Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. In most infants with GOR the outcome is benign & self-limiting. (1)
Peak incidence of GOR is around 4 months of age, and it resolves spontaneously by 1-2 years of age in most patients.(2)
Regurgitation (possetting or spitting up) is the most common presentation in infants with GOR. Regurgitation of at least one episode a day is seen in:
* 50% of infants 0-3 months
* 67% of infants at 4 months
* 5% at 10 to 12 months of age (3)
It is important to note that in infants (younger than 1 year of age) who are otherwise well and symptomatic, regurgitation may be considered entirely normal. (4)
GOR occurs due to the transient, inappropriate relaxation of the lower oesophageal sphincter, which allows the stomach contents to pass into the oesophagus.
GOR can be physiological or pathological:
* Physiological GOR--when the infant has normal weight gain and experiences no complications and is generally well.
* Pathological GOR--also known as gastro-oesophageal reflux disease (GORD) is when reflux is associated with other symptoms like failure to thrive or weight loss, feeding or sleeping problems, chronic respiratory disorders, oesophagitis, haematemesis etc (3)
Several anatomical and physiological conditions make infants (younger than 1 year of age) more prone to GORD than older children and adults:
* Short, narrow oesophagus
* Delayed gastric emptying
* Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm
* Liquid diet and high calorie requirements, putting a strain on gastric capacity
* Larger ratio of gastric volume to oesophageal volume(4)
Most children have no specific risk factors for GORD. Children with the following conditions are at increased risk for developing GORD and for progressing to severe GORD:
* Severe neurological impairment
* Cystic fibrosis
* Gastro-oesophageal abnormalities (even after surgical repair), e.g. Oesophageal atresia, diaphragmatic hernia, pyloric stenosis
* Bronchopulmonary dysplasia (preterm infants with lung disease)
* Hiatus hernia
* Oesophageal sphincter disorders
* Raised intra-abdominal pressure(5)
GORD in infants and children can present with a variety of symptoms many of which can be relatively non-specific. Equally, other pathologies may lead to the development of reflux. Those in the early years tend to be based on observations by parents, while older, more vocal children express symptoms more akin to adult presentations.
As such, the history/symptoms will be broadly divided into those expected for infants (<1yr), young children (1-5yrs) and older children (>5yrs).
1) Excessive possetting/regurgitation
a) Possetting is a normal phenomenon in infants
b) Frequent episodes, together with vomiting may indicate underlying GORD
c) Projectile vomiting may indicate an obstructive pathology
2) Difficult/rapid cessation of feeds
a) There may be difficulty initiating feeds and latching
b) Early cessation may be precipitated with the onset of reflux
3) Failure to thrive
a) No weight loss can be expected
b) Weight loss crossing centiles on the growth chart must be addressed urgently
4) Sleep disturbance
a) Particularly after an evening feed
b) This is often associated with irritability and inconsolable crying
5) Irritability and inconsolable crying
a) One of the commonest presentations...
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