10%.³

Risk factors for GORD²

• Immaturity of lower oesophageal sphincter
• Chronic relaxation of lower oesophageal sphincter
• Increased abdominal pressure
• Gastric distension
• Hiatus hernia
• Oesophageal dysmotility
• Prematurity
• Cerebral palsy or other severe neurodevelopmental problems
• Congenital oesophageal anomalies

Presentation

Presenting symptoms include:

• Recurrent regurgitation or vomiting
• Epigastric and abdominal pain (often presenting as distress after feeds, behavioural problems, feeding difficulties and failure to thrive)
• Witnessed episode of choking or apparent life-threatening event³

Complications of GORD include:

• Oesophagitis (with haematemesis, anaemia or stricture formation)
• Respiratory problems (e.g. cough, apnoea, recurrent wheeze, and aspiration pneumonia)
• Feeding and behavioural problems and failure to thrive

Sandifer's syndrome is where reflux episodes are associated with dystonic neck movements (torticollis or opisthotonus).⁴

Diagnosis

In the majority of cases, this is made clinically, based on the history of effortless vomiting occurring after meals.
Where the history is less clear or where symptoms are more severe, investigation may be required.

Differential diagnosis

Consider congenital hiatus hernia, gastroenteritis, pyloric stenosis, urinary tract infection.

Investigations

• FBC
• 24-hour ambulatory oesophageal pH study - usually will show frequent dips in pH <4
• Barium meal - to exclude underlying anatomical abnormalities in the oesophagus, stomach and duodenum
• Endoscopy - where oesophagitis is suspected
• CXR - where aspiration is suspected

Management^1,2,3

General measures

Mild reflux in an otherwise well baby who is growing adequately and free of complications:

• Reassurance (benign condition, likely to resolve spontaneously)
• Simple feeding advice (avoid overfeeding, try increasing frequency and decreasing volume of feeds)
• Positioning - left lateral after feeding appears to improve oesophageal pH variables

Pharmacological

When simple measures fail to reduce reflux:

• Feed thickening (with agents such as Carobel®) may be helpful. Breast-fed infants can be given the thickener mixed to a paste prior to their feed. However, RCT evidence supporting or refuting this measure is lacking.⁵ Sometimes Infant Gaviscon® is mixed with food.
• Older children should be advised about lifestyle changes (avoiding provoking foods, weight reduction) and may be helped by an alginate-containing antacid.
• For more significant reflux or reflux-associated complications, advice from a paediatrician is usually required.
• H2-receptor antagonists (H2RAs) relieve symptoms of GORD and promote mucosal healing.
• Proton pump inhibitors (PPIs) are used in infants and children with moderate, non-erosive oesophagitis that is not responding to an H2RA. Endoscopically-confirmed erosive oesophagitis is usually treated with a PPI. Symptoms should be reassessed after 4-6 weeks and long-term treatment without full assessment of the underlying condition should not be undertaken.
• It has been argued that the mechanism of reflux in infants is such that prokinetic agents are a more logical form of treatment than acid suppression.⁶ However, the problem is what to use. The BNF does not recommend metoclopramide in children and young adults because of extrapyramidal effects. Domperidone is less troublesome but is not recommended in those weighing less than 15 kg. Due to reports of fatal cardiac arrhythmias or sudden death, from July 2000 cisapride was restricted to a limited access programme supervised by a paediatric gastrologist in the USA and in Europe, to patients treated within a clinical trial, safety study or registry programme. A Cochrane review concluded that there was little evidence of benefit from cisapride and that selective reporting of positive results had been misleading.^7,8

Surgical

When medical therapy fails, anti-reflux surgery (for example, fundoplication) may be considered in selected patients but it carries a significant risk of morbidity, including high failure rates. More than 60% of patients go back on PPIs for recurrence of GORD symptoms and a similar proportion have new symptoms that were not present pre-surgery.⁹

Prognosis

Most cases are benign with 55% resolved by 10 months and 80% resolved by 18 months. Not all infants require medications to control the symptoms. Surgery is required in a minority of patients.

• In patients whose reflux persists into later childhood, chronic cough, wheeze, clubbing, and recurrent pneumonias are a continuing theme.
• Growth and weight gain are adversely affected in two thirds of patients. Cerebral palsy, Down's syndrome, developmental delay, and Sandifer's syndrome are all associated with reflux. Two thirds of patients have delayed gastric emptying, and one third have aspiration pneumonia.

Document references

1. McIntosh N, Helms PJ, Smyth R. Forfar and Arneil's Textbook of Paediatrics 2004, 5th edition. Churchill Livingstone ISBN 0443071126
2. Kumar K, Sarvananthan R Gastro-oesophageal reflux in children. Clinical Evidence (requires subscription).
3. Liburd J, Hebra A; Gastroesophageal Reflux. eMedicine, May 2009.; Paediatric Article.
4. Theodoropoulos DS, Flockey RF, Boyce HW Jr; Sandifer's syndrome and gastro-oesophageal reflux disease. J Neurol Neurosurg Psychiatry. 1999 Jun;66(6):805-6.
5. Huang RC, Forbes DA, Davies MW; Feed thickener for newborn infants with gastro-oesophageal reflux.; Cochrane Database Syst Rev. 2002;(3):CD003211. [abstract]
6. Orenstein SR, Izadnia F, Khan S; Gastroesophageal reflux disease in children. Gastroenterol Clin North Am. 1999 Dec;28(4):947 [abstract]
7. Augood C, MacLennan S, Gilbert R, et al; Cisapride treatment for gastro-oesophageal reflux in children. Cochrane Database Syst Rev. 2003;(4):CD002300. [abstract]
8. Bourke B, Drumm B; Cochrane's epitaph for cisapride in childhood gastro-oesophageal reflux.; Arch Dis Child. 2002 Feb;86(2):71-2.
9. Hassall E; Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children.; J Pediatr. 2005 Mar;146(3 Suppl):S3-12. [abstract]

Internet and further reading

• Fox M, Forgacs I; Gastro-oesophageal reflux disease. BMJ. 2006 Jan 14;332(7533):88-93.
• PAGER; Pediatric / Adolescent Gastroesophageal Reflux Association.

Acknowledgements