In January 2015, NICE released a guideline on gastro-oesophageal reflux disease (GORD) in infants. Here, we summarise the key points.
GOR is when gastric contents move from the stomach up to the oesophagus. This most commonly happens after feeds and it happens in people of all ages.
It becomes GORD when that process causes symptoms (e.g. pain) that require some medical treatment. This is a subjective assessment and there is no clear cut clinical diagnosis.
Patients often mention silent reflux (or occult reflux) – this is where gastric contents move to the oesophagus but do not go up to the mouth. There may be no noticeable regurgitation or vomiting.
GOR is a normal physiological process and most infants don’t experience any distress because of it. Consequently most infants with GOR do not require investigation or treatment.
The key points NICE highlights when discussing with parents are:
- At least 40% of infants have GOR
- 5% of those have 6+ episodes per day, so it can be frequent
- It usually begins before 8 weeks and resolves in 90% by one year old
- We do not normally investigate or treat
For the parents – although you have reassured them, they should continue to look out for: projectile, bile-stained, or blood-stained vomiting; feeding difficulties; failure to gain weight; persistence after 1 year of age.
For us – we should only investigate if they present with more than one of:
- feeding difficulties
- poor growth
- chronic cough
- hoarse voice
- appearing distressed
- an episode of pneumonia
NICE has a very nice table of red flag symptoms which should make you think about something other than GOR.
These are loosely grouped into:
Surgical problems – bile-stained vomiting, projectile vomiting, abdo distension or masses, haematemesis.
Gastro/allergy problems – blood in stool, chronic diarrhoea, atopy (suggesting a possible cows milk protein allergy).
Urinary problems – late onset, appearing unwell, dysuria (suggesting a UTI).
Neurological problems – head circumference increasing more than 1cm per week, lethargy/irritability, bulging fontanelle (suggesting raised ICP).
Although GOR is thought of as being pretty benign, it can lead to complications such as reflux oesophagitis, aspiration pneumonia, otitis media, and dental erosion.
It doesn’t worsen asthma.
Some patient groups are higher risk, particularly those with neurodisability, congenital anatomical problems (such as diaphragmatic hernia or oesophageal atresia), and those born prematurely.
An upper GI contrast shouldn’t be routinely used to help diagnose the severity of GORD. This should only be requested if there are other risk factors, or if an alternative diagnosis is suspected.
An oesophageal pH study should be requested if patients may need a fundoplication, or they are having unexplained symptoms (such as apnoeas or seizures).
Simple measures can be implemented in formula-fed babies. A thorough review of feeding is needed, and the daily feeding volumes should be calculated (aim for around 150ml/kg/day). One should consider reducing the feed volume (if appropriate) or offering small and more frequent feeds. Finally a trial of thickened formula can be implemented. In breast-fed babies, a breastfeeding assessment may be helpful.
Drugs – if these measures have been trialled and have failed, then alginate therapy (e.g. Gaviscon) should be trialled for a couple of weeks (patient should be off thickened feeds).
Consider starting a PPI (omeprazole) or H2 antagonist (ranitidine) if infants have regurgitation PLUS feeding difficulties/distress/poor growth. This would be carried out as a four week trial. Choice of drug should be based on preference and age-appropriate preparations.
Prokinetics (e.g. domperidone, metoclopramide, erythromycin) are not recommended as a first line treatment.
Feeding – enteral tube feeding should only be considered if there problem with weight gain and other causes have been explored. This should be implemented only as part of an overall strategy to wean, and there must be a clear plan. Infants should continue with oral feeding during this time.
Surgery (fundoplication) should be considered if medical treatment and feeding regimens have not worked.
And another useful pearl…
There is no clear evidence on whether cows milk protein intolerance is linked to GORD and therefore a trial of hydrolysed formula is not proven to be effective. Further study has been recommended.
In summary, GOR is a physiological process that should only be investigated and treated in infants if they have symptoms other than simple vomiting/regurgitation.