GORD

Gastro-Oesophageal Reflux Disease (GORD) in Children

Gastro-oesophageal reflux disease (GORD) is a common condition in infants where stomach contents, including acid, flow back up into the oesophagus, causing symptoms. It is a normal physiological process in infants but is considered a disease when it causes distress, complications, or affects growth. The UK’s National Institute for Health and Care Excellence (NICE) guidelines distinguish between simple reflux, which is benign, and GORD, which requires management.

 

Pathophysiology and Aetiology

  • Physiological Reflux: This is a normal and common occurrence in infants, caused by the immaturity of the lower oesophageal sphincter (LOS). Most infants will outgrow this by 12-18 months of age.

  • GORD: When reflux causes significant symptoms or complications, it becomes a disease. Contributing factors can include a persistent lower oesophageal sphincter relaxation, a large feeding volume, or a slower stomach emptying.

 

Clinical Presentation

It’s crucial to differentiate between simple reflux, which can be managed with reassurance, and GORD, which requires a more structured approach.

 

Reflux (Benign)

  • Spitting up or vomiting without distress.

  • The child is otherwise well and is gaining weight normally.

  • The episodes are intermittent and do not appear to cause pain.

 

GORD (Pathological)

  • Distress: The child cries excessively and is irritable, especially during or after feeds.

  • Feeding difficulties: The child may refuse to feed, leading to poor weight gain or faltering growth.

  • Other symptoms: Hoarse cry, recurrent cough, or wheezing may be a sign of aspiration.

Important Considerations and Red Flags

  • Cow’s Milk Protein Allergy (CMPA): GORD symptoms can be a sign of CMPA. Consider a trial of a hypoallergenic formula or a maternal dietary exclusion of dairy if the child is breastfed.

  • Red Flags: The following should prompt immediate specialist referral to rule out a more serious cause:

    • Bile-stained vomit or projectile vomiting.

    • Significant faltering growth.

    • Difficulty swallowing.

    • Blood in the stool or vomit.

    • Distressed or unwell-looking child.

 

Management

The management of GORD in children follows a stepwise approach, starting with non-pharmacological interventions before considering medication.

 

Step 1: Non-Pharmacological Interventions

  • Parental Education and Reassurance: This is the most important step for simple reflux. Explain the condition and provide reassurance that the child is otherwise well and will likely outgrow it.

  • Feeding adjustments:

    • Thickening Feeds: For formula-fed infants, thickening the feed with a thickening agent (e.g., carob bean gum) can help reduce the frequency of reflux episodes.

    • Positioning: For older children, advise them to avoid lying down immediately after meals.

 

Step 2: Pharmacological Interventions

  • H2-receptor antagonists (H2RAs): If GORD symptoms persist despite non-pharmacological measures, an H2RA such as ranitidine (although now less common due to safety concerns) or famotidine can be used. These drugs reduce stomach acid production.

  • Proton pump inhibitors (PPIs): If H2RAs are not effective, a PPI such as omeprazole or lansoprazole may be considered. These are more powerful at suppressing stomach acid.

 

Step 3: Specialist Referral

A referral to a paediatric gastroenterologist is necessary if:

  • The child is still not thriving despite medical management.

  • There are signs of oesophagitis (e.g., blood in the vomit).

  • There is a suspicion of a different underlying diagnosis, such as cow’s milk protein allergy (CMPA).