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GOR-GORD Vomiting in infants/children

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GOR-GORD Vomiting in infants/children

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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-Suspect GORD in infants up to 1 year age if they present with regurgitation + one or more of the following
○ distressed behavior 
 excessive crying
 crying while feeding
 adopting abnormal neck posture
○ hoarseness and/ or chronic cough
 A single episode of pneumonia
( GORD may also present with extraoesophageal manifestations as cough , wheezing , laryngitis , pneumonia , recurrent sinusitis or otitis media )
 Unexplained feeding difficulties eg
○ refusing to feed
○ gagging or choking
 Faltering growth

Children over 1 yr may present with heartburn , retrosternal pain or epigastric pain


 

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