GORD in children

Definition/diagnostic criteria: Gastro-oesophageal reflux (GOR) refers to the passage of gastric contents into the oesophagus. When this causes symptoms or complications it is termed Gastro-oesophageal Reflux Disease (GORD). In children, this often manifests as regurgitation, vomiting, discomfort, and sometimes failure to thrive or respiratory problems.

Epidemiology: GORD is common in infants, with over 40% of parents reporting at least one episode of regurgitation per day in infants aged 0-3 months. However, the prevalence decreases with age, and symptoms resolve in 90% of affected infants by 12 months. The incidence and prevalence in older children are less well defined but are believed to be increasing alongside obesity rates.

Diagnosis

Clinical features

• Infants: Frequent regurgitation or vomiting, distressed behaviour, feeding difficulties, faltering growth.
• Older children: Retrosternal or epigastric pain, heartburn, recurrent regurgitation, chronic cough, hoarseness.
• Alarm symptoms: include signs of gastrointestinal bleeding, significant weight loss, generalised abdominal tenderness, dysphagia, or persistent forceful vomiting.

Investigations The diagnosis is almost always clinical. It would be very unusual to require specific investigations unless there is significant doubt about the diagnosis or very severe symptoms. In such cases, upper gastrointestinal contrast study (typically to exclude anatomical abnormalities), 24-hour oesophageal pH monitoring or pH-impedance monitoring or endoscopy with biopsies are required. Typical abnormalities might include oesophagitis on endoscopy or abnormal acid exposure on pH monitoring.

Treatment:

Conservative

• For infants: Smaller, more frequent feedings, thickened feeds, and ensuring the child remains upright for a period after feeding.
• For older children: Lifestyle modifications like avoiding food triggers, reducing obesity, and elevating the head end of the bed.

Pharmacological

• Antacids and alginates for symptomatic relief.
• H2 receptor antagonists (e.g., ranitidine) and proton pump inhibitors (e.g., omeprazole) are often used as the first-line medication for reducing gastric acidity and oesophageal irritation.
• Prokinetics (e.g., domperidone) might be used in some cases (usually under specialist review), but their use is controversial due to side effect profiles.

Surgical

• Nissen fundoplication is considered in severe cases unresponsive to medical therapy or in cases with life-threatening complications.

Prognosis The majority of infants with GORD spontaneously improve by 12-18 months of age. In older children, the prognosis is generally good, especially with lifestyle modifications and appropriate medical management. However, some may continue to have recurrent symptoms into adulthood, particularly those with severe disease or underlying conditions.