Reflux of stomach contents can vary from physiologically normal to severely pathological. It is important to be specific in defining terms and careful in labelling children with diagnoses.
Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus and is normal in infants if it is asymptomatic.
Gastro-oesophageal reflux disease (GORD) is the term used to describe this process in the presence of symptoms or complications from the reflux, which will be discussed further here.
Regurgitation (posseting) is the reflux of stomach contents beyond the oesophagus. This can represent a symptom of GOR or GORD but is also normal in infants.
Regurgitation is extremely common- it occurs in approximately 40% of infants. Regurgitation and GORD usually appear within the first 2 weeks of life.
GORD is difficult to quantify due to variation in definition. It is present in approximately 0.9% of children less than 13 years of age in theprimary care setting.
The lower oesophageal sphincter is responsible, along with the diaphragm, for preventing stomach contents from entering the oesophagus. In cases of GORD the tone of this muscular portion of the lower oesophagus is too low, resulting in uncontrolled reflux of stomach contents. Infants have a number of anatomical and physiological features that can contribute to this mechanism:
- Short, narrow oesophagus
- Delayed gastric emptying
- Shorter, lower oesophageal sphincter that is slightly above the diaphragm
- Liquid diet and high calorie requirement, distending the stomach and increasing pressure gradient between stomach and oesophagus
- Larger ratio of gastric volume to oesophageal volume
- Spending significant periods recumbent
- Parental history of heartburn or acid regurgitation
- Hiatus hernia
- History of (repaired) congenital diaphragmatic hernia
- History of (repaired) congenial oesophageal atresia
- Neurodisability (eg. cerebral palsy)
It is important and can be challenging to distinguish between GOR and GORD in infants. Frequent, effortless regurgitation of feeds is normal and there is no reliable investigation to distinguish between the two.
Ask about symptoms related to the episodes such as:
- Distressed behaviour (eg. excessive crying, unusual neck postures, back-arching)
- Unexplained feeding difficulties (refusing feeds, gagging, choking)
- Hoarseness and/or chronic cough in children
- A single episode of pneumonia
- Faltering growth
- If child is able to they may report retrosternal or epigastric pain
Take a full feeding history:
- Check position, attachment, technique, duration, frequency and type of milk.
- Calculate the volume of milk being given as babies can be over-fed and therefore have gastric over-distension.
- Ask about frequency and estimated volume of vomits
- Find out the relationship of symptoms to feeds.
The general physical examination should specifically note:
- Hydration status
- Signs of malnutrition
- Any abnormalities that may indicate a differential diagnosis. For example, atopy with feed intolerance may point to cow’s milk protein allergy.
- Assess growth charts to look for faltering growth.
- Pyloric stenosis: Frequent, forceful (projectile) vomiting in <2 month olds
- Intestinal obstruction: bile-stained (green or yellow-green) vomit, such as malrotation volvulus
- Any acute surgical abdominal issue: abdominal distension, tenderness, or palpable mass
- Upper gastrointestinal bleed: haematemesis (beware swallowed blood from cracked nipple if breastfeeding or patient with epistaxis)
- Sepsis: altered responsiveness, severe prolonged vomiting, petechial rash, bulging fontanelle if central nervous system involvement
- Raised intracranial pressure: rapidly increasing head circumference (>1cm per week), persistent headache and vomiting following periods of recumbence (eg. in morning)
- Blood in stool: consider bacterial gastroenteritis, cow’s milk protein allergy.
- Chronic diarrhoea, especially if atopic: consider cow’s milk protein allergy.
- Urinary tract infection especially if associated with lower urinary tract symptoms
- If onset is >6 months of age or symptoms persist beyond 1 year then reflux is unlikely
No investigations are required to diagnose reflux however they may be necessary to rule out other potential causes of the symptoms. For example urinalysis can be used to look for evidence of infection.
Consider non-pharmacological and pharmacological approaches:
- Effortless regurgitation in otherwise well infants is common. Approximately 40% of infants will experience this and no intervention is necessary. Symptoms should have started in the first 2 months of life and usually improves with age until they are 1 years old. Reassurance is key.
- If breastfed with frequent regurgitation causing marked distress, use an alginate (eg. Gaviscon) mixed with water immediately after feeds.
- If formula-fed with frequent regurgitation causing marked distress, use a step-wise approach:
|1st||Ensure infant is not over-fed (no more than 150ml/kg/day total milk)|
|2nd||Decrease feed volume by increasing frequency (eg. 2-3 hourly)|
|3rd||Use feed-thickener (or pre-thickened formula)|
|4th||Stop thickener and start alginate added to formula|
- For either group if there is no improvement with alginate therapy after a 2 week trial then start proton pump inhibitor or histamine antagonist (eg. Omeprazole or ranitidine)
- If symptoms persist refer to paediatrics and reconsider differential diagnosis
90% of infants will spontaneously resolve within the first year of life. As they grow older, take a more solid diet and spend more time upright so their predisposition to reflux is diminished.
Uncommon complications in children include:
- Reflux oesophagitis
- Recurrent aspiration pneumonia
- Recurrent acute otitis media (>3 episodes in 6 months)
- Dental erosion (especially in children with neurodisability)
Rare complications which are nonetheless important to consider in children presenting this way:
- Apparent life-threatening events (ALTE): a combination of symptoms including apnoea, colour change, change in muscle tone, choking and gagging