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GOR-GORD Vomiting in infants/children

Mothers presenting with infants with possible gastroesophageal reflux or gastroesophageal reflux disease is very common in general practice. This review of GOR-GORD in infants on A4Medicine presents the clinician with an easy visual of this common problem.The differences in  GOR-GORD, risk factors are mentioned and the box on red flags helps the clinician in considering and ruling out more serious causes. An assessment of GOR-GORD is followed by pharmacological management. Use of anti-reflux medications as proton pump inhibitors, Gaviscon, H2RA are cited and the author has reviewed the current management of GOR-GORD. The GP is also presented with an aid to help decide which patients may need further assessment in secondary care.

GOR-Passage of stomach contents into the oesophagus
 Considered physiological in infants when symptoms are absent or not troublesome
 More common in infants than in older children and young people -effortless regurgitation of feeds in young babies Gastro-oesophageal reflux ( GOR ) is very common affects at-least 40 % infants
 Usually begins before 8 weeks
 May be frequent ( 5 % of those affected 
have 6 or more episodes / day )
 Usually becomes less frequent with time and resolves in 90 % of infants before they 
are 1 yr old
 Does not usually need further investigations
 or treatment



Factors causing increased GOR in children-Transient lower oesophageal sphincter relaxation
 short narrow oesophagus delayed gastric emptying shorter lower oesophageal sphincter which is slightly above , rather than below the diaphragm liquid diet and high caloric requirement putting strain on gastric capacity larger ratio of gastric volume to oesophageal vol infants frequently recumbent

GORD-Effect of GOR leads to symptoms severe enough to merit medical treatment
 Symptoms can include
○ discomfort / pain
○ complications as oesophagitis or pulmonary aspiration
 Estimates of prevalence are imprecise ( children < 2 ) but number of children affected by GORD is thought to be small


Risk factors GORD-Premature birth Parental h/o reflux Obesity Hiatus hernia H/O congenital diaphragmatic hernia ( repaired ) H/O congenital oesophageal atresia ( repaired ) Neurodevelopmental disorders ( eg cebebral palsy )

Experts suggest that groups of children most affected by GORD are
○ otherwise healthy infants
○ children with identifiable risk factors
○ pubescent young people who acquire the problem in the same way as adults

Regurgitation –Voluntary & involuntary movement of part or all of the stomach contents up the oesophagus at least as far as the mouth and often emerging from the mouth
 It can suggest GOR or GORD in children
 Children < 1 yr – this can be normal

It is difficult to 
differentiate between 
in clinical practice- 
GOR and GORD , terms
 used interchangeably by health professionals and families .No simple , reliable 
and accurate 
diagnostic test to confirm if the condition is GOR or GORD

history-Assess for red flags
 Check if any risk factors or complications
 Feeding history
○ if bottle fed check which formula , preparation , frequency , volume consumed and any resistance or refusal to feed
○ Breast fed- enquire / advice about technique , positioning and attachment
 Age of onset of symptoms
○ GOR after 6 months suggests an alternative diagnosis
 Crying while feeding 
○ average is 2 hrs/ day for an infant but substantial individual variation
○ peak normal duration is at 6 weeks
 Frequency , estimated volume of regurgitation and vomiting
 Any respiratory symptoms and signs 
( eg hoarseness or chronic cough )
 Ask about back persistent back arching 
 Assess growth using centile chart

Suspect GORD-Establishing a diagnosis can be difficult Infants – presentation is different to older children and irritability coupled with back arching is considered equivalent of heartburn Presentation can overlap with CMA/ CMPA CMA/ CMPA and GORD/ GERD can co-exist and GERD can be induced by CMA/ CMPA
Regurgitation with vomiting Irritability with feeds and in post-prandial period Back arching Crying Food refusal Cough Apnoea

Regurgitation and vomiting Heartburn Nausea Epigastric pain/ stomach ache Cough and wheezing

Weight loss or inadequate weight gain Crying and fussiness during & after feeds Emesis and or / haematemesis Irritability Anaemia Bad breath , gagging or choking at the enf od feeding Sleeping disturbance and frequent night waking Abdominal pain Dental erosion Dystonic neck posturing Dysphagia Apnoea also spelt as apnea Respiratory symptoms

References

  1. GORD in children CKS NHS last revised March 2015 https://cks.nice.org.uk/gord-in-children
  2. Gastro-oesophageal reflux disease in children and young people : diagnosis and management NICE guideline Published January 2015 https://www.nice.org.uk/guidance/ng1
  3. Gastro-oesophageal reflux in children and young people Quality standard ( QS 112 ) Published January 2016 UKMi
  4. NICE Bites GORD- children and young people March 2015 https://www.sps.nhs.uk/articles/nice-bites-gord-in-children-and-young-people/
  5. Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children Ongoing vomiting in an infant BMJ 2017 ; 357:j 1802
  6. Tighe  M, Afzal  NA, Bevan  A, Hayen  A, Munro  A, Beattie  RM. Pharmacological treatment of children with gastro‐oesophageal reflux. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD008550. DOI: 10.1002/14651858.CD008550.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008550.pub2/full
  7. Parent FAQ from Healthy Children Org via  https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/GERD-Reflux.aspx
  8. Feeding volume data from Great Ormond Street Hospital for Children
http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/infant-feeding-formula
  9. Rybak, A.; Pesce, M.; Thapar, N.; Borrelli, O. Gastro-Esophageal Reflux in Children. Int. J. Mol. Sci. 201718, 1671. https://www.mdpi.com/1422-0067/18/8/1671/htm

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