Gastro-Oesophageal Reflux (Paediatrics GORD) ✅

🧾 Aetiology

• 🌊 Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus, with or without regurgitation or vomiting.
• ⚙️ In infants, this is commonly due to physiological immaturity of the lower oesophageal sphincter (LOS/LES), liquid feeds, and normal infant anatomy.
• ⚠️ GORD is diagnosed only when reflux leads to troublesome symptoms or complications severe enough to merit treatment.

⚠️ Risk Factors / groups more likely to have problematic reflux

• 👶 Prematurity.
• 🧠 Severe neurological impairment.
• 🔧 Repaired oesophageal atresia, congenital diaphragmatic hernia, or previous upper GI surgery.
• 🌬️ Chronic lung disease / bronchopulmonary dysplasia.
• ⬆️ Hiatus hernia.
• ⚡ Children with conditions predisposing to dysmotility or raised intra-abdominal pressure.

🔗 Important associated conditions / differential diagnoses

• 🥛 Cow’s milk protein allergy can mimic reflux symptoms.
• 🧠 Neurological impairment increases risk of severe reflux and aspiration.
• 🔧 Structural pathology should be considered if symptoms are atypical.
• 🚨 Progressively forceful vomiting in infants under 2 months should prompt urgent assessment for hypertrophic pyloric stenosis rather than being labelled simple reflux.

🚨 Possible complications of GORD

• 😣 Feeding aversion, distress, poor sleep, and pain.
• 📉 Faltering growth.
• 🩸 Oesophagitis, haematemesis, iron-deficiency anaemia.
• 🌬️ Recurrent aspiration problems or aspiration pneumonia in selected children.
• 🩸 Peptic stricture (rare).
• 🤕 Sandifer syndrome (abnormal posturing associated with reflux pain).

👀 Clinical Presentation

• ♻️ Regurgitation / posseting is common in healthy infants and is often physiological.
• 🍼 Most infants with uncomplicated GOR are otherwise well and thriving.
• 🚩 Features suggesting possible GORD include:
  • marked distress with feeds or frequent regurgitation,
  • feeding refusal or aversion,
  • poor weight gain / faltering growth,
  • persistent back arching / Sandifer-type posturing,
  • haematemesis, melaena, or dysphagia,
  • recurrent aspiration-type respiratory problems.
• ⏸️ Unexplained apnoeas or seizure-like episodes are red flags requiring specialist assessment, not routine community reflux treatment.

🚩 Red flags suggesting an alternative diagnosis or need for urgent referral

• 🟢 Bile-stained (green) vomiting.
• 💥 Progressively forceful vomiting.
• 🩸 Haematemesis or melaena.
• 🤒 Systemic illness, abdominal distension, or severe diarrhoea/constipation.
• 📉 Faltering growth.
• 🧠 Bulging fontanelle, seizures, or abnormal neurology.
• 🍼 Onset after 6 months or persistence of significant regurgitation beyond 1 year.

🧪 Investigations

• ✅ No investigations are needed for straightforward physiological reflux in a thriving infant.
• 📉 Oesophageal pH study or combined pH-impedance monitoring may be considered by specialists in selected cases, such as suspected recurrent aspiration pneumonia, unexplained apnoeas, non-epileptic events, or upper airway inflammation.
• 🎥 Upper GI contrast study is used to exclude structural disease in selected situations, such as bile-stained vomiting or dysphagia; it is not a routine reflux test.
• 🔬 Endoscopy ± biopsy is considered when there is haematemesis, melaena, dysphagia, persistent faltering growth with regurgitation, feeding aversion, persistent pain needing treatment, or concern about oesophagitis / eosinophilic oesophagitis.
• 🧪 Routine blood tests and chest X-ray are not first-line investigations for uncomplicated reflux.

💊 Management

• 🧑‍⚕️ First-line in infants with uncomplicated reflux: reassure parents that reflux is common and usually improves with time.
• 🥛 Feeding review: avoid overfeeding; consider smaller, more frequent feeds if appropriate.
• 🍼 In formula-fed infants with frequent regurgitation associated with marked distress, consider a trial of:
  • smaller, more frequent feeds, and
  • thickened formula.
• 🥛 If symptoms persist, NICE supports a trial of alginate therapy in infants with frequent regurgitation associated with marked distress when first-line measures have failed.
• 🧪 Consider trial exclusion of cow’s milk protein allergy if clinically suspected.
• 🛡️ PPIs or H2RAs are not for routine use in simple posseting; they are mainly considered for children with symptoms suggesting reflux-related pain, or offered for endoscopy-proven reflux oesophagitis.
• 🚫 Do not routinely offer metoclopramide, domperidone, or erythromycin to treat GOR/GORD without specialist advice and careful consideration of adverse effects.
• 😴 Babies should still be placed on their back to sleep; reflux management should not conflict with safer sleep guidance.
• 🔪 Surgery (for example fundoplication) is reserved for selected severe, treatment-resistant cases, usually under specialist care.

📚 References

• NICE NG1: Gastro-oesophageal reflux disease in children and young people
• NICE CKS: GORD in children
• NICE Quality Standard: Alginate therapy for infants with frequent regurgitation and marked distress
• BNFc/NICE: Gastro-oesophageal reflux disease

💊 Case Reports

• 🍼 Case 1 – Age 4 months (Physiological reflux): Frequent effortless regurgitation after feeds, but thriving and otherwise well. Diagnosis: Physiological GOR. Management: Reassurance and feeding review only. Teaching point: Posseting in a thriving infant is usually normal and does not need acid suppression.
• 🤢 Case 2 – Age 9 months (Possible GORD): Persistent regurgitation with marked distress, back arching, and poor weight gain. Management: Feeding review, consider thickened feeds / alginate, assess for cow’s milk protein allergy, and refer if symptoms persist or complications are suspected. Teaching point: Faltering growth and feeding aversion move the picture from simple GOR toward GORD.
• 😮‍💨 Case 3 – Age 6 years (Older child with reflux symptoms): Recurrent heartburn, upper abdominal discomfort, and nocturnal symptoms. Management: Consider acid suppression if clinically indicated and investigate further if symptoms are persistent, atypical, or associated with alarm features. Teaching point: In older children, reflux may present more like adult heartburn than infant posseting.