Introduction

Gastro-oesophageal reflux (GOR) is the regurgitation of gastric contents into the oesophagus. It is a normal physiological phenomenon at all ages. In most cases it is a benign self-limited condition which spontaneously resolves over a variable time period, usually in infancy. The refluxed gastric contents are generally rapidly cleared from the oesophagus without causing any significant clinical symptoms. Complications warranting medical intervention are uncommon. When complications do occur, it is referred to as GOR disease (GORD).

Pathophysiology

During periods of raised intra-abdominal pressure such as straining, there are a number of protective mechanisms which help to prevent GOR. These include contraction of the diaphragmatic crura around the lower oesophagus in the region of the lower oesophageal sphincter (LES), as well as compression of the intra-abdominal segment of the oesophagus. Many episodes of GOR are associated with transient relaxations of the LES.

In infants the LES is located above the diaphragm, rendering the above protective mechanisms ineffective. Therefore, infants are especially prone to GOR, particularly in the early months of life. However, with anatomical and physiological maturation, the natural history is of symptom resolution by late infancy in the vast majority. GOR is unusual in children older than 18 months.¹

Some children are particularly predisposed to develop GORD. These include premature infants, children with neurological conditions, such as cerebral palsy or neurodegenerative disorders, and children with anatomical anomalies such as tracheo-oesophageal fistula. These children have poor oesophageal motility with reduced clearance of refluxed gastric contents.

History

The cardinal symptom of GOR is visible regurgitation of milk post-feeds. This is usually called vomiting, although in GOR the expulsion of gastric contents is generally by an effortless spill, whereas true vomiting involves forceful contraction of abdominal wall musculature. In GOR, the regurgitation is not particularly forceful and the milk usually soils the child’s clothing. Likewise, the physiological ‘posseting’ of milk, which is common after feeding, usually just spills onto the child’s chin region. This is in contrast to the more projectile vomiting of pyloric stenosis, where the milk often propels to a more distant location.

The history is crucial in considering potential differential diagnoses and in identifying complications. Careful questioning regarding the relationship of vomiting to feeds, the content of regurgitated material (e.g. is there blood or bile?), apparent associated distress, and feeding behaviour, is essential. Episodic irritability related to feeds may indicate GOR, although the association between irritability and GOR in infants is generally weak. Atopic features such as eczema and a family history raise the possibility of cows’ milk protein allergy. A history of associated fever suggests an infective cause. Seizures and poor feeding raise the possibility of a metabolic or neurological disorder. Inquiry about associated symptoms such as poor weight gain and respiratory symptoms including apnoea, or wheezing is important to screen for potential complications. Onset of vomiting after 6 months of age is unusual in GOR and suggests an alternative cause.

Examination

Infants with benign GOR demonstrate a robust general condition. They appear well and are thriving. If the child appears unwell or lethargic another cause for the symptoms needs to be carefully considered. The presence of abdominal distension, abnormal tone, or hepatosplenomegaly suggests alternative diagnoses including anatomical anomalies, neurodevelopmental dysfunction or metabolic disorders. A pyloric tumour should be specifically palpated for in young infants. Note that occasionally, in a young infant with known GOR, a change in the character of the vomiting may indicate another evolving diagnosis on a background of GOR, such as pyloric stenosis or a urinary tract infection (UTI). Serial weight measurements should be plotted on the child’s growth chart. Respiratory examination is important to identify signs of bronchospasm or recurrent aspiration, which may complicate GOR. Conjunctival pallor indicates anaemia, which may be secondary to reflux oesophagitis. The urine should be screened by microscopy and culture for an occult UTI causing vomiting.

Differential diagnosis

There are many causes of vomiting in children, and it is important to consider a number of alternative causes that may mimic GOR (see Chapter 7.8 on Diarrhoea and vomiting). These include: infection, e.g. urinary tract infection, gastroenteritis; surgical conditions, e.g. malrotation and volvulus, pyloric stenosis, intussusception; metabolic disorders, e.g. inborn errors, diabetes; food allergy and raised intracranial pressure, e.g. hydrocephalus, posterior fossa tumour, subdural haematoma (Table 7.3.1).