Gastro-Oesophageal Reflux Disease (GORD) in Children

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Gastro-Oesophageal Reflux Disease (GORD) occurs when stomach acid frequently flows back into the oesophagus, irritating its lining. In children, GORD presents with persistent symptoms of reflux, beyond the expected physiological gastro-oesophageal reflux that is common in infants and usually resolves by 12 months of age.

Aetiology

GORD in children can be caused by a combination of factors, including:

• Immature lower oesophageal sphincter: In infants, this is the most common reason for reflux.
• Hiatal hernia: A structural defect where part of the stomach pushes into the chest cavity, leading to reflux.
• Neurological conditions: Children with conditions like cerebral palsy are at higher risk.
• Overfeeding or delayed gastric emptying: These can contribute to increased reflux episodes.

Pathophysiology

GORD occurs when the lower oesophageal sphincter (LES) is weak or relaxes inappropriately, allowing stomach contents to flow back into the oesophagus. This leads to irritation of the oesophageal lining by stomach acid, causing symptoms such as heartburn, regurgitation, and discomfort. In severe cases, the acid can cause damage to the oesophageal mucosa.

Risk Factors

• Premature birth and low birth weight.
• Neurological conditions, such as cerebral palsy.
• Family history of GORD.
• Obesity.
• Hiatal hernia or other anatomical abnormalities.

Signs and Symptoms

Symptoms of GORD in children may vary by age and severity, but common signs include:

• Frequent regurgitation or vomiting.
• Refusal to feed or difficulty feeding, leading to poor weight gain.
• Heartburn or chest discomfort, especially in older children.
• Coughing, wheezing, or recurrent pneumonia (due to aspiration).
• Abdominal pain or irritability after feeding.
• Hoarseness or sore throat.

Investigations

Diagnosis is primarily clinical, but additional investigations may be required in cases of persistent or complicated GORD:

• Upper GI endoscopy: Visualises the oesophagus and stomach to detect oesophagitis or structural abnormalities like hiatal hernia.
• Barium swallow: X-ray imaging to check for anatomical abnormalities.

Management

The treatment of GORD in children depends on the severity of the symptoms. Management begins with lifestyle and feeding changes, followed by pharmacological interventions if needed.

First-line Treatment:

• Positioning: Keep infants upright after feeds to reduce reflux episodes.
• Smaller, more frequent feeds: Avoid overfeeding to prevent reflux.
• Thickened feeds: Use of thickening agents in formula may help reduce regurgitation.
• Gaviscon Infant: A commonly used antacid that neutralises stomach acid and forms a protective barrier to reduce reflux. It is often recommended for mild cases.

Second-line Treatment (If symptoms persist):

• Proton Pump Inhibitors (PPIs): Medications such as omeprazole or lansoprazole are used to reduce acid production in the stomach and promote healing of the oesophageal lining. PPIs are typically prescribed for a trial period of 4-8 weeks.
• H2-receptor antagonists: Medications like ranitidine (no longer commonly used due to safety concerns).

Review and Referral:

• Review the child after 4-8 weeks of treatment to assess improvement in symptoms.
• Referral to a paediatric gastroenterologist is necessary if the child fails to respond to medical management, experiences complications (e.g., oesophagitis, weight loss), or has suspected anatomical abnormalities.
• Consider referral in children with recurrent respiratory infections or signs of aspiration.

References

1. NICE (2024). Gastro-Oesophageal Reflux Disease in Children: Diagnosis and Management. Available at: NICE Guidance
2. NHS (2023). Gastro-Oesophageal Reflux Disease in Children. Available at: NHS
3. British Medical Journal (2023). GORD in Paediatrics: Management and Treatment Guidelines. Available at: BMJ