Childhood Gastro-Oesophageal Reflux Disease

Synonyms: Childhood GORD.

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 post-prandially). GORD is said to occur when reflux is persistent, more frequent and give rises to troublesome symptoms or complications.¹

• 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 6 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

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 (eg cough, apnoea, recurrent wheeze, and aspiration pneumonia)
• Feeding and behavioural problems and failure to thrive

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

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.

Consider congenital hiatus hernia, gastroenteritis, pyloric stenosis, UTI.

• 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

• 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
• When simple measures fail to reduce reflux:
  • Feed thickening (with agents such as Carobelr) 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
  • Older children should be advised about life-style 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 a 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.
• Motility stimulants such as domperidone or erythromycin may increase the rate of gastric emptying and improve gastro-oesophageal sphincter action but there is unconvincing evidence of their long-term efficacy.
  Note, cisapride was a drug widely used for the treatment of GORD in children - however concerns emerged regarding its cardiac safety and a Cochrane Review ⁶ showing little evidence of efficacy and its use is now limited to those involved in clinical trials or safety studies.⁷
• 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.⁸