Gastro-Oesophageal Reflux (Paediatrics GORD)

🧾 Aetiology

• 🌊 Gastro-Oesophageal Reflux (Paediatrics GORD) – retrograde flow of gastric contents into the oesophagus
• ⚙️ Functional immaturity of the lower oesophageal sphincter (LOS), especially in the first year of life

⚠️ Risk Factors

• 📏 Short intra-abdominal oesophageal length
• 👶 First year of life, especially with neurodevelopmental disorders
• 🍼 Preterm infants with bronchopulmonary dysplasia
• 🔪 History of oesophageal or diaphragmatic surgery
• 🥛 Liquid diet & high-calorie requirements → strain on gastric capacity

🔗 Associated Conditions

• 🧠 Severe neurological impairment
• 👶 Prematurity
• 🌬️ Cystic fibrosis (thick secretions, recurrent cough)
• 🔧 Congenital anomalies: oesophageal atresia, diaphragmatic hernia, pyloric stenosis
• 💨 Bronchopulmonary dysplasia (preterm chronic lung disease)
• ⬆️ Hiatus hernia
• ⚡ Oesophageal sphincter disorders
• 🏋️ Raised intra-abdominal pressure (e.g. coughing, constipation)

🚨 Complications

• 😣 Pain, bleeding, iron-deficiency anaemia
• 🌬️ Pulmonary aspiration → recurrent bronchitis / pneumonia
• 🩸 Peptic stricture with oesophagitis
• 🤕 Sandifer’s syndrome (dystonic head/neck movements to relieve reflux pain)
• 😮 Apnoea spells in preterm infants
• ❓ Link to Sudden Infant Death Syndrome (SIDS) remains debated

👀 Clinical Presentation

• ♻️ Regurgitation (posseting/spitting up) – most common feature
  • Seen in ~50% of infants (0–3 months)
  • Peaks at 4 months (≈ 66%)
  • Settles by 10–12 months (≈ 5%)
• 🥴 Difficulty initiating feeds & poor latch
• 🛑 Early cessation of feeding triggered by reflux episodes
• 📉 Failure to thrive, sleep disturbance (esp. after evening feeds)
• 😭 Irritability & inconsolable crying (often worse after meals)
• ⏸️ Apnoeic episodes with observed pauses in breathing

🧪 Investigations

• 🧬 Bloods: FBC, U&E, LFTs
• 🩻 Chest X-Ray – aspiration, chronic lung changes
• 📉 24-hour oesophageal pH monitoring (gold standard for acid exposure)
• 🎥 Contrast studies – exclude structural anomalies
• 🔬 Endoscopy ± biopsy – assess mucosal damage, exclude eosinophilic oesophagitis

💊 Management

• 🥛 Feeding strategies: inert feed thickeners, smaller/more frequent feeds, positioning baby at 30° after feeds
• ⚡ Prokinetics: Domperidone (use with caution due to side effects)
• 🛡️ Acid suppression: Proton Pump Inhibitors (PPIs) or H2 blockers for severe/refractory cases
• 🔪 Surgical: Fundoplication for severe, resistant GORD or recurrent aspiration

📚 References

• Paediatric Gastro-Oesophageal Reflux Disease – BJMP

💊 Case Reports

• 🍼 Case 1 – Age 4 months (Physiological Reflux): Infant brought in for frequent regurgitation after feeds but otherwise thriving and gaining weight. No vomiting, distress, or respiratory symptoms. Diagnosis: Physiological GOR (gastro-oesophageal reflux) due to immature lower oesophageal sphincter. Management: Reassurance, smaller frequent feeds, keeping baby upright after feeding. No medication required. Teaching point: Physiological reflux is common in infants under 6 months and usually resolves spontaneously as sphincter tone matures.
• 🤢 Case 2 – Age 9 months (Symptomatic GORD): Baby with persistent vomiting, irritability after feeds, and poor weight gain. Frequent arching of back during feeding (“Sandifer’s syndrome”). Diagnosis: Gastro-oesophageal reflux disease (GORD) with feeding aversion. Management: Trial of thickened feeds and positioning advice; started on alginate therapy (Gaviscon Infant). Referred to paediatrics for possible proton pump inhibitor (PPI) if no improvement. Teaching point: When reflux causes poor growth, distress, or respiratory complications, it becomes pathological GORD requiring active management.
• 😮‍💨 Case 3 – Age 6 years (Chronic GORD with Respiratory Symptoms): Child with recurrent nocturnal cough, wheeze, and hoarse voice; symptoms worse after meals and lying down. No response to inhalers. Diagnosis: Extra-oesophageal manifestation of GORD. Investigations: 24-hour pH monitoring and endoscopy showed distal oesophagitis. Management: Lifestyle modification (no late meals, elevate head of bed) and omeprazole. Teaching point: GORD can present with atypical respiratory symptoms in older children — always consider reflux in refractory cough or wheeze.