Differential Diagnosis Gastro-oesophageal reflux (GOR) Investigations References Vomiting is common in infants and young children. It is important to differentiate between those infants who have a serious cause for their vomiting and those in whom it is likely to be mild (or physiologic) gastro-oesophageal reflux, over-feeding or excessive crying. Physiologic reflux in infants is characterised by effortless regurgitation in an infant who is otherwise well. Differential Diagnosis Common causes of vomiting are listed in table I. Fever, anorexia, lethargy or irritability point to infection as a possible cause. Bile-stained vomiting necessitates the exclusion of intestinal obstruction. Table 1 Causes of vomiting in infants and young children Infection, most commonly: - Otitis media - Gastroenteritis - Urinary Tract Infections - Meningitis Gastrointestinal obstructive disorders - Pyloric stenosis - Malrotation - Intussusception Gastrointestinal non-obstructive disorders - Gastro-oesophageal reflux - Appendicitis - Peptic ulcer disease - Coeliac disease - Food intolerance Cow s milk allergy Drugs / toxins Metabolic causes Gastro-oesophageal reflux Page: 1 of 5
Gastro-oesophageal reflux (GOR) This is the retrograde movement of gastric contents into the oesophagus. The acid and pepsin contents of the stomach irritate the oesophageal mucosa, which has no defence against their corrosive activity. Factors related to GOR include inappropriate relaxation of the lower oesophageal sphincter, poor gastric emptying and poor oesophageal clearance. GOR is an imprecise term referring to both mild episodic reflux after meals (physiologic GOR) and more significant reflux associated with complications (pathologic GOR). Regurgitation of small amounts of milk by infants is so common as to be almost normal, with a high rate of spontaneous resolution. If the infant is otherwise well and thriving, all that is required is reassurance and simple feeding advice. Reducing the volume and increasing the frequency of the feeds may lead to improvement, but is generally not necessary. Only children who suffer from complications of GOR require investigation or treatment. Possible complications are listed in Table 2. The history and examination is orientated towards detecting these complications. Table 2 Complications of gastro-oesophageal reflux Symptoms due to regurgitation - Failure to thrive Symptoms due to oesophagitis - Irritability - Loss of appetite - Haematemesis - Melaena - Peptic stricture with dysphagia Respiratory symptoms - Recurrent cough - Wheeze - Apnoea / cyanotic episodes - Stridor, hoarseness Neurobehavioural symptoms - Abnormal posturing or movements (Sandifer syndrome) Family dysfunction - Difficulties with attachment - Postnatal depression - Anxiety Gastro-oesophageal reflux Page: 2 of 5
Investigations Barium swallow When needed barium swallow/upper gastrointestinal series should be the study of choice GOR is an episodic event. It is to be expected that many cases are missed during the brief time (about five minutes) of screening. Even so, the barium swallow can crudely quantify reflux and may also suggest the presence of oesophagitis or dysmotility. Its main purpose, however, is to exclude structural abnormalities: Hiatus hernia Webs Stenosis/stricture Vascular ring Gastric outlet obstructive lesions Malrotation of the upper GI tract. Please see radiology guidelines regarding preparation (length of fasting depends on age of child) ph Monitoring This is more reliable, although false negatives occur. Indications: Unexplained recurrent respiratory symptoms, where other causes have been excluded, and GOR is not clinically evident Where apnoea is suspected to relate to GOR, but GOR is not clinically evident Before fundoplication, where symptoms are intractable to medical therapy, but where there is doubt about the diagnosis After fundoplication, to evaluate the effectiveness of surgery when symptoms persist or recur Where there is doubt about the diagnosis, because there is no spilling or vomiting Discuss all requests for a ph study with a Consultant Paediatrician. The referral then goes to the Gastroenterology Consultant who is on service at that time, for review of indications for the study. The ph study itself is usually performed over 24 hours, and is arranged by the Gastroenterology / CF Nurse Specialist. It cannot be performed on an infant who is on continuous feeding. Oesophageal Biopsy and Endoscopy of the Upper GI Tract This is usually unnecessary. Biopsy is useful for diagnosing oesophagitis, but cannot detect mild reflux. Consider it if the diagnosis remains uncertain (particularly where the symptoms are pain and irritability), if response to treatment is poor or if there is GI blood loss. It should also be performed prior to any referral for surgery. Referral to a Consultant Gastroenterologist will be required. Gastro-oesophageal reflux Page: 3 of 5
Most children with GOR do not require medication. Only thickening feeds has been shown to be of benefit in uncomplicated reflux. Most children will not require follow up in a medical clinic, but should be referred if they have the features in Table 3. The management principles are outlined in Table 4. Remember that a constantly irritable infant is extremely stressful for the parents, and empathy from the Paediatric team is fundamental to successful management. Most irritable infants under 3 months of age who are gaining weight well have colic rather than GOR. Table 3 Indications for further investigations Diagnostic uncertainty Failure of conservative therapy Presence or suspicion of complications: - Poor weight gain - Oesophagitis - Respiratory complications - Neurobehavioural symptoms Extreme parental anxiety Table 4 Conservative measures - Adequate burping - Avoid large volume of feeds - Avoid passive tobacco smoke - Thicken feeds: 1 teaspoon corn flour added to 100 ml of water, which is then boiled and used to make the formula; or proprietary thickeners / pre-thickened formulas available commercially Gaviscon - Infants: Powder now only available as sachets in NZ. Under 4.5 kg give one dose, over 4.5 kg two doses, mixed in with each feed. See box for further instructions. - Young children: Two doses mixed with half a glass of water or milk after each meal Gastro-oesophageal reflux Page: 4 of 5
Prokinetic agents - Metoclopramide: 0.1 mg/kg/dose 4 times daily (15-30 minutes before meals and at bedtime). The manufacturer does not recommend use of metoclopramide in patients under 2 years, except for specific indications, not including gastro-oesophageal reflux). A recent systematic study is not supportive of its use. Side-effects include sedation and extrapyramidal reactions. - Acid-reducing agents These are ineffective in uncomplicated gastroesophageal reflux in infancy. They are helpful in treating oesophagitis. Ranitidine: 2 to 4 mg/kg/dose 2 times daily (max. 150 mg/dose). Omeprazole: Now available as a mixture of Omeprazole in Sodium Bicarbonate, 2 mg/ml. The dose is: Weight <10 kg. 5 mg once daily Weight 10 20 kg. 10 mg once daily (maximum 20 mg daily) Weight > 20 kg. 20 mg once daily (maximum 40 mg daily) If considering higher doses than this, discussion with a gastroenterologist is recommended Surgical treatment Fundoplication Diversionary feeding procedure (gastrostomy or jejunostomy, open or percutaneous) Surgery is more likely to be required in children with developmental delay. References Up to date: Gastroesophageal reflux in infancy and of gastroesophageal reflux in infants and children. Revised January 2011 Cochrane data base of systematic reviews. Craig et al Metoclopramide, thickened feeds and positioning for gastroesophageal reflux in children under two years of age. ( Metpcolpramide is effective but causes sedation and thickened feeds are effective). Accessed 23 June 2011. Horvath A, et al The effect of thickened feed interventions on gastroesophageal reflux in infants: Systematic review and meta-analysis of randomised controlled trials. 2008 Pediatrics; 122(6):1268-1255 Van der Pol R et al Efficacy of proton pump inhibitors in children with gastroesophageal reflux disease: A systematic review. 2008 Pedaitrics; 127 (5(:925-935) Heine RG. Gastro-oesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol 2006:6 Paediatric Pharmacopoeia, Royal Childrens Hospital, Melbourne (drug doses) Gastro-oesophageal reflux Page: 5 of 5